Pneumothorax Complicating Aseptic Cavitating Pulmonary lnfardion *

•

Ferris M. Hall, M.D.;•• Edwin W. Salzman, M.D.;t Burton I. Ellis, M.D.;t and GeorgeS. Kurland, M.D.§

This report documents a pulmOIIIUY infardion secondary to an angiographically proven pulmonary embolus with complicating aseptic cavitation and pneumothorax. These two I'1U'e compHcatlons of pulmonary iufudion have not previously been cHnically or radiographically documented to occur simultaneously. 1be patient recovered aneveat~·

-

of the lung and pneumothorax are unusual Cavitation complications of puhnonary embolus, particularly

when the resulting puhnonary infarction remains aseptic. Both of these complications occurred in the patient whose case report we present. Previous reports of pneumothorax complicating pulmonary infarction are reviewed.

CASE REPoRT A 43-year-old white man was admitted to the Beth Israel Hospital with a one-day history of right-sided pleuritic chest pain. Two days prior to admission, he bad noted slight swelling of the right leg. Three weeks prior to admission, the patient had undergone an uneventful right meniscectomy. A preoperative chest x-ray fUm at that time was normal. A right-sided pleural friction rub was present on admission. Findings from the remainder of the physical examination, °From the Departments of Radiology, Surgery and Medicine, Beth Israel Hospital and Harvard M~cal School, Boston. •• Assistant Professor of Radiology. tProfessor of Surgery. tResident in Radiology; presently at Henry Ford Hospital. Detroit. §Clinical Professor of Medicine. Reprint requests: Dr. Hall, Beth Israel H087Jital, 330 BrookUne

l \

2. Chest x-ray film one week after admission. Infiltrate is present in right lower pulmonary field, with 1.5 X 2cm area of cavitation within it (arrows). FIGURE

including the cardiovascular system and lower extremities, were normal. A slight elevation in temperature was present on the first day of hospitalization; the patient thereafter remained afebrile, with normal leukocyte counts. The arterial oxygen pressure was 78 mm Hg. On admission a chest x-ray fUm showed a pleural-based infiltrate 5 em in diameter in the posterior basal segment of the right lower lobe, with a small right pleural effusion. A perfusion lung scan revealed a single small defect corresponding to the radiographically demonstrated parenchymal infiltrate. Selective pulmonary

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FIGURE 1. Selective pulmonary angiogram in slight left posterior oblique position done on second day of hospitalization. Saddle-shaped filling defect is seen within branching segmental artery ( tmOWS) supplying portions of posterior and possibly lateral basal segments of right lower lobe. There is poor progression of contrast medium beyond this defect.

232 HALL ET Al

FxcURE 3. Chest x-ray fUm on second admission. Large right pneumothorax is present (black and white arrows). No mediastinal shift is present. Poorly defined density (open arrow) may relate to pleural adhesions in region of infarction.

CHEST, 72: 2, AUGUST, 1977

Table

1-Rme~~~

of the Literature on Pneumotlaonu Complieefiq P..,mo,..,.ln/aredon

Age,

Year 915

Reference

Sex

Embolus Complito eating PneumoHeart thorax, weeks* Disease

Infarction Size**

Sepsis

++++

+ +

Large or Persist'Aint · Broncho- Tension Cavipleural Pneumo- Clinical Fistula thorax Co111'88 tationt

Hayashi't (case 7) (case 8)

37, M 40, F

+ +

T

1936

GuggenheiJn!

37, F

+

T

1936

Daniels'

20,M

1940

Marks' (case 1) (case 2)

17,M 24,M

+

T T

++++ ++++

+

Chester and Kra~ (case 2) (case 4)

41,M 66,M

+ +

2 3

+++ +++

+ +

1946

Rogers'

44,M

+

5

+++

1947

RaWBOn and Cocke7

38,M

+

3~

++++

1948

Levin et al1

T

T

T

T

1949

M1111110n and Hartman'

30,M

+

~-1

+++

+

1949

Salee10

63,M 33,M

+ +

1~

?

