CASE 5246 Published on 07.02.2008

Bronchiectasis complicated with pyopneumothorax

Section

Chest imaging

Case Type

Clinical Cases

Authors

Upadhyay S, Gupta S, Pujara K, Tripathi S.

Patient

41 years, male

Clinical History
A 41 year old gentleman known to have bronchiectasis presents with 4 day history of cough with purulent sputum, shortness of breath and haemoptysis.
Imaging Findings
A 41 year old gentleman presented to hospital with 4 days history of increasing shortness of breath (MRC dyspnoea scale-5), cough with green sputum and two episodes of haemoptysis. Patient had a past medical history of :- 1) left sided empyema 20 years ago which was drained and treated with antibiotics, 2) Bronchiectasis was diagnosed 4 years ago when HRCT revealed extensive bronchiectatic changes and volume loss in left lower lobe and minor changes in right middle and lower lobe. On this admission examination revealed tachycardia with pulse of 120/ min. and regular, pyrexia of 38 degree C, hypoxia with oxygen saturation of 89 % on air, respiratory rate 30 / minute and blood pressure 120/75 mm Hg. Respiratory system examination showed stony dullness and absent air entry in left hemithorax. Inflammatory markers were raised - white cell count 20.5 *109/l (neutrophils 17.9 *109/l), CRP 311 mg/l on routine blood examination. Urea and electrolytes were normal. Arterial blood gas FiO2 35 % - pH 7.39, pCO2 -5.46, pO2 -13.32, HCO3 -24.6, base excess -0.2. CXR revealed complete white out of left hemithorax and mediastinal shift to opposite side raising the possibility of massive pleural effusion or empyema. CT thorax revealed left pyopneumothorax. Patient was treated initially with left intercostal drain, intravenous antibiotics and then had a limited decortication and was to be considered for lobectomy at a later stage.
Discussion
Bronchiectasis has been defined as the abnormal and permanent dilatation and distortion of conducting bronchi and airway. Laennec first described it in1819. Bronchiectasis is categorized in the spectrum of chronic obstructive pulmonary disease (COPD); it is characterized by inflamed airways which collapse easily resulting in the air outflow obstruction and impaired clearance of the secretions. Its prevalence increases with age and it is more common in females. This damage can be congenital or may be acquired. Various factors like cigarette smoking, foreign body aspiration, rheumatic disease etc. all contribute to the damage. Usual clinical manifestations include cough, dyspnoea, wheezing and daily production of mucopurelent sputum, lasting for months to years and frequent visits to the hospital with repeated courses of antibiotic treatments. Patients with bronchiectasis have a longer duration of symptoms during exacerbations of COPD, a greater burden of pathogenic bacterial pathogens in the lower airway, and increased sputum inflammatory markers but the frequency of attacks is not increased.1 CXR is abnormal in 90% of cases. Abnormal findings include increased bronchovascular markings from peribronchial fibrosis and intrabronchial secretions, tram lines (parallel lines outlining dilated bronchi due to peribronchial inflammation and fibrosis), honeycombing, cystic areas with or without fluid levels and rib crowding from an atelectatic lung. High Resolution Computed Tomography (HRCT) is the gold standard test with sensitivity of 97%. Specific abnormality seen is dilation of airway more than 1.5 times the normal diameter.2 HRCT also shows 'signet ring' sign which is cross-sectional appearance of dialated bronchus abutting the pulmonary artery.3 Non specific abnormalities include airway dilation, bronchial wall thickening, plugging of airways by mucus, cysts indicating destructive disease. Other HRCT findings are lack of bronchial tapering, visualizing of bronchi within 1cm of costal pleura and adjacent to mediastinal pleura. Pulmonary function tests are done to assess the functional impairment due to the disease. Treatment options include aggressive treatment of the acute episode with appropriate antibiotics for 7 to 10 days. Most commonly identified bacteria include H influenza, P aeurginosa and streptococcus pneumoniae. Facilitating removal of respiratory secretions in patients with bronchiectasis is beneficial.4 Role of surgery is in removal of segments that are significantly damaged by the disease and are suspected in contributing to exacerbation, mucus impaction and in areas resulting in uncontrolled hemorrhage. There is role in removing damaged lung involved with multi-drug resistant organism like Mycobacterium Tuberculosis.5 Lung transplantation is an option in advanced disease especially in cases associated with cystic fibrosis. Complications include recurrent pneumonia requiring hospital admissions, lung abscess, empyema, haemoptysis, progressive respiratory failure and corpulmonale. . Last two complications are most common causes of pulmonary related deaths in bronchiectasis.
Differential Diagnosis List
Bronchiectasis complicated with left pyo-pneumothorax.
Final Diagnosis
Bronchiectasis complicated with left pyo-pneumothorax.
Case information
URL: https://eurorad.org/case/5246
DOI: 10.1594/EURORAD/CASE.5246
ISSN: 1563-4086