Q J Med 2015; 108:513–514 doi:10.1093/qjmed/hcu241 Advance Access Publication 29 November 2014

Clinical picture Empyema thoracic necessitans mimicking a tuberculoma gossypibomas, oleothorax, neoplasms, migration of inhaled foreign body and complication of tube thoracostomy placement. The current therapeutic strategy is to treat the causal agent and predisposing factors. Surgical repair is indicated only when symptoms are not controlled by medical management. In our case we use, as a diagnostic and therapeutic strategy, the positioning of a pleural drainage under ultrasound guidance with a minimally invasive technique. We have inserted a 14F small-bore percutaneous pigtails catheter (COOK Medical, Bloomington, Indiana, USA) in polyurethane. The pleural fluid’s aspiration revealed three hundred millilitre of a pale creamy fluid, consisting of a lymphocytic exudate pH 7.11, and subsequent pleural fluid culture was positive for sensitive Mycobacterium tuberculosis. The patient underwent surgical incision, drainage of the abscess and Video-Assisted Thoracic Surgery drainage of the pleural collection.

Figure 1. (A) Mass along axillary line. (B) Empyema thoracic necessitans at the CT scan imagine.

! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]

Downloaded from by guest on November 16, 2015

An 86-year-old man presented with fever and a mass along the axillary line (Figure 1A). His medical history was silent except for a non well-defined pleural disease 60 years before. First, a thoracic ultrasound and after a computed tomography (CT) scan (Figure 1B) demonstrated a well-defined mass of the chest wall with a fistulous tract that connects the subcutaneous collection to the pleural cavity (arrowheads). The diagnosis is that of an empyema thoracic necessitans aroused many decades after primary tubercular infection. It occurs when the infected fluid dissects spontaneously into the chest wall from the pleural space break creating a pathologic communication between the pleural cavity and the subcutaneous tissues. First described in 1640 by Gullan De Baillon when it developed after the spontaneous rupture of a syphilitic aneurysm, empyema necessitans is a rare entity today. The causes are infectious processes (pulmonary tuberculosis and chronic empyema),

514

Clinical picture

Standard anti-tuberculous therapy was begun and patient condition quickly improved. This case draws our attention to a very rare complication of pulmonary tuberculosis and its treatment. Photographs and text from: B. Lorenzati, Emergency Department, Emergency Medicine, ASO S. Croce e Carle, Cuneo, Via Coppino, Italy; A. Landi, L. Scaglione and E. Rolfo, Medicine Department, Internal Medicine, Azienda OspedalieroUniversitaria Citta della Salute e della Scienza, Torino, Corso Bramante, Italy; R. Cristofori, Surgery Department, Thoracic Surgery, Azienda Ospedaliero-Universitaria Citta della Salute e della

Scienza, Torino, Corso Bramante, Italy. email: [email protected] Conflict of interest: None declared.

References 1. Davies HE, Davies RJ, Davies CW. BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii41–53. 2. Gomes MM, Alves M, Correia JB, Santos L. Empyema necessitans: very late complication of pulmonary tuberculosis. BMJ Case Rep 2013; 2013.

Downloaded from by guest on November 16, 2015

Empyema thoracic necessitans mimicking a tuberculoma.

Empyema thoracic necessitans mimicking a tuberculoma. - PDF Download Free
157KB Sizes 0 Downloads 4 Views