It is all in the timing! Spotting the culprit in a case of recurrent pneumothorax

Madhan Kumar; Mercy Kiranmai; Sundeep M. C. Kisku; K Parvathy Suresh; Sneha Deena Varkki

doi:10.4103/cmi.cmi_24_21

CASE REPORT

Year : 2021 | Volume : 19 | Issue : 4 | Page : 290-291

It is all in the timing! Spotting the culprit in a case of recurrent pneumothorax

Madhan Kumar¹, Mercy Kiranmai¹, Sundeep M. C. Kisku², K Parvathy Suresh³, Sneha Deena Varkki¹
¹ Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, India
² Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India
³ Department of Radio Diagnosis, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission	26-Apr-2021
Date of Decision	26-Apr-2021
Date of Acceptance	06-May-2021
Date of Web Publication	07-Dec-2021

Correspondence Address:
Dr. Sneha Deena Varkki
Department of Pediatrics, Christian Medical College, Vellore, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cmi.cmi_24_21

Abstract

Recurrent pneumothorax is an entity that needs evaluation to determine the etiology. We report a case where the diagnostic delay occurred in a child with recurrent pneumothorax.

Keywords: Computed tomography thorax, foreign body, recurrent pneumothorax

How to cite this article:
Kumar M, Kiranmai M, Kisku SM, Suresh K P, Varkki SD. It is all in the timing! Spotting the culprit in a case of recurrent pneumothorax. Curr Med Issues 2021;19:290-1

How to cite this URL:
Kumar M, Kiranmai M, Kisku SM, Suresh K P, Varkki SD. It is all in the timing! Spotting the culprit in a case of recurrent pneumothorax. Curr Med Issues [serial online] 2021 [cited 2023 Jun 7];19:290-1. Available from: https://www.cmijournal.org/text.asp?2021/19/4/290/331823

Introduction

Tension pneumothorax is an emergency that requires life-saving intervention. The diagnosis can be confirmed by plain radiography. Computerized tomography (CT) scan has an important role in diagnosis when the pneumothorax is recurrent or unresponsive to treatment. We report a case of recurrent pneumothorax in a child to highlight the need for planning CT imaging to optimize diagnostic yield.

Case Report

A 3½-year-old boy presented to a secondary care hospital with episodic cough for 10 days and fast breathing and respiratory distress for 1 day. Tension pneumothorax was diagnosed at this initial presentation. There was no injury, skin infection, rash, choking on small objects, weight loss, or contact with tuberculosis before this. Pneumothorax was managed by intercostal chest drainage for 6 days, following which complete lung expansion was achieved. Antibiotics were administered for possible infectious etiology. At discharge, 8 days later, respiratory distress had improved, but the cough persisted.

In the ensuing 2 months, the child was evaluated in another hospital where serial plain chest radiographs revealed persisting pneumothorax. CT thorax confirmed a collapsed lung and a large pneumothorax on the left side with mediastinal shift to the right. The family at this juncture refused to repeat intercostal chest drainage.

Two and a half months after the onset of symptoms, the child presented to our center for the management of recurrent pneumothorax. On examination, the child was alert and had mild respiratory distress. Respiratory rate was 58/min, heart rate was 106/min, and SpO₂ was 98% on room air. Respiratory system examination revealed suprasternal retractions, tracheal shift to the right side, hyperresonance on percussion, and decreased breath sounds over the left hemithorax.

Differential diagnoses that we considered were rupture of a cystic malformation of the lung, cystic lung involvement due to Langerhans cell histiocytosis or bronchopleural fistula. Previous CT thorax films were reviewed. There was no cyst or nodule in the right lung. Left lung was completely collapsed and could not be assessed.

A repeat CT thorax done after drainage of pneumothorax and complete expansion of the left lung revealed a low-density lesion within the left main bronchus at the level of bifurcation of the main bronchus, causing near-total luminal obstruction of the left main bronchus [Figure 1]. There was hyperinflation of the left lung and a shift of the trachea and mediastinum to the right. There were no cysts or nodules in the now fully expanded left lung. A flexible bronchoscopy confirmed intraluminal obstruction, and pieces of an almond seed were retrieved using a rigid bronchoscope. Postoperative period was uneventful. The child was symptom-free 48 h after the procedure. Informed written consent was obtained from the parents.

Figure 1: Computed tomography chest showing opacity in the left main bronchus, causing emphysema of the left lung. Small pneumothorax and subcutaneous air are seen on the left.

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Discussion

Recurrent pneumothorax in toddlers and young children is often secondary to acute bacterial infections or a chronic infection like tuberculosis.^[1] It can also be a complication of surgical procedures, positive pressure ventilation, or secondary to air trapping in asthma or bronchiolitis. Langerhans cell histiocytosis and cystic congenital lesions of the lung, although rare, can present with recurrent pneumothorax.^[2]

Diagnosis of foreign body aspiration, a common accidental injury in toddlers and preschoolers, can sometimes be delayed. About two-thirds of patients present within 72 h of aspiration.^[3] In some cases, foreign body aspiration is detected only after the development of chronic complications such as bronchiectasis.^[4]

Pathogenesis of pneumothorax following foreign body aspiration is intriguing. The foreign body functions as a ball valve, leading to air trapping within the lung parenchyma, resulting in rupture and air leak into the pleural cavity. The end result is pneumomediastinum or pneumothorax.^[5] It could also be a complication during difficult retrieval of an aspirated object using a bronchoscope.^[6]

In the clinical case described here, the family did not witness any choking episode before the onset of symptoms. Recurrence of pneumothorax was diagnosed by plain radiography. In the CT of the thorax, collapsed lung and displaced mediastinum obscured the visualization of the foreign body which was present within the lumen of the airway. Only after complete expansion of the lung was achieved, airway could be assessed and cause of pneumothorax detected.

This case highlights the need for planning radiological investigations to answer a specific diagnostic question.

Conclusion

Foreign body aspiration is a rare cause of recurrent pneumothorax in children. For optimal diagnostic yield in the case of recurrent pneumothorax, CT scan should be performed after maximal lung expansion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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