Emergency department diagnosis of a concealed pleurocutaneous fistula in a 78-year-old man using point-of-care ultrasound.

Abstract

Although the differential diagnosis for chest wall masses is broad, the vast majority are abscesses, lipomas, or sebaceous cysts. Post-operative chest wall masses can also include infection, hematoma, seroma, cancer recurrence, metastasis, and lung hernia. Bedside ultrasound has been well documented to be beneficial in the differentiation of superficial pathology.[1,2] Pleurocutaneous fistula is a pathologic communication between the pleural space and subcutaneous tissues of the chest wall. Pleurocutaneous fistula is a rare complication of tube thoracostomy, video-assisted thoracic surgery (VATS) procedures, and various pulmonary infections. There are multiple case reports of pleurocutaneous fistulas occurring after tube thoracostomy as well as secondary to pulmonary infections including tuberculosis.[3–7] VATS is becoming an increasingly common surgery for treatment of lung carcinoma, spontaneous pneumothorax, and various indications in the trauma setting. Several cases series documenting VATS complications describe pleurocutaneous fistulas after VATS procedures.[8,9] Point of care ultrasound (POCUS) is increasing in use as a diagnostic tool in the emergency department.[1,2,10–13] Here we present a case that highlights the intersection of a rare complication of a common procedure and the value of ultrasound in the diagnosis of undifferentiated masses and dyspnea in the emergency department.