Medical Image of the Month: Coccidioidal Pneumatocele Complicated by Pulmonary Hemorrhage

Figure 1. Axial CT of the chest without contrast 12 years prior to this hospitalization demonstrates an irregularly-marginated right upper lobe cyst measuring 1.5 x 1.6 cm (red arrow).

Figure 2. Axial CT of the chest without contrast obtained 4 months prior to this admission demonstrated a cavitary lesion now measuring 6.3 x 8.2 cm, thin-walled, with small internal air-fluid level and adjacent small pleural effusion without any internal debris (red arrow).

Figure 3. An axial CT angiogram of the chest in lung windows demonstrated a right upper lobe pulmonary cavitary lesion increased in size to 10.5 cm in largest dimension with almost complete opacification (red star) concerning for a superimposed infection.

A 77-year-old man with emphysema, hypertension, hypothyroidism, and diabetes mellitus presented with two days of worsening cough that progressed to massive hemoptysis. His hemoptysis included clots the size of golf balls and multiple episodes of frank blood, measuring half a cup each. His symptoms included dyspnea at rest, fatigue, and a 15-20-pound weight loss in three weeks. He denied fevers, night sweats, chest pain, hematemesis, and prior hemoptysis. Additionally, he had a history of coccidioidomycosis complicated by a cavitary lung lesion. Per chart review, 12 years prior to this hospitalization the patient had an irregularly-marginated right upper lobe cyst measuring 1.5 x 1.6 cm (Figure 1). A CT scan obtained 4 months prior to admission showed the cavity to be 6.3 x 8.2 cm thin-walled and clear of debris (Figure 2) – consistent with a pneumatocele. The patient was referred to thoracic surgery for possible resection at that time but was lost to follow up.

Admission labs showed a decrease in hemoglobin to 13.4 from a baseline of 15.1 g/dL and white blood cells of 10,300 cells/µL. Blood cultures were negative. CT angiography now demonstrated an increase in the right upper lobe pulmonary cavitary lesion to 10.5 cm in largest dimension with almost complete opacification of the lesion - concerning for a superimposed infection. Imaging also showed tree-in-bud nodules in right middle and lower lobes without evidence of a pulmonary embolism (Figure 3). Coccidioidomycosis serologies by EIA showed a non-reactive IgM with reactive IgG. Acid fast bacilli staining of the sputum was negative. Bronchoscopy performed in the hospital showed fresh blood present in the trachea and in the visualized tracheobronchial tree. Active bleeding was noted only from the posterior segment of the right upper lobe. A bronchoalveolar lavage was performed confirming alveolar hemorrhage centered in the right upper lobe. Lidocaine with epinephrine was instilled to stop bleeding. No endobronchial lesion was seen.

The case was evaluated by an interventional radiologist and cardiothoracic surgeon at our institution. They both felt the patient would benefit from transfer to a larger medical center for definitive management of his hemorrhage. He was transferred to a tertiary academic center for a right upper lobectomy, which he tolerated well.  Surgical pathology and bronchoscopy cultures ultimately grew coccidioides immitis and the patient was discharge on a treatment course of oral fluconazole.

Pulmonary pneumatoceles are thin-walled, air-filled cystic structures. Most pneumatoceles are encountered in infancy; however, they can appear at any age (1). Pneumatoceles are known sequelae of pneumonia but can also occur due to blunt thoracic injury or as a rare side effect of chemotherapy (2,3). While the mechanism of pneumatocele formation is unclear, several theories have been postulated including check-valve bronchial obstruction and narrowing or from parenchymal necrosis with accompanying focal collections of air within the interstitial tissue (5). Such cases are typically asymptomatic and do not require intervention as they resolve within weeks to months (6). While many pneumatocele resolve on their own without additional intervention, complex pneumatoceles may result in uncontrolled hemorrhage, as portrayed in this case, or infected lesions unresponsive to antibiotics - necessitating surgical intervention (7). Other complications of pneumatoceles are rare and may include a tension pneumatocele with cardiorespiratory compromise or pneumothorax (8). 

Staphylococcal pneumonia is frequently complicated by pneumatocele development, with pneumatoceles thought to occur in 61% of cases of staphylococcal pneumonia (9). However, the literature of pneumatocele development following cocci infection is scant. In immunocompetent hosts, infections from coccidiosis are transient, with pulmonary complications (often nodules and self-limited thin-walled cavities) occurring in less than 10% of patients (10).  Complications from coccidiosis infection are usually brief fatigue, dyspnea, cough, and arthritis, with chronic infection or severe complication being rare. Here, we report a case of a gradually enlarging pneumatocele in the setting of cocci infection that eventually eroded into the pulmonary vasculature. The resulting massive hemoptysis was refractory to epinephrine injection and not amenable to catheter embolization. Upper lobectomy was required for definite treatment of the pulmonary hemorrhage.

