I Went to New York City and All I Got Was a Heimlich Valve: Conservative Management of TB Empyema With a Bronchopleural Fistula

Abstract

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tuberculous (TB) empyema with a bronchopleural fistula (BPF) is a late-stage presentation of active infection within the pleural space that is rare and difficult to treat. We report a case of a patient with TB empyema complicated by a BPF, which was managed conservatively with anti-TB medications and nonsurgical intervention. CASE PRESENTATION: A 45 year old male from Guyana with hypertension presented with shortness of breath and dyspnea on exertion. He denied fevers, chills, night sweats and cough but endorsed an unintentional weight loss of 20 lbs over the past month. He had a large left sided pleural effusion which drained a purulent fluid with a pH of 6.9, WBC 63120 Polys85%, RBC 1400. A chest tube was placed and he was started on broad spectrum antibiotics for empiric coverage. However, when AFB stains returned positive, he was given isoniazid, rifampin, pyrazinamide and ethambutol. Pleural fluid cultures grew mycobacterium tuberculosis. Multiple attempts were made to remove the chest tube by weaning suction and with clamp trials but an air leak persisted. A chest CT showed a thickened pleura and a clear BPF track which explained our findings at the bedside. The decision was made to manage the BPF conservatively with low suction and the eventual placement of a Heimlich valve. A follow-up CT scan was performed and the BPF was still present but the fistula track appeared to have diminished. Patient tolerated the Heimlich valve and was discharged from the hospital with recommendations for close follow-up with pulmonary and cardiothoracic surgery. DISCUSSION: In patients with difficult-to-treat TB empyema complicated by BPF, surgical interventions such as decortication, pneumonectomy and thoracoplasty can be attempted, but these are invasive procedures with variable outcomes. Conservative management with a Heimlich valve will likely not fully re-expand the lung given the thickened visceral pleura but may allow enough time for the fistula track to begin to heal, as seen in our patient, and hopefully close completely. CONCLUSIONS: A conservative approach may allow a patient with TB empyema and BPF to avoid more invasive procedures and may allow for an improved quality of life. Reference #1: Subotic, D.,Yablonskiy, P., Sulis, G., Cordos., Petrov, D., Centis R. et al, Surgery and pleura-pulmonary tuberculosis: a scientific literature review. J Thorac Dis. 2016;8:E474-E485 Reference #2: Xiong, Y.,Gao, X., Zhu, H., et al. Role of medical thoracoscopy in the treatment of tuberculous pleural effusion. J Thorac Dis 2016;8:52-60 DISCLOSURE: The following authors have nothing to disclose: Jason Lam, Angeliki Kazeros No Product/Research Disclosure Information