A pancreatico-bronchial fistula with right hydropneumothorax

A 39-year-old heavy drinker was admitted to Saga Medical School Hospital on February 21th, 1987. He had suffered from dyspnea, chest pain and lumbago three weeks prior to admission. His chest X-ray showed right hydropneumothorax and right lower lobe atelectasis and his CT scan showed a cystic lesion in the mediastinum. His laboratory data showed a high level of amylase in serum, urine and pleural effusion. A fistula connecting the pancreas to right pleural cavity was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP). In addition, bronchoscopy showed complete obstruction of the right lower bronchus (B7). These bronchoscopic findings and hydropneumothorax on his chest X-ray suggested the leakage of pancreas juice through the pancreatico-pleural fistula injured the lung tissue directly and produced a bronchopleural fistula. In this case, hyperalimentation and drug therapy using protease inhibitor resulted in successful closure of the fistula and reexpansion of the collapsed lung.     

Colo-pleural fistula

A case of non-traumatic colo-pleural fistula is recorded for the first time as the cause of a long-standing pleural empyema. The patient was treated with drainage, antibiotics and parenteral nutrition. The fistula was the result of a diverticulitis coli and/or a pancreatitis.     

Is there any role for medical thoracoscopy in the treatment of empyema in children?

It is still controversial whether surgical or nonsurgical treatment approaches are most appropriate for empyema in children, and there are no data regarding the role of medical thoracoscopy in this population. The aim of this study was to describe our experience with medical thoracosocpy in children with multiloculated and organizing pneumonia. We retrospectively reviewed children admitted to our hospital with a diagnosis of empyema from 2011 to 2021 and treated with medical thoracoscopy. A total of six patients with empyema were treated by medical thoracoscopy; empyema was multiloculated in five cases and organized in one case; all children in the study recovered completely with full lung expansion after chest X-rays, and no disease sequelae were reported after clinical follow-up. Our small case series suggests that in selected cases, medical thoracoscopy could safely and effectively treat pleural empyema in children, with less invasiveness and reduced psychological consequences.     

A case of benign asbestos pleural effusion suspected on thoracoscopic examination under local anesthesia]

We report the case of a 92-year-old man with a 13-year history of occupational asbestos exposure who presented with a complaint of dyspnea. In September 2001, bilateral pleural effusions were revealed on chest radiography, and continued to progress despite treatment for heart failure. Chest CT revealed calcification of the pleura but no abnormal findings in the lung fields. Both pleural effusions were exudative and lymphocytes were the predominant cells contained in them. Antituberculous chemotherapy had no effect on the exudates. In March 2002, thoracoscopy was performed under local anesthesia (medical thoracoscopy). Plaque was recognized on the parietal pleura; however, the serosal surfaces of the parietal and visceral pleura were smooth, and no evidence of malignancy, especially malignant mesothelioma, was noted. The patient's condition was diagnosed as benign asbestos pleural effusions. Prednisolone was administered, and these effusions gradually decreased. Cases of benign asbestos pleural effusion occurring simultaneously with massive bilateral effusions are rare. Thoracoscopy aided in the differential diagnosis of this case.     

New trends in the diagnosis and treatment in parapneumonic effusion and empyema

Despite treatment with antibiotics, patients with complicated parapneumonic effusion (PPE) and empyema have an increased morbidity and mortality due at least in part to inappropriate management of the pleural effusion. PPE should be considered in all patients with pneumonia as antibiotic therapy is being initiated. If the diaphragms cannot be seen throughout their length on the chest radiographs, a lateral decubitus radiograph, ultrasonography or computerized tomography scan should be obtained. If the effusion is more than 10 mm in thickness, a therapeutic thoracentesis should be performed. If the fluid cannot all be removed and the characteristics of the pleural fluid indicate a poor prognosis, a chest tube should be inserted. If the drainage is incomplete due to loculation of the PPE intrapleural fibrinolytics or thoracoscopy should be performed. If the lung does not reexpand completely with thoracoscopy, then decortication should be performed without delay.     

