The patient was a 47-year-old man, sport teacher, referred to us for a persistent respiratory distress. He was taken to a city hospital 3 days before admission for severe acute respiratory distress and chest pain. A chest X-ray done in that hospital revealed a pneumothorax on the right side, and a chest tube was then inserted. Despite the presence of the indwelling chest tube, the patient continued to complain of dyspnoea and later developed subcutaneous emphysema. A chest CT scan was then requested to look for the possible cause of the pneumothorax. It revealed a massive pneumothorax with subcutaneous emphysema on the right side associated with a typical complex aspergilloma cavity well defined at the right lung apex (Figures 1 and 2). The patient was then referred to our hospital for further management.
On arrival, he was conscious, alert, and oriented in time and space but dyspnoeic, presenting with signs of respiratory distress. The vital parameters on arrival revealed the following: blood pressure: 136/93 mmHg, heart rate: 86 beats/min, respiratory rate: 28 cycles/min, temperature: 38.5 C, and oxygen saturation: 79% on 6 l/min of nasal oxygen. There was massive air in the drain. A second chest drain was inserted. As a sport teacher, he did exercises regularly. He was treated for pulmonary tuberculosis 2 years back and was declared healed. Elsewhere, his past medical and surgical history was unremarkable. He had no specific complaints for 2 years and had been fine ever since. He also complained of cough and blood-stained sputum.
The physical exam revealed an anxious patient with severe dyspnoea and massive subcutaneous emphysema (diffuse subcutaneous air with tympanic chest, all over the trunk and the cervical and scrotal regions as seen in Figure 3). Despite insertion of the second drain, there was still a persistent significant air leak with hypoxia. A preoperative workup was thus quickly done and revealed a hemoglobin count of 14 g/dl, a negative HIV serology, and a normal coagulation profile. The other laboratory results were normal, and the patient was taken to the operating room for a thoracotomy one day after admission. The patient underwent a right thoracotomy under general anaesthesia with a selective lung intubation obtained by the regular endotracheal tube pushed in the left lung. We carried out a small posterior muscle-sparing incision of 14 cm and entered the chest at the fifth intercostal space as previously reported. Perioperatively, we found massive pleuropulmonary adhesions in the mediastinal region. The upper and middle lobes were totally collapsed, fibrotic, and very small. The lower lobe had less adhesions and was thus freer. A decortication was done with caution. We found chronic pulmonary aspergillosis (aspergilloma cavity containing the fungal ball) in the right upper lobe. The entire right upper lobe had been replaced by the aspergilloma and directly connected to the main bronchus. The middle lobe was fibrotic and diffusely diseased. There were no visible bullae (Figure 4).
We did a double lobectomy: upper and middle. There was bleeding of moderate volume due to the decortication. Only one drain was left in place, and the simple drainage system that we have reported was used, which uses respiratory movements and gravity. The drainage system was left open on the first day and converted to a closed system 3 days after the surgery. He received amoxicillin and clavulanic acid as antibiotics for 72 hours, tramadol and diclofenac for pain control, and enoxaparin for prevention of deep venous thrombosis. He resumed regular diet the same day after surgery and was out of bed the next day. Incentive spirometer was done having the patient blows in a rubber glove. The chest tube was removed on post-op day 5, and the patient was discharged 6 days after surgery. The pathology report confirmed the aspergilloma with no signs of active tuberculosis. He was seen as outpatient for regular follow-up and did not receive any more antituberculosis medication because the pathology did not show signs of persistent active disease; this was confirmed on the follow-up chest radiograph 17 months later (Figure 5).