A 69-year-old male presented with thoracic pain, cough and fever. Past medical history consisted of diabetes mellitus, hypertension, kidney transplant (immunosuppressive regimen consisting of betalacept and sirolimus), myocardial infarction requiring the placement of a coronary stent, dual chamber pacemaker, anticoagulation for deep venous thrombosis and a laparoscopic cholecystectomy performed five months earlier in the setting of gallbladder empyema (Fig. 1).
Clinical examination revealed a blood pressure of 100/80 mmHg and a heart rate of 91 bpm. Auscultation showed decreased air entry at the right pulmonary base. Abdominal and neurological exam were normal.
Chest X-ray showed moderate sized right pleural effusion (Fig. 2). Computed tomography (CT) of the chest and the abdomen revealed right loculated pleural effusion associated with passive collapse of the lung and mediastinal pleural thickening. Nodular structures with peripheral calcifications of 23 mm and 31 mm were observed in relation with the right hepatic lobe and below the posterior costo-diaphragmatic recess respectively (Fig. 3).
Fortunately, the operative report informed iatrogenic perforation of the gallbladder and stone spillage. Furthermore, we retrieved the surgical video, so we had a high index of suspicion of complications due to spilled gallstones (Fig. 1).
Transthoracic ultrasound guided aspiration of the pleural effusion was performed. Gram negative bacteria grew in cultures. Due to patient s frailty we opted for a minimally invasive approach placing a thoracic drain guided by CT (Fig. 4). Because of the persistence of the loculated pleural effusion and the lack of clinical improvement we decided to perform a lung decortication by video assisted thoracoscopy (VATS).
The patient was operated under general anesthesia, using a double-lumen tube. The surgical team was formed by a thoracic surgery resident (operating surgeon) and a staff surgeon as an assistant. We used two 12 mm incisions and performed an extension over the place where the previous thoracostomy tube was inserted for the use of an Alexis  retractor device. After decorticating the lung, we exposed the fissure and drained a collection in the posterior costo-diaphragmatic recess, seen in the CT. During the procedure a 1 cm defect was observed in the diaphragm (Fig. 5). Remnants of gallstones were retrieved from the subphrenic space and sent for bacteriological study. We performed the closure of the diaphragm defect with a non-resorbable suture and placed two chest tubes. The procedure was well tolerated by the patient and recovered in the intensive care unit (ICU) until post-operative day 3 when he was transferred to the general ward. Bacterial culture was positive for Extended Spectrum Beta-Lactamase (ESBL)-positive Escherichia coli, susceptible to erythromycin, imipenem, meropenem and tigecycline.
Chest tubes were withdrawn on days 5 and 7 respectively. Post-operative was uneventful until day 13, when the patient breakthrough with fever. A chest CT scan and a Covid 19 test (reverse-transcription polymerase chain reaction) were performed. The chest CT revealed persistence of the right pleural effusion with spontaneous hyperdense content, suggestive of hemothorax (Fig. 6). The Covid test result was positive.
After analyzing the case in a multidisciplinary team, we decided to perform a second VATS lung decortication to evacuate clotted blood and prevent further consequences. No active bleeding was found. Chest tubes were withdrawn on day 4 and 5 respectively. Chest x ray showed no pleural effusion or pneumothorax (Fig. 7).
On post-operative day 7 the patient developed type 1 respiratory failure, with elevated breathing rate and requirement of a venturi mask at 40 % O2 to maintain blood saturation over 93 %. A new chest CT revealed multifocal ground glass patterns with thickened interlobular and intra lobular lines (Fig. 8).
The patient was presented to the palliative care specialists and the ethics committee. Due to Covid-19 outbreak and the risk of aerosolization, non-invasive positive pressure ventilation (NIPPV) was not an option. Also, the patient was tagged as "low priority" for admission to ICU, since the scarce of beds and the few chances to benefit from the ICU.
After considering the patient s preferences with his surrogates, the comfort-focused care was opted. The patient died on post-operative day 11.
CT guided thoracostomy tube placement. B) Thoracentesis needle advancing into the pleural space.