Video assisted thoracoscopic surgery (VATS) in the diagnosis of intrathoracic pathology: initial experience

We report our experience with the use of video-assisted thoracoscopic surgery [VATS] in the diagnosis of intrathoracic disease of unknown origin. In the last two years, 32 patients (18 males) underwent this procedure for diagnostic purposes. Of them, 18 patients had lung pathology, eight mediastinal and six pleural disease. All attempts at achieving a tissue diagnosis were unrewarding. In all of them, diagnostic thoracotomy was being contemplated to procure tissue for histopathological diagnosis. Diagnostic thoracoscopy was successful in providing tissue diagnosis in all the patients with lung disease; seven of the eight patients with mediastinal pathology and five of the six patients with pleural lesions. Diagnostic thoracoscopy was associated with minimal morbidity, short hospital stay, better cosmetic result and quicker return to work as compared to conventional thoracotomy. We conclude that video-assisted thoracoscopy is an excellent diagnostic tool to confirm tissue diagnosis in patients with undiagnosed chest diseases.     

A case of localized pleural mesothelioma containing a wedge-shaped area of aeration]

A 32-year-old man was admitted to our hospital because of an abnormal shadow on the chest X-ray film, which was detected on mass survey. The chest X-ray film on admission revealed an irregular mass shadow in the pleural layer between the left upper lobe and the lower lobe, and this shadow had a wedge-shaped area of aeration inside it. Needle biopsy under ultrasonography suggested a localized pleural mesothelioma. Surgery to resect the tumor revealed that it was pedunculated and had developed from the pleura of the left S5 segment. The resected specimen showed lung tissue invaginating into the tumor through a concave area of the tumor. The chest X-ray findings of this case are very unusual, and we were unable to find a similar case of localized pleural mesothelioma in the literature.     

A rare case of hemothorax due to rupture of an arteriovenous fistula: successful treatment by enucleation]

Hemothorax due to a rupture in an arteriovenous fistula is rare. We report a case in a 26-year-old woman who presented with continuous right chest pain. On admission, chest radiography revealed a nodular shadow in the right lower lung field with right pleural effusion. The pleural effusion aspirated was blood, suggesting a hemothorax due to the rupture of a pulmonary arteriovenous fistula. The shunt between A 8 and V 8 was confirmed in pulmonary arteriograms. A photomicrograph of the resected specimen showed a dilated arteriovenous fistula, part of whose inner wall was abnormally thin. The pleural wall surrounding the fistula was hypertrophic in parts, suggesting possible repetitive inflammation related with the rupture. Although transcatheter embolization is useful in the treatment of arteriovenous fistulae, it is technically difficult, and cases of fatal complications have been reported. While surgical resection is the most reliable treatment available, the present patient was already at high risk of dying. Accordingly, we chose to perform enucleation, and this was successful.     

A case of tuberculous pleurisy developing contralateral effusion during anti-tuberculosis chemotherapy

A 55-year-old woman was admitted to our hospital because of chest pain, fever, and right pleural effusion that was exudative and lymphocyte-dominant with a high level of adenosine deaminase (ADA). Since her blood QuantiFERON-TB 3G test (QFT) was positive, she was diagnosed with tuberculous pleurisy. After initiation of anti-tuberculosis chemotherapy with isoniazid, rifampicin, ethambutol, and pyrazinamide, her symptoms improved. Later, liquid culture of the pleural effusion turned positive for Mycobacterium tuberculosis. On the 18th day of treatment, her chest X-ray and computed tomography exhibited pleural effusion in a moderate amount in the left thorax, with subsiding pleural effusion in the right thorax. Thoracocentesis demonstrated that the left thorax effusion was also exudative and lymphocyte-dominant, with elevated QFT response and high ADA concentration, suggesting tuberculous pleurisy. Mycobacterium tuberculosis was detected in the culture of a left pleural biopsy specimen obtained by thoracoscopy. We assumed that the left pleural effusion was due to paradoxical worsening because (1) on admission no effusion or lung parenchymal lesion was detected in the left hemithorax, (2) on the 14th day of treatment she was afebrile without pleural effusion on both sides, and (3) the bacilli were sensitive to the drugs she had been taking regularly. We performed drainage of the left effusion and continued the same anti-tuberculosis drugs, which led to the elimination of all her symptoms and of the pleural effusion on both sides. In conclusion, paradoxical worsening should be included in the differential diagnosis when contralateral pleural effusion is detected during the treatment of tuberculosis.     

