Presentation
Chronic cough, intermittent night sweats and short of breath on exertion.
Patient Data
Loculated left pleural effusion.
Crowding of ribs at left mid and lower hemithorax indicating left lung volume loss.
A few attempts of pleural tapping/aspiration performed where 100 mls of straw-colored pleural effusion drained for biochemistry and cytology investigation.
Repeat chest radiograph.
Post pleural tapping chest radiograph showed multiple air-fluid levels within the loculated left pleural effusion. These are in keeping with left hydropneumothorax.
Perstent left lung atelectasis with ground glass opacity in the mid and lower zones.
Small left hemithorax with mediastinal and cardiac shift to the left side indicate left lung volume loss.
Presence of moderate to large degree of left pleural effusion, where the left pleural effusion has complex features. Left parietal and visceral pleural rind thickening and enhancement give rise to split pleural sign suggestive of left pleural empyema.
Multiple large locules of air trapped within left pleural space indicate presence of multiple internal septations as well as air introduced iatrogenically. No extra-thoracic extension of empyema.
Multiple lung fibrotic bands at left lung, especially at left lower lobe. Passive lung atelectasis in the left lower lobe due to pleural empyema.
No suspicious lung nodule, cavitation or tree in bud appearance.
No right pleural effusion.
Multiple enlarged mediastinal lymph nodes at the prevascular, aortopulmonary window and left paratracheal region.
Case Discussion
Left loculated pleural effusion with split pleura sign compatible with pleural empyema. Aspirated left pleural effusion yield positive result for tuberculous mycobacterial infection confirmed by Genexpert test (a nucleic acid amplification test, is particularly useful for extrapulmonary tuberculosis with negatively stained smear1).
The small volume of the left lung which fails to expand following pleural aspiration indicates lung entrapment. Hydropneumothorax develops due to abnormally low pleural pressure. Gas can enter the pleural cavity through aspiration puncture sites or through pleural micro-tears. The chronic trapped lung cannot expand to fill in the aspirated pleural space.
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