A 41 year old gentleman presented to the Emergency Department of a General Hospital complaining of sudden onset left sided chest pain. He has no past medical or surgical history. He is a smoker with a 25 pack year history.
Chest radiograph was reported as a large left sided pneumothorax. This was treated with insertion of a 28 Fr chest drain. Due to the acute presentation with significant respiratory sepsis, it was not possible to perform valid pulmonary function tests on this patient. During his hospital stay, he continued to have a significant air leak and his lung failed to re-expand fully.
On day 7 of admission, he spiked a temperature of 38.2  C and became septic. His chest radiograph showed a left sided pleural effusion raising the suspicion of an empyema. Sampling of his pleural fluid was turbid looking with a pH of 6.96. He was subsequently referred to our tertiary referral centre on day 10 for further management (Fig. 1).
On arrival, the patient was severely dyspnoeic and febrile but otherwise haemodynamically stable. His physical examination was unremarkable apart for decreased air entry to the left lower zone which was dull to percussion.
Hb 12.7 g/dL, WCC 13.9 x 109/L, alpha-1 antitrypsin was negative.
CT thorax was performed and reported as a large loculated left sided hydropneumothorax with fluid in the base and large pneumothorax locules/complex bullous lung disease compressing the upper lobe. The right lung was normal. He was commenced on broad spectrum antibiotics - Flucloxacillin, Vancomycin, and Pipperacillin/Tazobactam - as per microbiology advice with minimal improvement (Fig. 2).
We proceeded to perform emergency left posterolateral thoracotomy and decortication with lung volume reduction surgery. Preoperative V/Q testing is not used as a routine preoperative investigation at our institution and thus was not performed. His operative findings showed multiple giant bullae in the upper lobe, and a lower lobe with thick pleura that was decorticated. Note that this patient's preoperative flexible bronchoscopy was normal. Due to significant bullous disease and adhesions due to the empyema, it was considered too risky to perform a thoracoscopic debridement on this patient.
Histopathology report of surgical samples contained a left apical bullae measuring 4.7 x 2 x 1.5 cm and another left lung bullae measuring 11.8 x 6.5 x 3 cm. Microscopic examination of these bullae confirmed large airspaces lined by variably thickened but uniformly fibrotic walls. Decorticated parietal pleura were also sent showing fibrotic and thickened pleura with surface fibrin, mesothelial cell hyperplasia and eosinophils with scattered lymphoid aggregates. There was no evidence of malignancy.
Microbiological examination of the parietal pleura grew coagulase negative staphylococcus bacteria and was negative for acid-alcohol fast bacilli and for mycobacteria TB culture.
The patient's respiratory status significantly improved along with excellent radiological results. He was discharged on day 7 post operatively. Postoperative pulmonary function tests were not performed as the patient's respiratory status was not compromised (Fig. 3).
CT thorax showing a large left sided hydropneumothorax and giant bullae. Right lung was normal.