Thoracic D&C Pres

19 April 2012

61 yoM s/p CABG, Mitral Valve and

MACE procedure 2010 Developed a RLL lung abscess

approximately 4 months prior to presentation which was managed with IV antibiotics

For the last two months he has had hemoptysis, coughing up old blood, particularly after lying down for long periods of time

PMH: Inclusion body myopathy, XOL, HTN, CAD, DM, hypothyroidism

PSH: Pacemaker, appendectomy, RIHR, elbow surgery, CABG, MACE, mitral valve repair

ALL: NKDA Meds:

levothyroxine,glimepride, methylpred, ropinorole,azathioprine, spironolactone,lasix,coreg, ramipril,Klor-con,nasonex, janumet

SH: Retired FF, no smoking, no EtOH

ROS: otherwise negative PE

109/71 102 16 97.7 HEENT: No LAD PULM: CTA B COR: RRR ABD: Soft, NTND

Bronchoscopy- Blood and bloody secretions emanating from the RLL

CT Scan

1. Volume loss and consolidation within the right lower lobe with associated bronchiolectasis and bronchiectasis with multiple bronchials communicating with a large loculated hydropneumothorax. Favor complicating empyema and bronchopleural fistula. This is associated with endobronchial spread of infection with multifocal regions of diffuse tree-in-bud and centrilobular nodules within the right middle lobe, and right lower lobe. Right upper lobe to lesser degree.

Pt was taken to the OR on 6 April for a RVATS, decortication

Extensive lower lobe decortication was performed

Fluid within the cavity was bloody Pleural biopsies were taken from within

the cavity The entire cavity and surrounding lung

were resected with Endo GIA stapler

An additional small broncho-pleural fistula was discovered after inflating the lung, this was oversewn with a chromic suture

The entire staple line and surface of the lung was coated with ProGel

Pathology– Surgical Pathology Microscopic Interpretation– Pleura, right (specimen #1); biopsy:– - Acute and chronic pleuritis with necrotic tissue and

numerous fungal hyphae (see Comment).

– Cavity wall, right lung (specimen #2); biopsy:– - Inflamed fibrous tissue with necrosis and fungal hyphae.

– Right lung, lower lobe (specimen #3); wedge resection:

– - Portions of lung with bronchiectatic cavity, necrotizing granulomas, and patchy organizing pneumonia (see Comment).

Pt was left intubated due to inclusion body myositis and poor tidal volumes

He was extubated on POD#1 Pt was discharged home on POD#10

and had no hemoptysis during his hospital stay

Inclusion Body Myopathy

Inclusion body myopathy (IBM2) is characterized by slowly progressive distal muscle weakness that begins in the late teens to early adult years with gait disturbance and foot drop secondary to anterior tibialis muscle weakness.

Unknown cause, thought to be either autoimmune or degenerative (there are both hereditary and sporadic types)

Affected individuals are usually wheelchair bound about 20 years after onset

Bronchopleural Fistula

Most commonly seen after pulmonary resection but the incidence is low (1-2%)

Spontaneous fistulas usually occur in association with TB, bacterial pneumonia or lung abscess

Bronchopleural Fistula

Symptoms– Coughing up of serosanguinous fluid or

pus– Fever– Malaise– General symptoms of toxicity– Newly formed air-fluid level on chest

radiograph

Bronchopleural Fistula

Management– Post-resection fistulas

Chest tube suction Fibrin sealants placed through the

bronchoscope

– Spontaneous Fistulas Definitive bronchial closure with possible

muscle flap Acutely ill patients should be stabilized and

empyema should be allowed to become chronic