A Rare Case of Tubercular Pyo–Pneumothorax Herniating through the Inter-Costal Drainage Site

A 53 year old diabetic male, who was on anti – tubercular treatment, presented with an expansile swelling on his chest, at the intercostal drainage (ICD) site. He was diagnosed to have a left sided tubercular hydro – pneumothorax, about six weeks earlier. He had noticed the swelling at the ICD site, 5 days ago and he had no pain. Clinically, an expansile swelling of size 5 x 4 cm, was seen at the 6^th ICS, in the mid axillary line, which was partially reducible, with palpable crepitations [Table/Fig-1]. The left hemi – thorax showed reduced movements and breath sounds. Contrast enhanced computer tomographic (CECT) images of thorax showed left upper lobe consolidation, with cavities and a hydro – pneumothorax. The left pleural space was seen to extend through the dehiscence on lateral chest wall, forming an air – filled subcutaneous swelling. [Table/Fig-2]. Anti-tubercular therapy was continued and a fresh ICD was inserted at the lower intercostal space, which drained the purulent fluid. After a week, repair and layered suturing was done at the site of dehiscence. The wounds approximated and healed over the next 3 – 4 weeks. A pyo-pneumothorax which is caused by tuberculosis is common in endemic areas [1]. There is one report in the literature on herniation of an emphysematous bulla through an ICD site [2]. However, herniation of a pyo-pneumothorax through a closed ICD site was not found in our literature review.

[Table/Fig-1]:

Serial photographs demonstrating an expansile swelling with expiratory and inspiratory movements in left infra axillary area(marked with black arrows)

[Table/Fig-2]:

Transverse and coronal images by CECT of thorax showing pleural space extending through the left lateral chest wall dehiscence forming an air-filled subcutaneous swelling(marked with white arrows)

Financial or Other Competing Interests

None.