Imaging: Student/Resident Case Report Poster - Imaging |

Pneumothorax Necessitans: Rare Complication of Empyema Thoracis FREE TO VIEW

Ravish Singhal, MD; Saleem Shahzad, MD
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New York Methodist Hospital, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):666A. doi:10.1016/j.chest.2016.08.760
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SESSION TITLE: Student/Resident Case Report Poster - Imaging

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Pneumothorax necessitans is a rarely reported condition, which occurs when a pneumothorax communicates with an extra thoracic space through a thoracic wall defect.

CASE PRESENTATION: We report a 57 year old male with past medical history significant for HIV, who presented with shortness of breath for 3 weeks. On admission he underwent computed tomography (CT) of the chest which revealed a complex loculated pleural effusion for which he underwent thoracentesis. Pleural fluid analysis revealed pH of 6.43, white blood cell count of 152,000 with 93% neutrophils, which was consistent with empyema thoracis. He subsequently underwent video-assisted thoracoscopic surgery (VATS) decortication with chest tube placement. After resolution of drainage he was discharged home on intravenous ceftriaxone for pan-sensitive streptococcus pneumoniae. During his 1 month follow up, he complained of a painless lump arising from VATS surgical incision site along the right chest wall. Physical examination revealed a nontender, nonerythematous, fluctuant mass without crepitus that was fully reducible by manual pressure, as demonstrated by Video 1. He underwent repeat CT chest (Figure 1), which revealed large right-sided pneumothorax which communicated with extrathoracic wall, suggestive of pneumothorax necessitans. Subsequent chest tube placement led to improvement in pneumothorax and chest wall mass.

DISCUSSION: This report highlights the physical and radiologic examination features of pneumothorax necessitans, a potential complication of empyema thoracis. The hallmark of pneumothorax necessitans is a large, painless, chest wall mass that is fully reducible.

CONCLUSIONS: While there have been a few published case reports describing this condition, to our knowledge, this is the video depicting physical examination findings. Prompt recognition of this entity would help deter additional procedures.

Reference #1: Tripathi, S.P., Massad, M.G., Mehta, V.K., Benedetti, E., Geha, A.S. Pneumothorax necessitans presenting as a presternal pneumothoracocele. Annals of Thoracic Surgery. 2000;69:266-267.

Reference #2: Kuan YC, SH, How, et.al. Empyema thoracis complicated by pneumothorax necessitans manifesting as lobulated, localized subcutaneous emphysematous swellings. Annals of Thoracic Surgery. 2011 Jun; 91(6):1969-71.

DISCLOSURE: The following authors have nothing to disclose: Ravish Singhal, Saleem Shahzad

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