Sylvester Moses MD, Gregory Gardner MD, Ella Starobinska MD, and Arthur Wolff MD

Department of Internal Medicine

University of Arizona

Tucson, AZ USA

References

1. Flaherty RA, Keegan JM, Sturtevant HN. Post-pneumonic pulmonary pneumatoceles. Radiology. 1960;74:50-3. [CrossRef] [PubMed]
2. Aissaoui O, Alharrar R. Traumatic pulmonary pseudocyst: a rare complication of blunt thoracic injury. Pan Afr Med J. 2019 Apr 11;32:180. [CrossRef] [PubMed]
3. Sangro P, Bilbao I, Fernández-Ros N, Iñarrairaegui M, Zulueta J, Bilbao JI, Sangro B. Pneumatocele during sorafenib therapy: first report of an unusual complication. Oncotarget. 2017 Dec 22;9(5):6652-6. [CrossRef] [PubMed]
4. Quigley MJ, Fraser RS. Pulmonary pneumatocele: pathology and pathogenesis. AJR Am J Roentgenol. 1988 Jun;150(6):1275-7. [CrossRef] [PubMed]
5. Zuhdi MK, Spear RM, Worthen HM, Peterson BM. Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. Crit Care Med. 1996 Feb;24(2):330-3. [CrossRef] [PubMed]
6. Kaira K, Ishizuka T, Yanagitani N, Sunaga N, Hisada T, Mori M. Pulmonary traumatic pneumatocele and hematoma. Jpn J Radiol. 2009 Feb;27(2):100-2. [CrossRef] [PubMed]
7. Kesieme EB, Kesieme CN, Akpede GO, Okonta KE, Dongo AE, Gbolagade AM, Eluehike SU. Tension pneumatocele due to Enterobacter gergoviae pneumonia: a case report. Case Rep Med. 2012;2012:808630. [CrossRef] [PubMed]
8. Dines DE. Diagnostic significance of pneumatocele of the lung. JAMA. 1968 Jun 24;204(13):1169-72. [CrossRef] [PubMed]
9. Nayeemuddin M, Jankowich MD, Noska A, Gartman EJ. A strange case of coccidioidomycosis: utilization of bronchoscopy to diagnose a chronic cavitary lesion. Am J Resp Crit Care Med. 2018;197:A5427 [Abstract].

Cite as: Moses S, Gardner G, Starobinska E, Wolff A. Medical image of the month: coccidioidal pneumatocele complicated by pulmonary hemorrhage. Southwest J Pulm Crit Care. 2020;20(3):84-6. doi: https://doi.org/10.13175/swjpcc008-20 PDF 

Medical Image of the Week: Hematopneumatoceles from Pulmonary Lacerations

Figure 1. Chest x-ray showing irregular patchy regions of ill-defined consolidation in the left upper lobe and lingula, as well as suggestion of cystic changes (arrow).

Figure 2. Chest CT axial views, soft tissue and lung windows at the level of the aortic arch (A), right pulmonary artery (B) and the heart (C) showing mixed consolidative and nodular left lung opacities suggestive of pulmonary contusions, as well as contrecoup injury in the right lung, in addition to multiple cystic spaces containing air-fluid levels consistent with pulmonary lacerations.

Figure 3. Chest CT coronal views, soft tissue and lung windows showing consolidative and nodular lung opacities as well as fluid layering in cystic spaces (red arrows). A shattered spleen (yellow arrow) is also seen.

A 17-year-old man was brought to the emergency room after a fall from a 50-foot bridge. He was hypoxemic on presentation, requiring endotracheal intubation. Chest computed tomography (CT) revealed bilateral airspace opacities consistent with pulmonary contusions, and multiple air-fluid levels diagnostic of pulmonary lacerations (Figures 1-3).

Pulmonary lacerations are rare complications of blunt chest trauma (1). They can be contained within the lung parenchyma or may extend through the visceral pleura causing a pneumothorax. Due to its elastic recoil, the surrounding lung tissue pulls back from the laceration resulting in a round or oval cavity that may fill with air (pneumatocele), blood (hematocele) or both (hematopneumatocele). Lacerations are often obscured on chest x-ray as they are usually surrounded by contusion, requiring a CT for detection (2). They are classified into four types according to the mechanism of injury: Type 1 (compression rupture injury, most common type, usually centrally located), Type 2 (shearing against the thoracic spine, involving the paraspinal region of the lower lobes), Type 3 (rib penetration into the lung periphery, usually associated with a pneumothorax) and Type 4 (adhesion tear, in regions of pleuropulmonary adhesions) (3). Pulmonary lacerations heal more slowly than contusions and may last up to several months, over time becoming increasingly filled with blood, before regressing (2).

Our patient underwent an exploratory laparotomy with a splenectomy. The pulmonary lacerations were managed conservatively. He was successfully extubated on day#10 and discharged home on day#14 with a plan to follow his lacerations with monthly chest radiography.

