INTRODUCTION: Lung pledgets are an extremely uncommon and unique etiology of recurrent pneumonia. Although rare, a unique radiological presentation may serve as a diagnostic tool; and a clinical suspicion could avoid delay in the management and complications.
CASE PRESENTATION: 49-year old nonsmoking man presented with productive cough, fever and anorexia for 6 months. He had no response to repeated courses of antibiotics. His past medical history was significant for gastroesophageal reflux disease and a non-resolving right upper lobe (RUL) necrotizing pneumonia refractory to medical management requiring partial wedge resection three years ago. His postoperative course was uneventful and follow-up chest computerized tomograms (CT) showed a thin RUL linear opacity presumed to be the suture line. He remained asymptomatic until his current presentation. His physical examination was normal except for a postoperative healed scar and decreased breath sounds on right upper part of his chest. He had slightly elevated white blood cell counts. Sputum cultures were negative. The chest radiographs revealed progressively worsening recurrent RUL round pneumonia over 6 months. A CT chest revealed interval increase of a round consolidation to 5.0 × 7.1 cm size involving the right apical and posterior segments causing localized mass effects with unusual multiple linear-appearing high densities and dysmorphic calcification within the lesion suggestive of possible retained material from the previous surgery. A positron emission tomogram confirmed a hypermetabolic process. Bronchoalveolar lavage showed gram-negative rods and oral flora. Fine needle aspiration showed benign fibrosis and mixed inflammation. The patient underwent right upper lobectomy for a consolidation refractory to medical management. During right upper lobectomy, the surgeons discovered pledget material and prolene sutures within the RUL abscess. Pathology showed an extensive parenchymal fibrosis with areas of pneumonia and abscess. The cultures grew Streptococcus constellatus, Prevotella species, and Peptostreptococcus species. The postoperative course was uneventful with complete recovery.
DISCUSSIONS: The use of pledgets in the lung is very uncommon in thoracic surgeries other than vascular procedures. Rarely pledgets are used to control peri-operative hemorrhage and prevent post-operative pulmonary fistula in partial lobectomies and to support suture lines. Despite sterile surgical techniques, pledgets in the lung are more susceptible to secondary infection since they are exposed to a non-sterile post-operative environment in thoracic procedures such as a non-sterile extracorporeal environment via the mouth and airways. Pledget infections have not been described in the literature. Moreover, it is very unusual to see pledgets presenting as a recurrent lung infection three years after the lung surgery warranting reoperative thoracotomy as seen in our case. The risk for infection is unlikely to be related to the surgical technique, but rather, related to anatomy and co-morbid issues such as gastroesophageal reflux disease and chronic aspiration. The pledget may provide a nidus for infection through repeated chronic aspiration. In this case, microbiological cultures from lobectomy specimen grew primarily anaerobic and oral microorganisms, suggesting a chronic aspiration as a source of infection of lung pledgets.
CONCLUSION: Lung pledgets are a unique cause of recurrent non-resolving pneumonia. A clinical suspicion and peculiar radiological presentation could avoid delay in the diagnosis warranting early thoracotomy.
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