One year and seven months old female child presented with a complaint of intermittent dry cough of 3 weeks' duration associated with high grade intermittent fever and loss of appetite. She has no contact history with known pulmonary tuberculosis patients. For her above complaints, she was taken to a nearby health center where she was given antibiotics (amoxicillin syrup) for 7 days but showed no improvement. Subsequently, she was referred to our hospital, but her parents preferred to take her home. Two weeks later she presented to our institute with worsening of cough and shortness of breath. On presentation her vital signs were deranged and oxygen saturation was 70% with atmospheric air. She was in respiratory distress with grunting, intercostal and subcostal retraction. She also had absent air entry on her left posterior lower two-third of the lung field. She was also cachexic with evidence of severe acute malnutrition. Otherwise, she has no history of drug allergy, self or family history of relevant medical or surgical illness.
Her basic laboratory examinations revealed leukocytosis of 26,500 with left shift. Sputum gene x-pert for tuberculosis was negative and chest x-ray showed homogenous opacity on the left side.
With these findings, the surgeon tapped her left chest which revealed frank pus. With an impression of post pneumonic empyema thoracis, chest tube was inserted at the left triangle of safety using a feeding (nasogastric) tube due to lack of the proper thoracic tube. Upon chest drain insertion, about 100 ml frank pus was drained and her respiratory distress improved. Pleural fluid analysis revealed an increased white cell count of 16,000 with neutrophil of 77.7%. Post procedure, she was transferred to an intensive care unit and put on oxygen support as well as wide spectrum antibiotics (ceftriaxone and metronidazole). On the 2nd post procedure day after chest tube insertion, she developed a worsening of shortness of breath. Together with this, she became tachycardic (120-140 beats/minute) with muffled and distant heart sounds. For these new findings, a control chest x-ray was taken (Fig. 1) and it showed pneumopericardium with a classical "halo sign". In addition to the pneumopericardium, there was also left side pneumothorax, and a misplaced chest tube. Otherwise, the cardiac functions were reserved upon echocardiographic evaluation.
With the diagnosis of iatrogenic simple pneumopericardium with pneumothorax, the surgical team decided to manipulate the chest drain and observe her closely with conservative management. She was put on facemask oxygen, intravenous (IV) antibiotics, nutritional treatment, and analgesics. In subsequent days following the procedure, the pneumopericardium decreased and the chest drain output reduced remarkably (Fig. 2, Fig. 3). The left side chest tube was removed on the 10th day after insertion.
Subsequently, the patient showed a remarkable improvement and was discharged from the hospital in a stable condition.