Medical Image of the Week: Bronchopleural Fistula

Figure 1. The blue arrow indicates a fistulous communication between bronchus and the pleura.

Figure 2. Red arrow indicates radiotracer trapping in the pleural space and adjacent right anterior lower lung field.

A 58-year-old man with past medical history significant for chronic smoking and seizures was referred to the emergency room after a chest x-ray done by his primary care physician for evaluation of cough showed a hydropneumothorax. His symptoms included dry cough for past 2 months without fever, chills or other associated symptoms. He did not have any thoracic procedures performed and had no past history of recurrent infections. He was hemodynamically stable. Physical examination was only significant with decreased breath sounds on the right side of the chest.

Thoracic CT with contrast was performed which showed complete collapse of the right lower lobe, near complete collapse of right middle lobe as well as an air-fluid level. There was a suspicion of a direct communication between bronchi and pleural space at the posterior lateral margin of the collapsed right lower lobe (Figure 1). The presence of bronchopleural fistula (BPF) was confirmed with the help of lung scintigraphy, which showed trapping of radiotracer in the right lung at a location consistent with the chest CT findings of BPF (Figure 2). The patient was admitted and extensive infectious work up was negative. Biopsy of the right pleura was negative for malignancy. He underwent video-assisted thoracoscopic surgery (VATS) decortication of his right lung and was stable on subsequent follow up with complete resolution of his cough.

BPF has mortality rate between 18 to 67% (1). CT of the chest can occasionally demonstrate a direct fistulous communication, as seen in our case.  However, Westcott and Volpe (2) have shown sensitivity of CT chest to be 50%. Other useful noninvasive imaging techniques include lung scintigraphy. In this modality, the fistula is identified by seeing a trapping of radioisotope labeled gas as there is no mechanism for a clearance of gas after its diffusion into the pleural space.  Raja et al. (3) demonstrated that lung scintigraphy had 83% sensitivity and 100% specificity in diagnosing BPF.  

As seen in this case lung nuclear scintigraphy offers a cheaper, more sensitive, and less invasive approach to diagnosis of BPF.

Hem Desai MD, MPH and Anthony Witten DO

Department of Internal Medicine

University of Arizona

Tucson, AZ USA

References

1. Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg. 1997 May;63(5):1391-6; discussion 1396-7. [CrossRef] [PubMed]
2. Westcott JL, Volpe JP. Peripheral bronchopleural fistula: CT evaluation in 20 patients with pneumonia, empyema, or postoperative air leak. Radiology. 1995 Jul;196(1):175-81. [CrossRef] [PubMed]
3. Raja S, Rice TW, Neumann DR, Saha GB, Khandekar S, MacIntyre WJ, Go RT. Scintigraphic detection of post-pneumonectomy bronchopleural fistulae. Eur J Nucl Med. 1999 Mar;26(3):215-9. [CrossRef] [PubMed] 

Cite as: Desai H, Witten A. Medical image of the week: bronchopleural fistula. Southwest J Pulm Crit Care. 2016;13(3)150-1. doi: http://dx.doi.org/10.13175/swjpcc069-16 PDF

Medical Image of the Week: Empyema Necessitans

Figure 1. Panel A: chest radiograph on admission showed mass like lesion centered at the right upper lobe. Panel B: Coronal CT cut showing loculated fluid collection demonstrating peripheral rim enhancement. There is extension of pleural fluid into the soft tissues of the adjacent right chest wall (white arrow).

Figure 2. Panel A: chest radiograph after VATS decortication and antibiotic course shows resolution. Panel B: axial CT cut after completion of therapy shows complete resolution.

A previously healthy 46-year-woman was evaluated for two week history of right shoulder pain, associated pleuritic chest pain and dyspnea.

Chest radiograph showed right apical mass (Figure 1A). Imaging  showed loculated fluid collection with extension into the soft tissues of the adjacent right chest wall suggestive of empyema necessitans (Figure 1B).

Chest Tube placement was done along with broad spectrum antibiotics. Blood and pleural fluid cultures showed methicillin-resistant Staphylococcus aureus (MRSA). Due to persistence of loculation despite antibiotics, she underwent a video-assisted-thoracoscopic surgery (VATS) for decortication and further drainage of the effusion.

Symptoms and radiologic findings improved and she was discharged with intravenous antibiotics to complete a six week course. Chest imaging at six week period showed complete resolution (Figure 2).

Empyema necessitans, defined by the extension of an empyema through the parietal pleura, into surrounding tissue is becoming rare with the routine drainage of empyema and antibiotics use. Common causative pathogens include Mycobacterium tuberculosis, Actinomyces israelii, Streptococcus pneumoniae, and Staphylococcus aureus (1). Surgical treatments for thoracic empyema include chest tube drainage, debridement via VATS, decortication, open window thoracostomy, and thoracoplasty (2).

Kai Rou Tey MD¹, Bhupinder Natt MD²

¹Department of Internal Medicine - South Campus and ²Department of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Kono SA, Nauser TD. Contemporary empyema necessitatis. Am J Med. 2007;120(4):303-5. [CrossRef] [PubMed]
2. Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg. 2007;32(3):422-30. [CrossRef] [PubMed] 

Cite as: Tey KR, Natt B. Medical image of the week: empyema necessitans. Southwest J Pulm Crit Care. 2015;11(6):271-2. doi: http://dx.doi.org/10.13175/swjpcc139-15 PDF 

March 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man with a history of severe asthmatic bronchitis presented with a 6 week history of intermittent fever, productive cough, shortness of breath, and decreased appetite. Four weeks earlier the patient was presumptively treated with amoxicillin for presumed community-acquired pneumonia, with some improvement, but his symptoms recurred 10 days following completion of his course of therapy. The patient also thought he was diagnosed with a COPD exacerbation during this time period and was treated with a short course of corticosteroids without improvement.

The patient was seen by his pulmonologist who noted decreased breath sounds over the right thorax, and referred the patient to the emergency room.

In the emergency room, a leukocytosis (white blood cell count = 17.4 x 10⁹ / L with neutrophilia) was noted. Broad-spectrum antibiotic coverage was re-instituted and frontal chest radiography (Figure 1) was performed.

Figure 1: Frontal (A) and lateral (B) chest radiography

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to move to the next panel)

1. The chest radiograph homogeneous complete right lung consolidation
2. The chest radiograph shows a right-sided mediastinal mass
3. The chest radiograph shows homogeneous right lung opacity suggesting right lung collapse
4. The chest radiograph shows homogeneous right lung opacity suggesting a large right pleural effusion
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. March 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014:8(3):161-9. doi: http://dx.doi.org/10.13175/swjpcc015-14 PDF