Pulmonary small lymphocytic lymphoma (mucosa-associated lymphoid tissue type) associated with pulmonary hyalinizing granuloma

A case of pulmonary hyalinizing granuloma (PHG) and concomitant low-grade, small lymphocytic lymphoma of the lung is presented. This is the first occurrence of pulmonary lymphoma in patients with PHG ever reported. The infiltrates around a left lower lobe nodule with left pleural effusion and thickening seen on chest CT were histologically proven to be lymphomatous infiltrates of the lung, pleura, and chest wall muscle. We believe that the lymphoma developed around the nodule and spread to the pleura and muscle in our patient. When infiltrates around the nodules, pleural effusion, or adenopathy are developed in a patient with proven PHG, close follow-up, biopsy, or careful cytology should be seriously considered to rule out a developing lymphoma.     

可弯曲电子内科胸腔镜在恶性胸腔积液诊断中的应用

目的探讨可弯曲电子内科胸腔镜在恶性胸腔积液诊断中的应用时机和指征。方法2005年7月至2007年7月,对首都医科大学附属北京朝阳医院应用尖端可弯曲电子内科胸腔镜(LTF-240型)检查并确诊的37例恶性胸腔积液患者临床资料进行回顾性分析,所有患者经胸腔积液细胞学、痰细胞学、支气管镜检查等仍不能确诊胸腔积液性质,临床上高度疑诊恶性胸腔积液者,行内科胸腔镜治疗。结果37例患者最终诊断:肺癌20例,其中肺鳞癌5例(其中1例经手术证实,而胸腔镜检查为阴性),肺腺癌12例,肺腺鳞癌1例,小细胞癌2例;胸膜转移癌14例,其中乳腺癌转移4例,卵巢癌转移1例,肾透明细胞癌并胸膜转移1例,恶性胸腺瘤转移1例,其他部位转移癌7例;恶性胸膜间皮瘤2例;非霍奇金淋巴瘤1例。主要并发症为术后伤口疼痛(21例),对症治疗可缓解,无肺水肿、感染、出血等并发症。结论可弯曲电子内科胸腔镜检查是一项安全、有效、易操作的检查方法,对有肿瘤病史、大量胸腔积液、胸部CT提示肿块影或胸膜病变者可早期积极进行内科胸腔镜检查。     

Xanthomatous pleuritis mimicking mesothelioma

Recurrent non-malignant exudative effusions remain a diagnostic and potentially management dilemma. Fluid characteristics frequently narrow the differential but fail to offer a definitive diagnosis. Medical thoracoscopy is well tolerated and allows direct visualization and biopsy of pleural processes under conscious sedation. Rarely, macroscopic appearance and even histology may be misleading. We present a case of xanthomatous pleuritis that mimicked early mesothelioma. Our patient was a 69-year-old female with a large left pleural effusion. Her medical history was significant for a recent small pericardial effusion without cardiac dysfunction. Thoracentesis revealed a non-malignant exudative effusion. Thoracoscopy demonstrated two foci of raised soft plaques with petechial hemorrhage and adhesions. Preliminary evaluation suggested chronic inflammation admixed with proliferating spindle cells and necrosis. The immunohistochemical phenotype of the spindle cells favored a spindle and epithelioid cell neoplasm, mesothelioma. Because of discord between pathologists, we repeated the thoracoscopy through the existing chest tube/thoracoscopy site. We acquired more tissue for special stains and outside review. Following extensive immunohistochemistry, the diagnosis of xanthomatous pleuritis was made. Our patient quickly recovered with steroid therapy and is without recurrence 18 months later. This case demonstrates the utility and nuances of medical thoracoscopy in a perplexing case of xanthomatous pleuritis.     