++++ T

+ +

+

1942

(case 1) (case 2)

Infarct

T T

Death Death

Autopsy Autopsy

T

Death

Autopsy

+

Survival

None

+

Death Death

Autopsy Autopsy

Death Survival

Autopsy Autopsy

Survival

Autopsy

Death

Autopsy

T

T

+

Survival

Autopsy

+ +

Death Survival

Autopsy None

+++

Death

Autopsy

1~-2

+++

Survival

None

~§

+ + +

+

Death Death Death

Autopsy Autopsy Autopsy

+

+

Death

Autopsy

Death

Autopsy Autopsy

?

T

T

T

Myatt11

24,M

1957

Goldschlag11

18,M

1965

Mundth et al11·" (case 1) (case 2) (case 3)

49,M 62,M 63,M

+ + +

2-3 ~1§

++++ ++++ +++

1966

Payetet ala

28, F

+

2

+++

1967

BlundeJlUI (case 1) (case 2)

46,F 391 F

+

5-7

++++ ++++

McFadden and Luparello17

49, F

+

5

1972

Jackiewicz et al 11

401 F

1977

Present case

43,M

2-3

T T

+ T

T

+++

1954

1969

Confirmation of

++++

T

+ +

+

T

?

+

+

+ + +

+

+ T +

+ +

+

+

+++

T

T

+++

+

Death

Surgery; Angiogram; survival specimen +

Surgery; Autopsy death Survival

Angiogram

*Estimated interval. **++++ 1 Very large, U 1 infarction of entire or almoet entire lobe; and+++ 1 large. (All infarctions were relatively large.) tin all casee but that of McFadden and Luparello and the preeent case, cavitation was not demonstrated radiologieally1 but rather at autopsy, and cavities were apparently filled with blood and debris, rather than air. tThls report and moet other early reports were based on autopsy material with little or no clinical data. Pulmonary information in some of ~ patiente may have been secondary to necrotizing pneumonia, rather than to a pulmonary embolus. §Short interval of time between pulmonary embolus and pneumothorax in theee cases may relate to use of poaitive-prefBI allliated respiration. angiographic studies showed a discrete 6lling defect in a segmental artery to the right lower lobe (Fig 1 ) . The diagnosis of pulmonary embolus with infarction was made, and treatment with heparin was begun. A repeat chest x-ray film obtained one week after admission showed central cavitation of the otherwise unchanged consolidation (Fig 2). The patient's clinical condition improved rapidly, and on the

CHEST, 72: 2, AUGUST, 1977

eighth day of hospitalization, he was discharged on oral therapy with anticoagulant drugs. A follow-up chest x-ray film obtained six days after discharge showed diminution in the size of the in6ltrate, with slight further enlargement of its cavity. Retrospectively, this x-ray film demonstrated a very small right-sided poeumoth~ rax. The patient was afebrile and physically active at home.

PNEUMOTHORAX COMPLICAnNG CAVITAnNG PULMONARY INFARCT 233

Twelve days after discharge, the patient was awakened with discomfort in the right side of his chest and dyspnea and was readmitted to the hospital. On admission, a chest x-ray fihn showed a very large right pneumothorax without mediastinal shift ( Fig 3). The plasma prothrombin time was twice the control, and anticoagulation therapy was continued. A chest tube was inserted, and under suction there was reexpansion of the right lung. The patient remained afebrile throughout this admission, and the leukocyte count was normal. He was discharged on the fifth day of hospitalization, without recurrence of symptoms. A follow-up chest x-ray film obtained four months later was entirely normal. DISCUSSION

This case demonstrates two rare complications of pulmonary infarction: cavitation and pneumothorax. Although it appears logical to associate these two entities, it is actually very uncommon for a patient with pneumothorax secondary to a pulmonary infarction to have an associated air-filled cavity within the infarction; and, likewise, a cavitating pulmonary infarction rarely results in a pneumothorax. Most of the case reports of these two complications occurring together have had the cavities diagnosed only at autopsy, where they were found to contain blood and cellular debris rather than air. A single previous report radiologically documented both a pneumothorax and an air-filled cavity within the infarction, but in that patient, unlike our patient, the infarction was septic, with the cavity representing an abscess communicating between a bronchus and the pleural cavity.U Twenty-four cases of pneumothorax complicating pulmonary infarction have been previously reported in the world literature, 1 " 18 and these are summarized in Table 1. Many of the early cases of this complication were based entirely upon autopsy material, without clinical or radiologic documentation. In some of these patients, the pulmonary cavitation or the pneumothorax (or both) may have related to the frequently accompanying necrotizing pneumonia, rather than being secondary to a pulmonary embolus. Our patient is the second reported case of pneumothorax occurring secondary to pulmonary infarction with angiographic proof of a pulmonary embolus. There were only seven survivors among the 24 patients reported in Table 1, and none of these had as benign a course as did our patient. This favorable outcome relates primarily to the lack of complicating cardiopulmonary disease or sepsis and correlates to a lesser extent with a relatively small infarction and a relatively long interval of time between the initial infarction and the occurrence of the pneumothorax (Table 1). Cavitation of infected pulmonary infarctions is unusual.19 Cavitation of a totally aseptic pulmonary infarction is rare, with only 17 cases found in a review of the subject20 in 1968 and two subsequent case reports. 21 In our patient the enlargement of the cavity and its juxtapleural location probably both predisposed to the development of the pneumothorax.

