From Highs to Lows: Plastic Wrapper Pyopneumothorax

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Am J Respir Crit Care Med

Keywords

alcohol, amoxicillin, antibiotic agent, cefepime, metronidazole, vancomycin, abnormal respiratory sound, adult, aged, alligator forceps, altered state of consciousness, anemia, asthma, bronchoscope, bronchoscopy, case report, chest tube, clinical article, community acquired pneumonia, complication, conference abstract, decortication, dentition, double lumen tube, drug combination, drug therapy, empyema, endotracheal tube, female, foreign body, foreign body aspiration, Fusobacterium nucleatum, hemidiaphragm, human, hydropneumothorax, intestine flora, intravenous drug administration, leukocytosis, nausea and vomiting, obstructive pneumonia, pleura empyema, pleura fluid, pleura thickening, pneumonic effusion, pyopneumothorax, respiratory distress, right lung, risk factor, Streptococcus constellatus, surgery, therapy, thoracocentesis, thoracoscopy, thorax radiography, thrombocytosis, videorecording

Abstract

Introduction: Post-obstructive pneumonia and subsequent empyema is a recognized, yet under described complication of endobronchial obstruction. It occurs in approximately 2 - 5% of patients hospitalized for community acquired pneumonia, and in adults it is typically due to malignancy. Here we describe a 42-year-old female who developed a variant of thoracic empyema known as pyopneumothorax, due to an aspirated foreign body. Case Description: A 42-year-old female with history of asthma and opioid use disorder presents with nausea and vomiting that began 8 weeks prior to admission. Vitals were stable and she appeared to be in mild respiratory distress with diminished breath sounds at the right mid to lower lung fields. She had leukocytosis, thrombocytosis and anemia. CXR identified elevated right hemidiaphragm with lucency suggestive of hydropneumothorax. CT chest/abdomen demonstrated an 18.5 cm loculated fluid collection in the right hemithorax with air fluid level suggestive of chronic empyema and pleural thickening. She was initiated on cefepime, vancomycin, and metronidazole. Thoracentesis drained 2 liters of pus and pleural fluid cultures grew Streptococcus constellatus and Fusobacterium nucleatum. She was taken to the operative room for video-assisted thoracoscopy and right pulmonary decortication. Bronchoscopy revealed a foreign body within the right mainstem bronchus with complete occlusion. A plastic wrapper, measuring about 1 inch long, was successfully removed from the right mainstem bronchus using alligator forceps en bloc with the bronchoscope and endotracheal tube. The patient was subsequently reintubated with a double lumen tube and underwent successful irrigation, decortication and chest tube placement of the right chest. Antibiotics were continued and following resolution of air leaks the chest tubes were removed. She was successfully discharged home with 4 weeks of amoxicillin. Discussion: Risk factors for foreign body aspiration are childhood or elderly age, poor dentition, trauma or altered mental status in this case from alcohol or drugs. A possible complication of aspirated foreign body is post-obstructive pneumonia which occurs distal to the obstruction and can progress to parapneumonic effusion and empyema. In the presented case, pleural fluid cultures grew Streptococcus constellatus, a gram-positive facultative anaerobe found in oral and gut flora, and Fusobacterium nucleatum a gram-negative obligate anaerobic periodontal pathogen. If left untreated the developing empyema may become compartmentalized or loculated. In the organizing phase, a fibrinous pleural peel may encase the lung, with the potential to restrict respiration. With appropriate antibiotics and drainage these complications can be avoided.

Volume

211

Issue

Supplement 1

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