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Chest clinic
Images in Thorax
Rapid-growth pneumatocele mimics massive pneumothorax in a HIV-positive patient
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  1. Min-Shiau Hsieh1,2,
  2. Chun-Ku Chen3,
  3. Wing-Wai Wong4,5,
  4. Chien-Sheng Huang1,6
  1. 1Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
  2. 2Department of Surgery, National Yang-Ming University Hospital, Yilan, Taiwan
  3. 3Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
  4. 4AIDS Prevention and Research Center, National Yang-Ming University, Taipei, Taiwan
  5. 5Division of Infectious Diseases, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
  6. 6National Yang-Ming University School of Medicine, Taipei, Taiwan
  1. Correspondence to Dr Chien-Sheng Huang, Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, No 201 Section 2 Shih-Pai Road, Taipei 112, Taiwan; huangcs{at}vghtpe.gov.tw

http://dx.doi.org/10.1136/thoraxjnl-2012-201990

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    Learning points

    • A fast-growing giant pneumatocele can develop in the HIV-positive patient with suspected PCP infection complicated with pneumothorax and compromised pulmonary reserve. CT scans might be helpful for differential diagnosis.

    • Surgical intervention by video-assisted thoracoscopic surgery for unroofing the pneumatocele and pleurodesis might be an effective treatment to resolve the respiratory comprise and pneumothorax.

    We present a rare fast-growing giant pneumatocele in a patient presenting with suspected pneumocystis pneumonia (PCP) infection and bilateral pneumothoraces as a primary manifestation of AIDS (HIV viral loading test: 628 000 copies/ml). Tube thoracostomies were performed and complicated with enduring air leakage and subcutaneous emphysema. Follow-up chest x-rays showed an enlarging radiolucency over the left upper lung field that was interpreted as massive pneumothorax with passive lung atelectasis. Positive ventilation was also applied due to disease progression (The CD4+ T-lymphocyte count was 18/cu mm). Repeated chest CT scans disclosed a newly formed giant bullous-liked lesion in the left upper lung field (figure 1). Video-assisted thoracoscopic surgery for unroofing the cystic lesion (pneumatocele) and pleurodesis successfully allowed the patient to wean from the ventilator and be discharged uneventfully (figure 2).

    Figure 1
    Figure 1

    (A) Chest CT scan on Day 1: showed symmetric bilateral perihilar ground-glass opacity with predominant upper and middle lung zone involvement; (B) chest radiograph on Day 14 showed spontaneous bilateral pneumothoraces; (C) chest radiograph on Day 18 depicted enlarging radiolucent area in bilateral lung fields with further collapse of both lungs and extension of subcutaneous emphysema, progressive pneumothorax with passive lung atelectasis; arrows indicated the new giant pneumatocele already formed; (D) repeated chest CT disclosed a giant cystic lesion in the left lung. This figure is only reproduced in colour in the online version.

    Figure 2
    Figure 2

    Intraoperative findings: (A) a giant bullous lesion (pneumatocele) compromised the residual pulmonary parenchyma; (B) necrotic debris inside the pneumatocele which revealed only coagulase negative staphylococcus species infection; (C) unroofing the pneumatocele by video-assisted thoracoscopic surgery; (D) trimming of the margin of pneumatocele with healthy parenchyma to minimise the air leakage. This figure is only reproduced in colour in the online version.

    Discussion

    HIV with PCP infection complicated with necrotising alveolitis in the subpleural pulmonary parenchyma that resulted in pneumothorax and pneumatocele have been well reported.1 ,2 Nonetheless, a rapid-growth giant pneumatocele could be misinterpreted as massive pneumothorax without expectation.

    References

    1. ↵
      1. MacDuff A,
      2. Arnold A,
      3. Harvey J
      . Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(Suppl 2):ii18–31.
      OpenUrlFREE Full Text
    2. ↵
      1. Huang L,
      2. Cattamanchi A,
      3. Davis JL,
      4. et al
      . HIV-associated Pneumocystis pneumonia. Proc Am Thorac Soc 2011;8:294–300.
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    View Abstract

    Footnotes

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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