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Pulmonary puzzle
A 76-year-old lady with chronic cough and a discharging chest wall sinus
  1. Mandar Deshpande1,
  2. Ajay Kamath1,
  3. Kieren Allinson2,
  4. Danielle Peat2,
  5. Wyn Parry3
  1. 1Department of Respiratory Medicine, Norfolk & Norwich University Hospital, Norwich, UK
  2. 2Department of Histopathology, Norfolk & Norwich University Hospital, Norwich, UK
  3. 3Department of Thoracic surgery, Norfolk & Norwich University Hospital, Norwich, UK
  1. Correspondence to Dr Mandar Deshpande, Specialty Registrar, Department of Respiratory Medicine, Norfolk & Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK; mandar.deshpande{at}nnuh.nhs.uk

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A 76-year-old lady was referred to the respiratory clinic with a 6-month history of a discharging left chest wall sinus. She also had a 6-month history of dry cough, left chest wall pain and breathlessness. There was no history of fever, haemoptysis, weight loss or night sweats. She was a lifelong non-smoker and there was no history of asbestos exposure.

Investigations showed elevated white blood cell count of 14.5×109/l (neutrophil count 11×109/l) and C reactive protein 87 mg/L; renal and liver function tests were normal. Sputum cultures were negative.

She had a laparoscopic Nissen fundoplication 12 years earlier, complicated by perforation of the oesophagus. Subsequently, 6 years later, she developed dyspnoea; a chest x-ray at this time revealed a left-sided pleural-based abnormality. A thoracoscopic biopsy suggested benign pleural thickening/fibrosis. After thoracoscopy, she developed a discharging sinus around the access port site, which was excised.

The patient then relocated to the region and presented with a persistent discharge from the original chest wall sinus. Oral penicillin was …

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