A 79-year-old male presented to his primary care physician with the chief complaint of an enlarging lump on his chest. He first noticed it 2-3 days prior to presentation, and thought it had increased in size over that time. He had no pain, fevers, chills, or malaise.
The patient's past medical history was significant for tuberculosis which was treated with left pneumonectomy and thoracoplasty in 1950. He had oxygen dependent chronic obstructive pulmonary disease.
On physical examination, he had an erythematous lump on his left anterolateral chest wall. It was fluctuant and mildly tender. His temperature was 99.2 degrees Farinheit.
Needle aspiration of the lump yielded pus. An incision and drainage was performed, which revealed copious pus and a large abscess cavity, estimated to measure approximately 15 x 7 cm. On exploration and palpation of the wound, there was concern for communication with the pleural space.
A chest radiograph was obtained (Fig. 1). This demonstrated truncation and deformation of the upper left ribs with collapse of the chest wall and volume loss of the left hemithorax. The left hemithorax was nearly completely opacified and plaque like calcifications were present along the chest wall. A small amount of air was present.
Subsequently, computed tomography of the chest was performed (Fig. 2). This demonstrated absence of most of the left first through 7th ribs and distortion and collapse of the left upper thorax. The upper chest wall was apposed to the superior mediastinum. The hemithorax was peripherally calcified and filled with fluid and several air-fluid levels. Lobular areas of high attenuation tissue were contiguous with the chest wall, mediastinum and diaphragmatic surfaces. The subcutaneous abscess cavity was filled with air and fluid.
Intraoperative bronchoscopy revealed a normal right bronchus and intact left bronchial stump without evidence of bronchopleural fistula. A left thoracotomy incision was made and 2 left ribs were resected. The pleural space was filled with 400cc of pus, white necrotic material, and lobules of granular, clay-like yellow material. Following extraction of this material, an Eloesser flap was created by sewing the skin to the parietal pleura, creating a 4 x 10cm opening for pleural drainage. The patient tolerated the surgery well. 2+ Acid fast bacilli were present on AFB stain of the pleural fluid. Appropriate anti-tuberculous therapy was initiated.