A 45-years-old woman complained of coughing with purulent sputum up to 500 ml per day, dyspnea at rest, fever up to 38  C, sweating, weakness, lack of appetite, and weight loss, and she was admitted in Sechenov University Clinic for Phthisiopulmonology in 2015. She had contact with a neighbor regarding TB.
In 2002, destructive TB with right lung seeding and smear-positive findings were detected by a local hospital physician after the patient complained of cough and hyperthermia. Antituberculars were administered. However, during treatment, the undulating progression accompanied with formation of the fibrotic cavities in the right lung and left upper lobe was observed, and then total empyema occured on the right with bronchopleural fistula. In 2008, after mycobacterial TB (MTB) drug resistance was determined, different treatment regimens were prescribed. The patient received TB therapy until 2015 but with low adherence. The patient was consulted several times by thoracic surgeons in various institutions. Surgical treatment was considered to be contraindicated due to disease progression and low respiratory reserves.
The patient was brought to our clinic in severe condition. On examination, she had pale skin, was underweight (body mass index [BMI] of 16.6 kg/m2), and had dyspnea at rest (respiratory rate of 27 per minute). During chest percussion, on the right tympanic sound was heard in all fields of the right lung up to the VII rib level, but only until the subclavian region in the left lung. On auscultation, no breath sounds were heard on the right lung, and amphoric breathing with rales in the upper sections were heard on the left lung.
Computed tomography (CT) revealed complete collapse of the right lung and total pleural empyema with a liquid level. On the left lung, a giant fibrotic cavity of up to 15 cm in diameter with a liquid level occupied almost the entire upper lobe (Fig. 1A-D). It was surrounded by foci of various sizes.
Values of spirometric parameters vital capacity (VC) and forced expiratory volume in 1 s (FEV1) were 1.41 L(41 %) and 0.74 L(25 %), respectively. The partial pressures of blood gases were 63 mmHg and 44 mmHg for pO2 and pCO2, respectively. The 6-minute walking test (6MWT) distance was 270 m. Fibrobronchoscopy revealed bilateral purulent endobronchitis. Blood tests showed leukocytosis 11.7 x 1012/L., erythrocyte sedimentation rate (ESR) of -54 mm/h, ALT 132Units/L. Acid-fast bacilli were found in the sputum. MTB presence and XDR were confirmed by culture methods.
Considering the aforementioned findings, the patient was diagnosed with smear-positive bilateral fibrotic-cavitary pulmonary XDR TB complicated with total chronic pleural empyema on the right lung, cachexia, chronic bronchitis and respiratory failure was diagnosed without difficulties. Moreover, the patient had chronic viral hepatitis C.
The prognosis without surgical treatment was extremely poor. Patients with destructive TB of a similar prevalence in the presence of XDR die within 1-3 years. Considering the vital indications and the patient's attitude, the consulium of surgeons, phthisis pulmonologists, and anesthetists decided to perform a multi-stage surgery.
The first stage was carried out in September 2015. It included draining of the empyema cavity on the right lung and transsternal transmediastinal right main bronchus occlusion (Giller D.B.). The operation time was 125 min, and blood loss was 50 ml.
Histological examination of the removed main bronchus specimen of the revealed active bronchial TB. Local draining of the empyema cavity was continued in the postoperative period. The patient's condition improved significantly, dyspnea decreased, the sputum amount did not exceed 50 ml per day, and body temperature returned to normal. At 2 months after the first stage of surgery, despite the decrease in VC and FEV1, exercise tolerance increased significantly. VC and FEV1 values were 1.14 L (33 %) and 0.74 L (22 %), respectively; pO2 and pCO2 were 72 mmHg and 44 mmHg, respectively; and the 6MWT distance was 440 m.
In November 2015, the second stage of surgical treatment was carried out. Upper lobectomy with partial S6 resection was performed on the left lung (Giller D.B.) (Fig. 2A). The operation time was 260 min, and the blood loss was 600 ml. The lung was exposed to the hilum from a total dense, bleeding adhesions. The interlobar fissure was roughly consolidated. The cavern penetrated the upper lobe in the S6 projection. The upper lobe vessels were exposed, ligated, and intersected separately. The upper lobe bronchus was stapled and additionally manually sutured with atraumatic sutures. A giant cavern was found in the resected specimen (Fig. 2B). Histological study verified fibrotic-cavitary TB and upper lobe bronchus TB. Delayed lung expansion occured in the postoperative period (Fig. 2C).
After 1 year, CT scan showed a completely expanded lung (Fig. 2A, D). The disabled right lung was collapsed, and the empyema cavity was filled. Functional condition improved. As a result, VC and FEV1 values were 1.42 L(41 %) and 0.98 L(33 %), respectively. The partial pressures of blood gases were pO2-67 mmHg and pCO2-43 mmHg, and the 6MWT distance was 425 m.
The third stage of surgery was performed during the Moscow International Conference of Thoracic Surgeons. Pleuropneumonectomy was performed on the right lung (Giller D.B., Ruckert J.C.). The operation time was 180 min, and the blood loss volume was 550 ml.
The resected specimen included the destroyed right lung and empyema cavity (Fig. 3A). Histologically, TB was confirmed. The postoperative period was uneventful, and TB chemotherapy was continued. The patient was discharged in satisfactory condition with a completely filled postpneumonectomy cavity (Fig. 3B).
At follow-up two years and 10 months after the surgery, the patient's condition was good. She gained 19 kg of body weight (BMI of 23.2 kg/m2), and she had not experienced productive cough. CT did not detect signs of TB reactivation (Fig. 3C.D). MTB was not detected in the sputum in every examination following the second stage. Spirometry parameters VC and FEV1 amounted to 1.37 L(40 %) and 0.95 L(32 %), respectively. The partial pressures of blood gases were pO2-77 mmHg and pCO2-39 mmHg, and the 6MWT distance was 420 m. The patient easily did the work at home, went shopping, went to the 3rd floor without stops. The patient was pleased of the treatment outcomes.