Udit Chaddha MD¹, Darren Maehara MD¹, Ioan Puscas DO¹, Ashley Prosper MD², and Ramyar Mahdavi MD¹

¹Division of Pulmonary, Critical Care and Sleep Medicine and ²Department of Radiology

Keck School of Medicine of the University of Southern California

Los Angeles, CA USA

References

1. Nishiumi N, Maitani F, Tsurumi T, Kaga K, Iwasaki M, Inoue H. Blunt chest trauma with deep pulmonary laceration. Ann Thorac Surg. 2001;71(1):314-8. [CrossRef] [PubMed]
2. Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma. Radiographics. 2008;28(6):1555-70. [CrossRef] [PubMed]
3. Wagner RB, Crawford WO, Schimpf PP. Classification of parenchymal injuries of the lung. Radiology. 1988;167(1):77-82. [CrossRef] [PubMed]

Cite as: Chaddha U, Maehara D, Puscas I, Prosper A, Mahdavi R. Medical image of the week: hematopneumatoceles from pulmonary lacerations. Southwest J Pulm Crit Care. 2017;15(1):46-8. doi: https://doi.org/10.13175/swjpcc078-17 PDF 

Medical Image of the week: Endobronchial Valves

Figure 1. Bronchoscopic view of the endobronchial valves in the right upper lobe sub-segments.

Figure 2. Post procedural chest x-ray shows the valves (encircled). Other findings on this chest x-ray include a tracheostomy tube, right sided chest tube, left sided PICC line. Bilateral pneumatoceles are also seen (arrows).

A 39 year-old woman was referred to our hospital for evaluation of persistent broncho-pleural fistula after severe necrotizing streptococcal pneumonia. She had undergone a segmentectomy for the necrosis resulting in the broncho-pleural fistula. Her overall medical condition and malnutrition precluded another major surgery such as a muscle flap for the persistent air leak. Endobronchial valve placement was attempted to minimize the gradient and leak across the parenchymal defect to promote healing.

A sequential balloon occlusion technique was used to localize the leak to the right upper lobe, which was the site of the previous surgery. The sub-segments were measured and three endobronchial valves (Spiration®, Olympus Respiratory, USA) (1). Valves of 5 mm, 6 mm and 7 mm – were placed in the three sub-segments of the right upper lobe (Figure 1) with a flexible bronchoscope. Near elimination of the air leak was seen post procedure. Figure 2 shows post procedure chest x-ray showing the three valves.

Removable endobronchial valves have been shown to be safe and effective in cases of persistent post-operative air leaks (2).

Bhupinder Natt MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner University Medical Center-Tucson

Tucson, AZ USA

References

1. Olympus Corporation. Spiration® valve system. Available at: http://www.spiration.com/us/product-overview (accessed 6/21/16).
2. Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski RA, Musani AI, Kucharczuk JC, Gonzalez HX, Springmeyer SC. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011 Jan;91(1):270-3. [CrossRef] [PubMed]

Cite as: Natt B, Knepler J. Medical image of the week: endobronchial valves. Southwest J Pulm Crit Care. 2016;13(1):34-5. doi: http://dx.doi.org/10.13175/swjpcc057-16 PDF

Medical Image of the Week: Pneumatocele

Figure 1. Portable AP film showing a large cystic lesion in the left lower lobe in addition to small bilateral pleural effusions and adjacent consolidation.

Figure 2. Axial enhanced CT scan section showing a large cystic space with an air-fluid level with adjacent consolidated atelectasis. No perceptible wall is seen.

A 50-year-old man presented with polymicrobial pneumonia which included Proteus mirabilis, Enterobacter cloacea and MRSA pathogens. A large cystic lesion with an air-fluid level was found on chest imaging in a region of pneumonia (Figure 1). There was associated mass effect onto the adjacent lung. No perceptible wall was noted which would be more associated with a cyst rather than a cavity or abscess. Directed aspiration of this lesion resulted in decompression without further complication. Minimal sterile fluid was recovered. Therefore the proposed diagnosis was a pneumatocele within the setting of infection. Pneumatoceles may be challenging at times to distinguish from a cavity particularly when surrounded by airspace disease however merit consideration in the differential diagnosis particularly in the absence of findings of a thick irregular wall.

The exact mechanism causing development of a pneumatocele is not known, but believed to develop due to a check valve type bronchiole or bronchiolar obstruction (1). Pneumatoceles most commonly undergo spontaneous remission within weeks to months without any known long term implications. Complications occur rarely and include pneumothorax, tension pneumatocele, and secondary infection of a pneumatocele. Usual treatment is directed towards the underlying pneumonia with appropriate antibiotics. In rare cases percutaneous drainage may be necessary and is ideally performed with a small bore catheter to minimize trauma. The role of positive pressure ventilation in development of a pneumatocele is unclear.

Bhupinder Natt, MD and Veronica Arteaga, MD

Divisions of Pulmonary and Thoracic Imaging

University of Arizona College of Medicine

Tucson, AZ

Reference

1. Lysy J, Werczberger A, Globus M, Chowers I. Pneumatocele formation in a patient with Proteus mirabilis pneumonia. Postgrad Med J. 1985;61(713):255-7. [CrossRef] [PubMed]

Reference as: Natt B, Arteaga V. Medical image of the week: pneumatocele. Southwest J Pulm Crit Care. 2014;9(2):126-7. doi: http://dx.doi.org/10.13175/swjpcc102-14 PDF