Medical Image of the Week: Extrapleural Pneumolysis for Tuberculosis

Figure 1. PA (A)/Lateral (B) chest films showing a mass like opacity of the left upper lung field.

Figure 2. Representative image from the thoracic CT in soft tissue windows showing a well-circumscribed, oval-shaped, heterogeneous density within the left upper and mid anterior chest with some expansion and destruction of overlying ribs.

The advent of antibiotics revolutionized the management of tuberculosis, a disease that even in the 1950s was a top 10 cause of death in the United States. The first drug to be developed was streptomycin, approved after a clinical trial in 1946. The following decade saw the addition of ethambutol, rifampin, and isoniazid (1). Though we take for granted the use our multidrug regimens nowadays, physicians once had limited interventions for this frequent and devastating infection. Such interventions included surgical techniques to collapse the affected lobes, starving the mycobacterium of their preferred oxygen rich environment. One such technique was known as plombage, or extrapleural pneumolysis. Plombage is a term derived from the Latin for lead or plumbum and entails the insertion of a space occupying material into the pleural space with subsequent compression of the affected lung portion. This was seen as an alternative to the use of thoracoplasty, which required removal of multiple ribs allowing the chest wall to collapse, leading to deformity and a loss of lung function (2). Though rarely seen now, we present the imaging of an elderly female with endometrial cancer with lung metastasis who interestingly had undergone such a procedure when she developed cavitary tuberculosis as a teenager in 1952.

Tuffler first developed extrapleural pneumolysis in 1891; he placed fat into the pleural cavity reporting successful control of tuberculosis infection. The technique over the subsequent decades became popular especially as a response to the endemic tuberculosis seen post- the Second World War. Many attempts were made to designate an ideal inert material for use. Though unclear in our patient given the remote history of the procedure, published reports include placement of muscle, fat, air, mineral oil, gauze, paraffin, rubber sheeting, and even inflated Lucite balls. Fortunately, complications of the procedure, even decades later, are rarely seen now. Complications listed in the literature, however, do include infection, hemorrhage, fistula formation, migration of material, and even malignancy. Despite its popularity, there were mixed results in effectiveness and variable complication rates, in one series nearly 50% of patients developed an infection (3). In our patient, it was successful, with no history of recurrence with negative sputum and serologic testing. She did notably report having been treated with a long course of antibiotics as well.

Kareem Ahmad, MD

Department of Internal Medicine

Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine

University of Arizona

Tucson, AZ, USA

References

1. Zumla A, Nahid P, Cole ST. Advances in the development of new tuberculosis drugs and treatment regimens. Nat Rev Drug Discov. 2013 May;12(5):388-404. [CrossRef] [PubMed]
2. Young FH. Extraperiosteal plombage in the treatment of pulmonary tuberculosis. Thorax. 1958; 13(2):130-5. [CrossRef] [PubMed]
3. Murphy JD, Elrod PD, et al. Surgical treatment of residual cavities following thoracoplasties for tuberculosis. Dis Chest. 1948 Sep-Oct;14(5):694-706. [CrossRef] [PubMed]

Cite as: Ahmad K. Medical image of the week: extraplerural pneumolysis for tuberculosis. Southwest J Pulm Crit Care. 2016;13(5):244-5. doi: https://doi.org/10.13175/swjpcc106-16 PDF

Medical Image of the Week: Necrotizing Soft Tissue Infection

Figure 1. Axial view showing extensive gluteal and perineal soft tissue inflammation with gas formation (arrow).

Figure 2. Saggital view showing gas formation (arrow).

A 70-year-old man with a history of coronary artery disease, chronic back pain, and general debilitation presented to the emergency department with complaints of fever, weakness and right buttock discomfort. Physical exam was remarkable for a temperature of 101.7º F, and for moderate erythema of the skin of the right inguinal area and right buttock, with associated tenderness. Laboratory exam was significant for a WBC of 22.7 K/ɥL, erythrocyte sedimentation rate of 82 mm, and serum creatinine phosphokinase of 2856 U/L. CAT of the abdomen and pelvis demonstrated extensive gluteal and perineal soft tissue inflammation with gas formation, consistent with a necrotizing soft tissue infection (Figures 1 and 2).

