THE CASE OF A DISGUISED PNEUMOTHORAX

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: A multitude of causes can be associated with secondary spontaneous pneumothorax (SSP). Over 70% of cases are associated with chronic obstructive pulmonary disease. Other causes range from genetic risk factors (Cystic fibrosis/Marfans), necrotizing pneumonia (Pneumocystis Jiroveci /Staph Aureus) or lung cancer. Although there are various causes, the presentation is most often the same. Most patients present with dyspnea and chest pain. It is rare that a pneumothorax is diagnosed by abdominal computer tomography (CT). This report examines a case about an elderly female who was found to have a spontaneous pneumothorax secondary to pneumonia that presented with abdominal pain with diffuse tenderness. CASE PRESENTATION: A 77 year old female presented as an outside hospital transfer for altered mental status from a nursing home. Patent originally had a cough with was associated with shortness of breath and was initially prescribed Augmentin by the nursing home physician. Unfortunately, patient’s condition did not improve and she started to rapidly decline, eventually requiring assistance with daily activates. A chest x-ray (CXR) was remarkable for a right lower lobe infiltrates. Patient was febrile with a leukocytosis that lead to a diagnosis of pneumonia, and was started on broad-spectrum antibiotics. With treatment, her mentation started to improve along with her leukocytosis. Four days after initiation of treatment, she was found to be hypotensive with systolic pressure in the 80s, tachycardic and hypothermic. Portable CXR was read as resolution of the right lower lobe infiltrates with development of right upper lobe atelectasis. On examination, diffuse abdominal tenderness was noted. An abdominal CT with contrast was performed that was remarkable for a large right sided pneumothorax with no intra-abdominal pathology. A subsequent CT chest was performed that revealed a 20% collapse of the right lung with no tracheal deviation. At this point, a pigtail catheter was placed which lead to resolution of her abdominal tenderness, tachycardia and hypotension. The pigtail was in place for three days then removed with no subsequent complications. DISCUSSION: Secondary pneumothorax is a challenging diagnosis, especially when the etiology is infection. Among SSP, 11% of cases were linked to infectious causes. Age and gender play a substantial role in the incidence of SSP. Per 100,000 of the general population, the rate in men is 6.3 cases, where as its 2.0 for women. Additionally,the ages of 60 to 65 seem to have the highest incidence of SSP in the general population. CONCLUSIONS: Our patient’s presentation was far from the norm of most patients with SSP. Ninety-five percent of affected patients complain of acute chest pain accompanied by shortness of breath. None of these symptoms were present in our patient despite the severity of her pneumothorax. Unlike most, this pneumothorax was disguised. Reference #1: Choi WI. Pneumothorax. Tuberc Respir Dis (Seoul). 2014;76(3):99-104. Reference #2: Zarogoulidis P, Kioumis I, Pitsiou G, et al. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014;6(Suppl 4):S372-6. Reference #3: Takuya Onuki, Tomoyuki Kawamura, Shuntaro Kawabata, Masatoshi Yamaoka, Masaharu Inagaki. (2019) Neo-generation of neogenetic bullae after surgery for spontaneous pneumothorax in young adults: a prospective study. Journal of Cardiothoracic Surgery DISCLOSURES: No relevant relationships by Mahwish Hussain, source=Web Response No relevant relationships by Karan Panchal, source=Web Response No relevant relationships by Sunil Ramaswamy, source=Web Response