Presentation
A 49-year-old man had a productive cough, chills, fever, weakness, exertional dyspnea and pleuritic chest pain for 4 weeks. The patient was afebrile. Breath sounds were diminished over the right chest area. The patient's leukocyte count was 45 ´ 109/L. Chest radiographs (Fig. 1) showed apical pneumothorax, an air–fluid level with opacity of the right lower chest field and mediastinal shift to the left. Computed tomography of the chest (Fig. 2) confirmed the presence of a large homogeneous fluid collection in the right chest field, pneumothorax and mediastinal shift to the left, with some gas adjacent to the compressed lung.
FIG. 1. Chest radiographs of a 49-year-old man: posteroanterior view (left) and lateral decubitus view (right).
FIG. 2. Computed tomographic image of the same patient's chest.
The patient was treated with broad-spectrum antibiotics. A large-bore chest tube was placed. Several litres of foul-smelling fluid were evacuated from the chest under high pressure. Cultures were polymicrobial and grew both aerobes and anaerobes. Streptococcus viridans and Peptococcus were isolated in cultures from this patient. The patient was again treated with broad-spectrum antibiotics, and a thoracostomy tube was placed.
What is the diagnosis?
Diagnosis
Tension pyopneumothorax is a rare cause of pulmonary symptoms that has been seen in patients with a ruptured esophagus,1 lung necrosis2 and a postpneumonectomy bronchopleural fistula.3 Tension pyopneumothorax has also been seen as a complication of pneumonia and empyema.4,5 We have treated one other patient with tension pyopneumothorax secondary to pneumonia and empyema.
We assume that the pneumothorax and shift of the mediastinum resulted from positive pressure due to gas from the Peptococcus, a gas-producing organism, accumulated in the pleural space.
Acknowledgments
The Medical Editing Service of the Permanente Medical Group Physician Education and Development Department provided editorial assistance.
Submissions to Surgical Images, soft-tissue section, should be sent to the section editors: Dr. David P. Girvan, Victoria Hospital Corporation, PO Box 5375, Station B, London ON N6A 5A5 or Dr. Nis Schmidt, Department of Surgery, St. Paul's Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6.
Competing interests: None declared.
Correspondence to: Dr. James H. McClenathan, Department of Surgery (Dept. 286), Kaiser Permanente Medical Center, 710 Lawrence Expressway, Santa Clara CA 95051; fax 408 851-2398; james.mcclenathan@kp.org
References
- 1.Matsumoto MA, Rockoff SD, Aaron BL. Tension pyopneumothorax. Rare presentation of ruptured Barrett's esophagus. Chest 1993;103:1604-6. [DOI] [PubMed]
- 2.Juettner FM, Arian-Schad K, Kraus I, et al. Total unilateral lung gangrene in Hodgkin's disease: treatment by thoracostomy. Ann Thorac Surg 1991;51:302-3. [DOI] [PubMed]
- 3.Lams P. Radiographic signs in post pneumonectomy bronchopleural fistula. J Can Assoc Radiol 1980;31:178-80. [PubMed]
- 4.Gainanov FKh, Borisov IuB, Suleimanov NIa, et al. [Pneumoperitoneum as a complication of destructive pneumonia and tension pyopneumothorax in a child.] Vestn Khir Im I I Grek 1985;135:97-8. [PubMed]
- 5.Hussain SA. Tension pyopneumothorax in staphylococcal pneumonia. Postgrad Med 1977;61:238. [DOI] [PubMed]