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Management of a complex thoracic infection, one compartment at a time
  1. Ahmed Elhoffy,
  2. Alaa Amin,
  3. Ahmed S Sadaka,
  4. Maged Hassan
  1. Department of Chest Diseases, Alexandria University Faculty of Medicine, Alexandria, Egypt
  1. Correspondence to Dr Maged Hassan, Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt; magedhmf{at}

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A Elhoffy

I would like to present the case of a patient admitted to a tertiary hospital in Egypt with symptoms of lower respiratory tract infection. The interpretation of the patient’s baseline imaging and the decision regarding the best management were challenging. A man aged 28 years attended the emergency department with a 4-week history of symptoms of cough productive of small volumes of yellowish sputum, worsening chest pain and dyspnoea and few days’ history of vague left upper quadrant abdominal pain and constipation. He had a background of bronchial asthma and was a cigarette smoker, but he denied intravenous drug use. On examination, he was afebrile. Reduced breath sounds were noted on the left side and his abdomen was lax. Blood tests showed a C reactive protein (CRP) of 173 mg/L, a white cell count (WCC) of 11.5×109/L, platelet count of 662×109/L and serum albumin of 20 g/L. A chest radiograph showed multiple air fluid levels on left side with inconspicuous lung markings (figure 1A). He went on to have an urgent CT scan of the chest (figure 1B–E and online supplemental video). A test for human immune deficiency virus came back negative and a transthoracic echocardiogram was unremarkable.

Supplementary video

Figure 1

(A) Admission chest radiograph showing two air-fluid levels on the left side, with contralateral mediastinal shift and right upper zone cavitary lesion. (B) CT of the chest, axial cut in lung window confirming a right upper lobe abscess and an air-filled cavity replacing the left upper lobe. (C) CT chest, axial cuts, showing compressed residual upper lobe with encysted hydro-aerial lesions anteriorly and posteriorly. (D) CT chest, axial cuts, showing the extent of the posterior hydro-aerial lesion. Note the outer margin of the fluid collection with air intervening between fluid and the chest wall (arrows). (E) CT chest, …

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  • Contributors All authors treated the patient. AA and MH collected the images of the report. AE and MH co-wrote the manuscript. All authors reviewed and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.