Role of medical thoracoscopy in the diagnosis of pleural effusions

BackgroundMedical thoracoscopy (semi-rigid and rigid thoracoscopy) have revolutionized the management of undiagnosed pleural effusions. Though semi-rigid thoracoscopy has a good diagnostic yield in malignant and tubercular effusions, its role in the management of a complicated pleural effusions is debatable. Hence, rigid thoracoscopy becomes handy in these cases. The present study looked into the role of medical thoracoscopy in the diagnosis of pleural effusions in different conditions.MethodsThis study included all patients who underwent medical thoracoscopy at our center between May-2010 and March-2020. Basic demographics data, type of medical thoracoscopy used, and histopathology details were collected and analyzed.ResultsA total of 373 patients were subjected to medical thoracoscopy (202 semi-rigid thoracoscopy and 171 rigid thoracoscopy). Out of whom 246 (66%) were males, the mean age was 51.9 ± 13.2 years. Diagnosis was achieved in 370 patients with a yield of 99.2%. The diagnostic yield in semi-rigid thoracoscopy was 99.5% with lung malignancy being the most common diagnosis (41%; n = 81), followed by tuberculosis (31%; n = 61). The diagnostic yield in rigid thoracoscopy was 100% in our study. Along with high diagnostic yield, complete drainage and lung expansion was seen in 93.5% (160 out of 171 patients) without requiring a second procedure.ConclusionsSemi-rigid thoracoscopy and rigid thoracoscopy should complement each other in the diagnosis of pleural effusions. Rigid thoracoscopy should be considered as the procedure of choice in a complicated pleural effusion.     

A case of hypereosinophilic syndrome associated with pulmonary infarction and hepatic vein obstruction (Budd-Chiari syndrome)

A 21-year-old man was admitted in March 1987 with low grade fever and chest pain. Eosinophilia had been pointed out and PIE syndrome was diagnosed in another hospital a month before admission. Steroid therapy had been started. On the first admission, the chest roentgenogram showed bilateral pleural effusion and a nodular shadow in the left lower lung field. Open lung biopsy was performed and a diagnosis of pulmonary infarction was made. Eosinophilia, low grade fever and chest pain were improved by steroid therapy. He was discharged in April 1987. He was readmitted in September 1987 because of fever, back pain and abdominal distension. On the second admission, eosinophilia (4,510/mm3) was pointed out. The case was diagnosed as hepatic vein obstruction by hepatic vein angiography, liver biopsy and ultrasonic examination. He had transient remission on corticosteroid and anti-coagulant therapy. This case was considered as a rare case of hypereosinophilic syndrome associated with pulmonary infarction and Budd-Chiari syndrome.     

A 62-year-old woman with bilateral pleural effusions and pulmonary infiltrates caused by extramedullary hematopoiesis

A 62-year-old female presented with a 1-month history of irritating cough and increasing dyspnea. A chronic idiopathic myelofibrosis had been diagnosed 5 years ago. CT of the chest and abdomen showed bilateral pleural effusions with a thickened pleura, nodular infiltrations in both lungs, enlarged intraabdominal lymph nodes and splenomegaly. Pleuroscopy (medical thoracoscopy) on the left side revealed dense tumorous nodules mainly on the posterior chest wall pleura, but also on the diaphragm and the lung. Biopsies taken from the chest wall pleura revealed extramedullary hematopoiesis (EMH) with abnormal megakaryocytes as well as myeloid and erythroid precursors. After unsuccessful tetracycline pleurodesis, talcum slurry was instilled via the chest tube without recurrence of the pleural effusion. Furthermore, treatment with hydroxyurea was started, and the disease regressed and then remained stable over the next 24 months. In conclusion, the pleuropulmonary findings were caused by EMH due to chronic idiopathic myelofibrosis. The definite diagnosis was established by pleuroscopy followed by successful pleurodesis with talc slurry, after tetracycline pleurodesis had failed.     

