A 48-year-old man had been diagnosed with severe chronic obstructive pulmonary disease and referred to our pulmonary clinic. His medical history revealed a 60-80 pack year smoking history and long-standing heavy alcohol consumption. He worked as an upholsterer, with exposure to glues and paints for 20 years. Tuberculin skin testing was negative with a positive Candida control. Sputum Gram-stain revealed many polymorphonuclear leukocytes and was AFB-stain positive. Culture growth indicated mycobacterium other than tuberculosis identified as Runyoun's Group III. Drug sensitivity testing demonstrated 0% resistance to the combination of isoniazid, rifampin, and ethionamide.His clinical condition gradually deteriorated despite antimicrobial therapy. Pulmonary function testing in 1994 demonstrated severe obstructive lung disease with a DLCO of 29% predicted (8.5 ml/min/mmHg). One month later, he developed acute bronchitis and during a severe coughing spell he noticed the acute onset of bulging of his left anterior chest wall. The bulge rapidly expanded during manoeuvres which increased intrathoracic pressure and rapidly reduced with cessation of these manoeuvres. In addition to the expansion and contraction of this chest wall bulge, physical examination was remarkable for sonorous breath sounds and the sound of 'gurgling' fluid within the bulge. A chest X-ray is shown in figure 1. A chest computed tomography (CT) scan (figure 2) was obtained in the semi-prone position during a Valsalva manoeuvre.
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