A 50-year-old, male patient presented during the day for an urgent consultation. For over 10?weeks, he had had a history of high-grade fever (39°C), cough with mucopurulent expectoration, shortness of breath, right-sided chest pain, weight loss (>10%) and night sweats. General examination showed a thin body build, pale skin and extreme dyspnoea with oxygen saturation of 77%. An examination of the chest revealed air and fluid in the pleural space on the right side of the body. All other systems were checked and were all clinically normal. A posteroanterior chest radiography was performed and showed an air–fluid level in the right hemithorax and a minimal shift of mediastinum towards the left.
A sputum sample was collected and examined by Neelsen staining. Based on the radiography findings, a computed tomography body scan and a chest ultrasound were requested to guide pleural puncture. Routine blood and urine tests and a thoracentesis were performed. Approximately 1050?mL of pleural liquid was obtained and samples were sent to the laboratory, for the culture of pleural pus on Lowenstein Jensen medium and incubated for a period of 2?months. Routine blood tests revealed 91% lymphocytes, 8.9?g?dL?1 haemoglobin, and 10?000 leukocytes per mm3 with 78% neutrophils and 7% eosinophils. Urine test results were normal. There was a 17-mm positive Mantoux reaction. Ziehl Neelsen staining of sputum showed acid-fast bacilli and culture of pleural pus on Lowenstein Jensen medium showed rough, dry and raised colonies with a wrinkled surface. Microscopy and culture of pleural fluid did not show any other fungus or bacteria. Pyopneumothorax is an uncommon condition with a combination of air and pus within the pleural space. Frequently, emphysema may precede a pneumothorax but certain underlying conditions, like tuberculosis, may increase the risk of chronic lung and some pleural diseases. Usually, tuberculosis with pyopneumothorax determine complications due to the rupture of a cavity into the pleural space so these complications make the treatment management even more difficult. The tuberculosis treatment must be given as national protocols require.
Typically, the treatment for pyo-pneumothorax is therapeutic thoracentesis with wide drainage and general antibiotics suitable for the identified organisms. This treatment needs to be given for almost 2?months. If these methods of treatments fail, surgical evaluation may be required. Isoniazid, rifampicin, ethambutol and pyrazinamide daily for 2?months (2 HRZE 7/7) followed by 4?months of isoniazid and rifampicin given three times a week (4 HR 3/7) is appropriate to treat pulmonary tuberculosis in a new case using treatment regimen 1. Drug doses were adapted to the weight of the patient according to national guidelines. Based on the clinical and paraclinical findings, this was confirmed to be a rare case of pyopneumothorax in an active tuberculosis patient. There was good clinical response to antituberculous therapy.Dr. Petru-Emil Muntean, MD, Masters Degree
Breathe (Sheff) 2018 Mar;14(1):43-48
Pulmonology, Spitalul Clinic Judetean Mures, Targu Mures, Romania.
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