Three basic subsets of necrotizing soft tissue infections (NSTIs) have been described. Type I infections are the most common form and are characterized by a polymicrobial process typically involving gram positive cocci, gram negative rods, and anaerobes. Type I infections occur most commonly in diabetics, in patients with severe peripheral vascular disease, or in the presence of other immune compromising conditions.  Type II infections involve Group A Streptococcus, either alone or in combination with Staphylococcus aureus. Type II NSTI’s occur most commonly in immunocompetent hosts. Type III NSTI’s, caused by Vibrio vulnoficus, are found in patients with exposure to warm sea water, with liver disease being the most common predisposing condition (1-3). Fournier’s gangrene is a NSTI that involves the perineum (2).

Physical examination often reveals fever and local erythema or tenderness. Gas formation may be present on imaging studies, with CAT scans more sensitive than plain films (1). Treatment relies on early antibiotic therapy with anaerobic coverage, fluid resuscitation, and aggressive debridement. Hyperbaric oxygen therapy may have a role as well (1). Mortality is high, in the range of 40%, and recovery is often prolonged (1,3).

Angela Taylor MD, Milena Beer PA, and Charles J. VanHook MD

Longmont United Hospital

Longmont, Colorado USA

References

1. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. [CrossRef] [PubMed]
2. Pucket Y, Fisher B, Dissanaike S. Clinical comparison of Fournier's gangrene to other necrotizing soft tissue infections. Research Journal of Infectious Diseases. 2015;3:1. [CrossRef]
3. Khamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Yodluangfun S, Tantraworasin A. Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthc Policy. 2015 Feb 16;8:1-7. [CrossRef] [PubMed] 

Cite as: Taylor A, Beer M, VanHook CJ. Medical image of the week: necrotizing soft tissue infection. Southwest J Pulm Crit Care. 2016 Mar;12(3):102-3. doi: http://dx.doi.org/10.13175/swjpcc005-16 PDF

Medical Image of the Week: Cutaneous Coccidioidomycosis

Figure 1. Right distal anterior thigh. Fungal culture grew Coccidioides immitis from biopsy.

A 46-year-old Hispanic man with no known past medical history presents to his primary care physician for a progressively worsening “rash” located over his right thigh. Patient described the lesion as raised, scaly, and itchy. It has been “growing” for the past one year and started out as a small “pimple”. Patient denied any trauma to the effected region over this time period. Surgical history was significant for a splenectomy 15 years prior that was needed after a traumatic accident. He works in construction and lives in southern Arizona. He denied alcohol, tobacco and or illicit drug use. Patient has attempted to treat this skin lesion with over the counter hydrocortisone ointment with no relief. He denied any other associated symptoms including fever/chills, headache, vision changes, night sweats, weight loss, cough, shortness of breath, and or joint pains. Vital signs were stable upon presentation. Physical exam was entirely benign other than the isolated skin lesion shown above (Figure 1). It measured roughly 5cm at its greatest dimension and was located just superior the right knee on the anterior portion of the distal thigh. Nodularity was appreciated upon palpation but no tenderness was noted. Areas of erythema were non-blanching. Small satellite lesions were seen on the perimeter.

He was sent to a dermatologist and biopsies were performed. Light microscopy and culture confirmed the diagnosis of cutaneous coccidioidomycosis. Initial laboratory work revealed a normal complete blood count and complete metabolic panel. Serum coccidioides IgM antibody was negative but IgG was confirmed to be positive with a reflex complement fixation titer of 1:16. Chest X-ray was normal. Patient was started on oral fluconazole 400mg daily. Repeat coccidioides IgG titers decreased to 1:8 at a four- week follow-up. Patient has been tolerating the medication well and skin lesion has begun to regress.

Norman Beatty MD¹ and Mayar Al Mohajer MD²

¹Departments of Internal Medicine and ²Infectious Diseases

University of Arizona College of Medicine

Tucson, AZ

Cite as: Beatty N, Al Mohajer M. Medical image of the week: cutaenous coccidioidomycosis. Southwest J Pulm Crit Care. 2015;11(5):226-7. doi: http://dx.doi.org/10.13175/swjpcc110-15 PDF

Medical Image Of The Week: Septic Pulmonary Emboli Misdiagnosed As Metastatic Disease

Figure 1. Representative thoracic CT axial images showing multiple pulmonary nodules (red arrows).

