AN EXTINCT CURE FOR AN ANCIENT DISEASE: RECOGNIZING PLOMBAGE

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Despite advances in the treatment of pulmonary tuberculosis (TB) in the last century tuberculosis remains one of the top ten causes of death worldwide [1]. Antibiotic therapy has supplanted surgical treatment and it is unusual to recognize patients with previous surgical treatments. We review the case of a patient with a history of TB who presented with a lung mass. Our goal is to reinforce awareness of an outdated TB treatment and to emphasize the importance of thorough history-taking in reaching the correct diagnosis. CASE PRESENTATION: A 71-year-old lady was referred to our service for evaluation of a left upper lobe mass. She reported no respiratory symptoms, but confirmed an abnormal sensation and a stabbing pain from her fingers radiating up her arm and across her chest. Given her suspicious arm pain a shoulder and spine x-ray were ordered which showed a large calcified mass in the left lung apex and volume loss in the left lung. She revealed that she grew up in an orphanage in Columbia . When specifically questioned, she recalls being diagnosed with TB and treated with surgery as a teenager in 1961 eight years before immigrating to the United States. Physical exam was significant for a left posterior thoracotomy scar and equal bronchovesicular breath sounds. All other components of the physical exam were within normal limits. A subsequent CT scan showed a non-enhancing 12 cm heavily ossified septated left upper thorax mass possibly arising from an upper left ribs. The mass contains chondroid matrix and peripherally high-density septations throughout with a low-density center. Brachial plexus involvement cannot be excluded. The mass was consistent with plombage treatment for TB and biopsy was not recommended. DISCUSSION: During the 1930s-1950s the standard of care for TB involved surgical collapse of the lung; a treatment called, “plombage”. A shift toward antibiotic treatment was made with the development of streptomycin in 1946, which was found to have curative effects [2]. Inert plombage materials included mineral oil, air, paraffin wax, and polymethyl-methacrylate (Lucite) balls [3]. Upon insertion into the chest cavity, the affected lobe would collapse, decreasing ventilation to the region and starving the aerobic bacteria of oxygen. As antibiotics to TB were developed plombage treatment fell out of favor in most parts of the world. Late complications of plombage can include hemorrhage, infection, chest wall deformities, fistulization to bronchi, great vessels in the thoracic cavity, and esophagus or brachial plexopathy. CONCLUSIONS: Obtaining the patient’s complete history particularly of tuberculosis treated in her native country in 1961 became central to the diagnosis of retained calcified Plombage material.It is important for physicians to move beyond the most likely diagnosis and rely on thorough history-taking skills to arrive at the correct diagnosis. Reference #1: 1. Mathers et al (2009). “Global and Regional Causes of Death” British Medical Journal Reference #2: 2. D'Arcy Hart P (August 1999). "A change in scientific approach: from alternation to randomised allocation in clinical trials in the 1940s". British Medical Journal. Reference #3: 3. Historical TB treatment – Plombage; QJM: An International Journal of Medicine, 2017 DISCLOSURES: No relevant relationships by Kristin Fless, source=Web Response no disclosure on file for Nirav Mistry; No relevant relationships by Mihir Odak, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Paul Yodice, source=Web Response