SEPTIC EMBOLI CAUSING PNEUMOTHORAX WITH FISTULIZATION TO THE RIGHT BREAST

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Bullous lung disease may either be idiopathic or secondary to environmental factors, and has been associated with IV drug users and HIV infection (1). Treatment of bullous lung disease depends on severity of dyspnea, ranging from smoking cessation to bullectomy. If left untreated, it may result in a secondary spontaneous pneumothorax (SSP). Here we present a patient that developed free air in her right breast from a ruptured bullae. CASE PRESENTATION: A 50 year old female with past medical history of anoxic brain injury secondary to cardiac arrest, chronic ventilator dependence, heroin abuse, endocarditis, septic pulmonary emboli, and breast augmentation presented to the ED with altered mental status and suspected seizures. In addition to altered mentation, her physical examination revealed a marked discordance in breast size, with an enlarged right breast. She was tachycardic, normotensive, and afebrile. CT chest revealed large areas of bronchiectasis, large bulla bilaterally, and right-sided pneumothorax with fistulization to the right breast. CT surgery was consulted and the patient underwent right thoracotomy with decortication of the right lung, along with breast implant removal and closure of the communicating fistula. Chest tube was placed until the pneumothorax resolved. DISCUSSION: The most common complications of giant bullae include pneumothorax, bronchogenic carcinoma, and fluid collection. SSP is a well-known complication and tube thoracostomy is often required for management. Due to the aggressive nature of the complications, management is directed towards prevention. This constitutes pleurodesis using mechanical abraision and bullectomy (usually when a bulla size is greater than 50% of the hemithorax). Though bullae have been associated with cigarette smoking, primary lung disease, and IV drug users, SSP is rarely seen with septic emboli and bacteremia (2). In our case, it was further complicated by a fistula formation and development of large amount of free air in the right breast. CONCLUSIONS: Bullae lung disease is a benign condition that may result in severe complications. Chronic large bullae should be evaluated frequently. This case highlights the various etiologies of bullae formation and we believe clinicians ought to include include pneumothorax and bronchopleural-subcutaneous fistulization as a differential when other causes are unexplainable. Reference #1: Martinez, F. Evaluation and medical management of giant bullae. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on March 15, 2019.) Reference #2: Okabe M, Kasai K, Yokoo T. Pneumothorax Secondary to Septic Pulmonary Emboli in a Long-term Hemodialysis Patient with Psoas Abscess. Intern Med. 2017;56(23):3243-3247. DISCLOSURES: No relevant relationships by Niaz Memon, source=Web Response no disclosure on file for Daniel Murphy; No relevant relationships by Yi Xiong, source=Web Response