Presentation
Known HIV-positive patient with COPD. Ongoing anti-retroviral therapy and tuberculosis treatment. Presents with hemoptysis and septicemia.
Patient Data
Hyperinflated lung fields are consistent with a known history of COPD. The trachea is central, with a tracheostomy in situ. The cardiomediastinal contour is normal.
There is a large, elliptiform, mass-like left hemithoracic opacity with sharp borders. There is no cavitation, no associated air-fluid level, no calcification, and no overlying rib erosion.
There is apical bronchovascular distortion consistent with previous pulmonary tuberculosis. There are bibasal effusions.
There is a left subclavian access CVP with overlying ECG leads.
The lateral view is absent, in keeping with a portable and intensive care setting.
CT confirms a left pulmonary pseudotumor with encysted heterogeneous pleural fluid oriented along the left oblique fissure with tapered ends (maximum HU-20). Multiplanar reconstructions assist in making this diagnosis in the absence of a lateral chest view while the patient is in a high-care setting. There are bibasal effusions with atelectasis.
There are hyperinflated lung fields consistent with known COPD, centrilobular and paraseptal emphysema, and pulmonary arterial hypertension.
There is bi-apical bronchovascular distortion, cicatricial emphysema, and right upper lobe chronic granulomas consistent with previous pulmonary tuberculosis. There are calcified left prevertebral and left hilar lymph nodes.
Previous imaging confirmed a tree-in-bud appearance within the right middle lobe and bilateral lower lobes consistent with recurrent/re-infection of pulmonary tuberculosis. The patient was on tuberculosis treatment at the time of this study.
There is a tracheostomy in situ. There are dense secretions/ blood inferior to the tracheostomy in view of the ongoing heamoptysis.
Image courtesy of Dr. K Kobo.
Follow-up X-rays on day 10 demonstrate a progression of parenchymal changes and a static appearance of the left pseudotumor. There is some resolution of the basal effusions.
On day 17, there are resolving parenchymal infective changes, improving left pseudotumor, and resolving bibasal pleural effusions.
On day 25, the left encysted fluid has significantly resorbed, and the pleural pseudotumor appears much smaller. The bibasal pleural effusions have totally resolved with a sharper diaphragmatic contour and normal cardiophrenic and costophrenic recesses. Residual chronic parenchymal changes in a setting of known COPD.
Case Discussion
A case of a large, left pleural pseudotumor due to left oblique fissural encysted pleural fluid with bibasal pleural effusions. The pleural pseudotumor progressively resorbed over a lengthy ICU stay and improved without any percutaneous or surgical drainage.
There is known COPD, with recurrent pulmonary tuberculosis on ongoing treatment. The patient is HIV-positive and on highly active antiretroviral therapy (HAART).