A 54-year-old previously healthy man presented with acute onset of left-sided, sharp pleuritic chest pain and dry cough. He denied having fever, hemoptysis, shortness of breath, or unintentional weight loss. Review of system was positive for bright blood per rectum for the last year. He had a root canal procedure done 3 weeks prior to presentation. His is a 30 pack-year smoker, drinks alcohol occasionally, but denied any IV drug use.

On admission, he was afebrile and hemodynamically stable. Clinical examination was positive for fecal occult blood test. CBC revealed WBC of 12,800/mm³ and his hemoglobin was11.9 g/dL. Thoracic CT scan with contrast was negative for pulmonary embolism, but showed multiple bilateral pulmonary nodules suspicious for malignancy (Figure 1). The left upper lobe showed a subpleural 2.4 x 1.5 cm rounded opacity and emphysematous changes. CT of the abdomen and pelvis showed folds in the stomach but was otherwise unremarkable.

Esophagogastroduodenoscopy was negative. Colonoscopy showed non-bleeding internal hemorrhoids. He underwent percutaneous CT guided lung biopsy. Pathology report showed distended alveoli filled with polymorphonuclear leukocytes mixed with fibrin consistent with septic emboli and no evidence of malignancy.  Special stains for organisms were negative. Blood cultures were negative, Trans-esophageal echocardiograph was normal. Mandibular film done was negative for dental abscess. HIV serology, Quantiferon gold, ß-d glucan, Aspergillus, and mycobacterial culture of sputum were negative. During his hospital stay he developed a fever and his WBC count increased. He was empirically started on broad spectrum antibiotics and he clinically improved significantly.

Septic pulmonary embolus (SPE) is a serious and uncommon condition that poses a diagnostic challenge and carries a high mortality (1,2). Presenting symptoms are often non-specific. Blood cultures may be negative initially. Similarly, chest radiography is not helpful to establish a diagnosis. CT is more useful, usually showing multiple peripheral nodular opacities. SPE can be suspected by the presence of potential source of underlying infection, febrile illness and multiple pulmonary nodules.

Dima Dandachi MD and Sathish Krishnan MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

1. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med 2014;108(1):1-8. [CrossRef] [PubMed]
2. Shiota Y, Taniguchi A, Yuzurio S, Horita N, Hosokawa S, Watanabe Y, Tohmori H, Ono T; Okayama Respiratory Disease Study Group. Septic pulmonary embolism induced by dental infection. Acta Med Okayama. 2013;67(4):253-8. [PubMed] 

Reference as: Dandachi D, Krishnan S. Medical image of the week: septic pulmonary emboli misdiagnosed as metastatic disease. Southwest J Pulm Crit Care. 2014;9(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc083-14 PDF

Medical Image of the Week: Empyema

Figure 1. Admission thoracic CT showing a low density collection in the right lung likely from necrosis (*).

Figure 2. Selected views from the thoracic CT obtained 1 week after admission. Panel A: Architectural distortion (white circle) suggests necrotizing pneumonia. Note fluid within the bronchus intermedius (*). Panel B: Defect in visceral pleura (arrow) with decompression of parenchymal necrosis into the pleural space.  Note enhancement and thickening of both pleural layers. Panel C: Defect in parietal pleura (black arrow) with fluid extending into the extrapleural space. Pericardial effusion (*), new left pleural effusion and left parietal pleura enhancement (white arrow) suggests spread of infection. Incidental hiatal hernia (+).

A 71 year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department complaining of dyspnea after recent admission for pneumonia. Chest CT shows a low density collection in the right lung suggesting necrosis (Figure 1). A CT obtained 1 week after admission (Figure 2) shows progression to empyema.

Management of empyema can be difficult. If the fluid cannot be removed with a therapeutic thoracentesis, a chest tube should be inserted and consideration be given to the intrapleural instillation of fibrinolytics (1). If the loculated effusion persists, the patient should be subjected to video-assisted thoracoscopic surgery. If the lung cannot be expanded with this procedure, a full thoracotomy with decortication should be performed. The definitive procedure should be performed within fourteen days.

Jason R. Young MD and David L. August, MD

Department of Radiology

Maricopa Integrated Health System

Phoenix, AZ

Reference

1. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006;3(1):75-80. [CrossRef] [PubMed]

Reference as: Young JR, August DL. Medical image of the week: empyema. Southwest J Pulm Crit Care. 2013;7(5):300-1. http://dx.doi.org/10.13175/swjpcc143-13 PDF