A 23-year-old man was admitted in a local general hospital on Dec. 12, 2015, because of complaints of chest tightness, shortness of breath, and dyspnea starting a week prior. He was diagnosed as bilateral tuberculous pleural effusion. Anti-tuberculosis treatment with four drugs (rifampin, isoniazid, pyrazinamide, and ethambutol) and thoracentesis therapy were given, and the specific volume of fluid was unknown. After a month the patient stopped pyrazinamide by himself. The left pleural effusion was controlled, but the right pleural effusion recurred repeatedly. Because of chest tightness and wheezing, the patient was referred to our hospital on March 29, 2016. Pyrazinamide rejoined the anti-TB regimen. On the day of admission and April 3, about 500 ml and 300 ml of pyogenic pleural effusion were respectively removed from the right pleural cavity, and operations were forced to stop because of severe chest pain. Ultra-sonography guided thoracentesis and thoracic close drainages were done, but there was no effect. Chest CT still showed right thoracic pleural effusion (Fig. 1) and pleural purulent fluid grew Mycobacterium tuberculosis until June 2016. However, the patient refused VATS and traditional thoracotomy. Therefore, we injected anhydrous ethanol into pleural cavity after getting the patient's consent on July 5, 2016. Pyothorax was controlled after 6 intrapleural injections of anhydrous ethanol. Table 1 shows volumes, methods of draining and characteristics of pleural effusion.
Intrapleural injection of anhydrous ethanol: After obtaining the patient's consent, centesis of pleural effusion guided by color Doppler ultrasound was performed. The first step: drain pleural fluid as much as possible; The second step: normal saline was injected into and drawn away from the pleural cavity. The amount of normal saline used for irrigation of the pleural cavity was the same volume as pus removed (For example, if we draw out 100ml pus, we should inject 100ml normal saline into the pleural cavity). We washed the pleural cavity with normal saline in order to determine whether the patient had bronchopleural fistula. The third step: 10-15 ml of anhydrous ethanol was injected every time, rinsing the pleural cavity repeatedly (Fig. 2), until the liquid was clear. No normal saline was used in this process. Finally: 10-15 ml of anhydrous ethanol was retained in the pleural cavity, waiting for the next fluid extraction.
We repeated the procedure every 1-2 weeks in the first month and every 2-4 weeks in the following months until color Doppler ultrasound showed no pleural effusion. It should be stressed in particular that we must observe whether the patient has a severe cough while washing the pleural cavity with normal saline. If the patient coughs out salty liquid, it suggests that the patient may have bronchopleural fistula, and we should stop washing the pleural cavity and the injection of anhydrous ethanol. If necessary, intrapleural injections of methylene blue will further confirm whether there is bronchopleural fistula or not. Of course, it is best to ask patients if they have any history of alcohol allergy before intrapleural injection of anhydrous ethanol.
The patient stopped antituberculous treatment in June 2017 and finally recovered fully. Re-examination of lung CT showed that the patient's right pyothorax was significantly improved on February 23, 2018 (Fig. 3). Meanwhile, color Doppler showed only pleural thickening without pleural effusion.