234 HALL ET AL

REFERENCES 1 Hayashi J: Uber tOtlichen Pneumothorax durch Infarlct und Emphysem. Frank£ Z Pathol16: 1-36, 1915 2 Guggenheim A: Pneumothorax par overture dans Ia plevre d'un infarctus pulmonarie chez une cardiaque. Ann Anat Pathol12:872-875, 1936 3 Daniels LP: Pneumothorax door een embolus in de arteria pulmonailia. Ned Tijdschr Geneeskd 80:1455-1459, 1936 4 Marks JH: Pulmonary infarction as a cause of pneumothorax. N Engl J Med 223:934-936, 1940 5 Chester EM, Krause GR: Lung abscess secondary to aseptic pulmonary infarction. Radiology 39:647-654, 1942 6 Rogers HM: Bilateral pulmonary infarction and pneumothorax complicating hypertensive, coronary heart disease with myocardial infarction: Report of a case. Am Heart J 32:519-528, 1948 7 Rawson AJ, Coclce JA: Infarction of an entire pulmonary lobe with subsequent aseptic softening causing sterile hemopneumothorax. Am J Med Sci 214:520-524, 1947 8 Levin L, Kernohan JW, Moersch HJ: Pulmonary abscess secondary to bland pulmonary infarction. Dis Chest 14: 218~232, 1948 9 Masson JM, Hartman SA: Sterile hemopneumothorax caused by softening and perforation of a puhnonary infarct. Dis Chest 16:42-48, 1949 10 Sales LM : Pneumothorax due to pulmonary infarct: A

report of two cases. J Indian Med Assoc 42:1146-1152, 1949

11 Myatt AV: Sterile hemopneumothorax due to pulmonary infarction. Dis Chest 25:588-589, 1954 12 Goldschlag H: Un cas de pneumothorax consecutif a un infarctus pulmonaire. Rev Med Suisse Romande 77: . 517-527, 1957 13 Case records of the Massachusetts General Hospital: Case 30-1965. N Engl J Med 273:98-106, 1965 14 Mundth ED, Foley FD, Austen WG: Pneumothorax as a complication of pulmonary infarct in patients on positive pressure respiratory assistance. J Thorac Cardiovasc Surg 50:555-560, 1965 15 Payet M, Sanlcale M, Moulanier M, et al: Pyopneumothorax secondaire a un infarctus pulmonaire au cours d'une maladie mitrale avec arythmie complete. Bull Soc Med Afr Noire Lang Fr 11:171-174, 1966 16 Blundell JE: Pneumothorax complicating puhnonary infarction. Br J Radiol40:226-227, 1967 17 McFadden ER, Luparello F: Bronchopleural fistula complicating massive pulmonary infarction. Thorax 24 :500505, 1969 18 Jackiewicz A, Solarslci W, Drol T, et al: Samorodna odma oplucna w prizebiegu mnogich zatorow plucnych. Gruzlica 40:85-87, 1972 19 Coke LR, Dundee JC: Cavitation in bland infarcts of the lung. Can Med Assoc J 72:907, 1955 20 Grieco MH, Ryan SF: Aseptic cavitary pulmonary infarction. Am J Med 45:811-816, 1968 21 Scharf J, Nahir AM, Munlc: J, et al : Aseptic cavitation in pulmonary infarction. Chest 59:456-458, 1971

CHEST, 72: 2, AUGUST, 1977