A CASE OF TUBERCULOUS BRONCHOPLEURAL FISTULA MANAGED WITH OPEN WINDOW THORACOSTOMY

Abstract

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary complications of tuberculosis are rare occurance in the developed world due to the widespread screening, early detection and prompt diagnosis. Here we present a case of tuberculous hydropneumothorax secondary to bronchopleural fistula formation in a 19 year old male and how we successfully managed the case with an Eloesser flap. CASE PRESENTATION: 20 year old male immigrant from Philippines with no significant past medical history presented to our hospital with complaints of worsening cough for past three months. On further questioning, he admitted to fifty pound weight loss over the same period. Physical examination was pertinent for absent breath sounds on the right side and increased resonance to percussion on the same side. A chest X ray obtained (Figure 1) showed large hydropneumothorax on the right side with complete collapse of the right lung. A chest tube for drainage was inserted immediately followed by a CT chest which showed concurrent findings. There was additional findings of extensive necrotic appearing consolidation involving portions of the right upper, middle and some portions of the lower lobe with perihilar necrotic lymphadenopathy. All of these pointed towards an infectious etiology. In the following microbiological work up, there was growth of Mycobacterium Tuberculosis in patient's sputum, but not in the drained pleural fluid. He was started on Rifampicin, Pyrazinamide, Isoniazide and Ethambutol. Since patient had a trapped lung with no signs of re-expansion, a decortication procedure with Eloesser flap to prevent re accumulation of fluid and assist re-expansion of the lung, was done (Figure 3) prior to discharge home. In one month follow up chest X ray, there was significant re-expansion of lung. On four month follow up, patient had significant improvement of his symptoms. The CT scan at four months showed healed flap and adequately re-expanded lung parenchyma (Figure 5). DISCUSSION: The active or chronic form of Mycobacterium Tuberculosis (MTB) infection can present in several ways. Bronchopleural fistula, a connection between bronchi or bronchioles and the pleural cavity, can form in both active and passive forms of MTB infection. Allowing re-expansion of a chronically collapsed lung requires surgical intervention. Pleurodesis through a VATS procedure to remove the fibrothorax is the initial step. Subsequently, an open window thoracostomy, or an Eloesser flap allows for long term drainage of the pleural fluid and creation of negative pressure within the thoracic cavity which aids the re-expansion of the collapsed lung. CONCLUSIONS: Tuberculosis is a disease with widespread prevalence in the developing world and it is important for physicians to be cognizant of its varying presentations, and keep it in their list of differentials when approaching diagnostically challenging cases. Reference #1: Donath J, Khan FA. Tuberculous and posttuberculous bronchopleural fistula: ten year clinical experience. Chest. 1984 Nov 1;86(5):697-703 Reference #2: Hurvitz RJ, Tucker BL. The Eloesser flap: past and present. The Journal of thoracic and cardiovascular surgery. 1986 Nov;92(5):958-61 Reference #3: Treasure RL, Seaworth BJ. Current role of surgery in Mycobacterium tuberculosis. The Annals of thoracic surgery. 1995 Jun 1;59(6):1405-9 DISCLOSURES: no disclosure on file for Dileep C Unnikrishnan; No relevant relationships by MOHANKUMAR DORAISWAMY, source=Web Response no disclosure on file for Wael Ghali; No relevant relationships by Ajay Narayan Venkatanarayan, source=Web Response