A 64-year-old man was admitted with a history of severe right pleuritic chest pain of a few days duration. He had been treated for diabetes mellitus and hypertension for twenty years, which were well controlled, without any complications. He also had a history of pulmonary tuberculosis, but denied alcoholism and drug abuse.
On admission, he had respiratory symptoms, including a mild cough, yellowish sputum and severe right pleuritic chest pain. He also had mild fever, with a body temperature of 37.3C, pulse rate 103/min, respiratory rate 18/min and blood pressure 150/80 mmHg. A chest examination revealed decreased breathing sound in the right lower lung. Laboratory studies revealed the following values: leukocytes 21,500/cu mm with 84% segmental neutrophil, 3% band forms, 10% lymphocyte and 4% monocytes; arterial pH 7.41, PCO2 37.5 mmHg, PO2 60.7 mmHg on room air.
The chest radiography taken on admission revealed a loculated pleural effusion, with suspicious consolidation in the right lower lung. A blood culture was obtained and treatment was started with intravenous antibiotics (cefpiramide 1 g every 12 hours and amikacin 500 mg every 24 hours). Sono-guided thoracentesis was performed. The pleural fluid contained a pus-like material: WBC > 1,000/mm3 almost PMNL; glucose 346 mg/dL; protein 4.3 mg/dL; LDH 2211 u/L. Bacteria, fungi and tuberculosis cultures were all negative, as were the blood and sputum cultures. On the fifth day of hospitalization, chest radiography revealed an air cyst and air fluid level in the right lower lung (Figure 1). On the ninth day, the size of the air-cyst had rapidly increased to about 9x11 cm in size; the air fluid level had also increased (Figure 2A).
Computed tomography of the chest was performed, and the enhanced chest CT scan showed a 9x11 cm-sized thin-walled cavitary lesion, with an air fluid level, pleural effusion and consolidation in the right lower lung (Figure 2B).
A percutaneous pig-tail catheter was inserted into the pneumatocele with the air fluid level, and foul-odored pus drained. The bacterial culture was positive for Bacteroid species, Peptostreptococcus asaccharolyticus and Fusobacterium species. On the same day, antibiotics were changed to intravenous clindamycin, 600 mg every 8 hours. On the next day, after percutaneous catheter drainage, the patient became afebrile, and the size and amount of the air fluid level of the pneumatocele progressively decreased. On the twenty-seventh day, there was no further drainage and the catheter was removed. Eventually, the patient was discharged on the thirty-sixth day of hospitalization.
(B) Enhanced chest CT scan showed a 9x11 cm sized, thin-walled cavitary lesion, with an air-fluid level, pleural effusion and consolidation in the right lower lung.