Thoracoscopy for the diagnosis of pleural disease

OBJECTIVE: To assess the accuracy and safety of thoracoscopy for the evaluation of pleural disease. DESIGN: Prospective evaluation of patients referred for thoracoscopy. SETTING: University hospital specializing in chest diseases. PATIENTS: We studied 102 patients with pleural disease, the cause of which had not been determined after initial investigation, including thoracentesis and needle biopsy. Eighty-six patients had pleural effusion, 11 had pleural mass, and 5 had pleural effusion in association with a known primary lung carcinoma. INTERVENTION: All patients had thoracoscopy under local anesthesia with mild sedation. Visually directed biopsies were done of parietal pleura. MEASUREMENTS: We recorded clinical characteristics, laboratory data, findings and duration of thoracoscopy, and any complications associated with the procedure. Hospital and clinic follow-up records were reviewed, and patients were contacted by telephone 12 and 24 months after thoracoscopy to assess their health status. MAIN RESULTS: One hundred and four thoracoscopies were done in 102 patients. A definitive diagnosis was established in 95 patients: 42 had malignant pleural disease and 53 had benign pleural disease. A diagnosis of benign pleural disease using thoracoscopy could not be confirmed in the remaining 7 patients because of insufficient follow-up information. Overall, thoracoscopy was 96% accurate with a sensitivity of 91%, a specificity of 100% and a negative predictive value of 93% for the diagnosis of pleural malignancy. Thoracoscopy was well tolerated under local anesthesia and entailed hospitalization for less than 24 hours in most cases. No deaths occurred, although 1.9% of patients had major complications, and 5.5% had minor complications. CONCLUSIONS: Among patients with pleural disease remaining undiagnosed after usual initial investigation, thoracoscopy done under local anesthesia is a rapid, safe, and well-tolerated procedure with an excellent diagnostic yield that is equivalent to that of thoracotomy.     

可弯曲内科胸腔镜术对胸膜疾病的诊治价值

目的探索可弯曲内科电子胸腔镜诊治胸膜疾病的价值及可行性。方法采用Olympus LTF-240型可弯曲内科胸腔镜对114例胸膜疾病患者在局麻下行开放式胸腔镜术，包括诊断组（含不明原因胸腔积液者及肺癌分期诊断者）、气胸组、胸膜固定术组及脓胸组。结果72例不明原因胸腔积液中确诊58例（80．1％），包括胸膜转移癌39例（肺癌胸膜转移38例、食管癌胸膜转移1例），胸膜间皮瘤3例，结核性胸膜炎15例，矽肺累及胸膜1例；未确诊的病例包括12例病理示非特异性炎症、2例胸腔镜检查未见异常。6例肺癌分期诊断者2例证实胸膜转移。13例气胸治愈7例（53，8％），胸膜固定术28例胸水均得到控制，脓胸6例均得到治愈。无1例出现严重并发症。结论可弯曲内科电子胸腔镜术容易耐受、安全、微创、费用低，是诊断疑难胸膜疾病及治疗难治性胸腔积液、脓胸的有效而实用的方法。     

Malignant transient pleural transudate: a sign of early lymphatic tumoral obstruction

In the absence of a responsible comorbid condition, the transudative character of a pleural effusion in patients with malignancy does not imply a favorable outcome. We report a case of colon carcinoma metastatic to lung and pleura presenting as a bilateral transudative pleural effusion. Tumoral diffuse lymphatic permeation was identified as the cause of lymphatic obstruction on pleural and transbronchial biopsies. The transudative character of the pleural effusion was transient denoting its obstructive origin.     

Chronic Necrotizing Pulmonary Aspergillosis Complicated by Pneumothorax

Abstract. A 61-year-old man presented with left-sided pneumothorax. On the chest computed tomograghy (CT), severe bilateral emphysema and left-sided pleural thickening were seen. His pneumothorax was drained with a chest tube. Because of a persistent air leakage, video-thoracoscopic wedge-resection of the suspected fistula and muscle-sparing minithoracotomy with extensive wedge resections of the left upper lobe were performed. Biopsy specimens showed micronodular mycetomas with septate hyphae highly suggestive of Aspergillus. The fungus destructed the lung tissue without vessel invasion. The patient had not been taking immunosuppressant drugs and had no prior opportunistic infections. Itraconazole was begun, the lung was expanded and the patient recovered. We propose that extensive resection of affected lung tissue in combination with long-term antifungal therapy with itraconazole is a valuable therapeutic option in patients with a complicated course of chronic necrotizing pulmonary aspergillosis (CNPA).     

Procedures in the evaluation of chest disease.

The evaluation of chest disease may require one or more procedures. Bronchoscopy, both rigid and flexible, mediastinoscopy, mediastinotomy, chest tube drainage, lung biopsy, thoracoscopy, and pleural biopsy are described, with indications, contraindications, and results detailed.