Presentation
Two weeks of persistent shortness of breath, productive cough and fevers despite oral antibiotics.
Patient Data
Opacification of the lower posterior 2/3 of the right lung with a gas-fluid level indicating hydropneumothorax (frontal, lateral). No visible air bronchograms.
The left lung and pleural cavity are clear.
Normal pulmonary vascularity bilaterally. No pneumomediastinum. No mediastinal shift.
Further assessment with CT is recommended.
Large right-sided loculated, dependent pleural collection containing gas locules consistent with hydropneumothorax. Diffuse enhancement and thickening of parietal and visceral pleura indicates empyema (split pleura sign). Minor hypertrophy of the extrapleural fat indicates a degree of chronicity.
Markedly enhancing passive atelectasis of the majority of the right lower lobe withmarked volume loss and air bronchograms. Partial atelectasis of the right middle and upper lobes. No bronchopleural fistula demonstrated. No evidence of esophageal perforation.
Normal left lung and pleural cavity. No endobronchial lesions. No mediastinal or hilar lymphadenopathy.
Purulent fluid was obtained.
Case Discussion
This is a 65-year-old man who presented to the GP with symptoms of persistent chest infection. A chest radiograph was taken in the community which led to prompt referral to the emergency department with findings of hydropneumothorax.
He was unwell with an increased oxygen requirement and raised serum inflammatory markers. CT of the chest confirmed hydropneumothorax, with suspicion for pyopneumothorax given the positive split pleura sign and gas locules.
An intercostal catheter (ICC) was inserted in the lower border of the 5th intercostal space between the lateral edge of pectoralis major and latissimus dorsi under ultrasound guidance. This procedure is known as thoracocentesis.
1.2L of purulent fluid was drained from the collection which was biochemically exudative. Microscopy showed both gram-negative bacili and gram-positive cocci, but cultured only Streptococcus intermedius bacterium. No malignant cells were identified.
He was treated with IV amoxicillin/clavulanic acid. The collection was successfully drained and he was discharged home after his ICC was removed one week later.
Though often used interchangeably, pyopneumothorax can be thought of as a sub-variant of thoracic empyema, with the former containing gas locules within the collection. Gas within an empyema is usually the result of gas-producing bacteria, but may also indicate bronchopleural fistula or esophageal perforation. While hydropneumothorax can be called radiologically, the fluid must be confirmed as purulent exudate (by thoracocentesis) before it can be called empyema.
Thoracic empyema is usually a complication of pneumonia, where serous fluid in the pleural space becomes infected and forms a collection. Presence of the split pleura sign and obtuse margins help to confirm pleural location and exclude intraparenchymal pulmonary abscess.
Correct insertion technique is important in thoracocentesis. The intercostal vessels are typically tortuous posteromedially but are more predictable lateral to the angle of the ribs lying along the concave inferior flange.
Case courtesy of Dr Luke Thomas.
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