Emergency department diagnosis of a concealed pleurocutaneous fistula in a 78-year-old man using point-of-care ultrasound

A Symphony of Challenges: Multi-Drug Resistant Tuberculosis, Pleurocutaneous Fistula, and Empyema Necessitans in Concert

“…Thoracic interventions such as the video-assisted thoracic surgery (VATS) procedure for lung cancer or tube thoracostomy (chest tube placement) for post-esophagectomy drainage are known causes of developing pleurocutaneous fistulas [ 2 , 6 ]. Similarly, patients diagnosed with primary pulmonary tuberculosis started on anti-tubercular therapy, underwent chest tube placement, and also developed a pleurocutaneous fistula [ 4 , 7 ].…”

Progression and Resolution of a Post-traumatic Pleurocutaneous Fistula

“…The resolution of the fistula was also documented through a series of daily chest X-rays following tube thoracostomy. Although not performed in this case, previously reported cases of PCF have demonstrated the utility of point-of-care ultrasound in visualizing subcutaneous emphysema in addition to concurrent thoracic pathology such as pleural effusion [ 8 ]. Though tube thoracostomy was successful, it is difficult to determine if the fistula has healed or if the expansion of the pleura back to the chest wall has sealed it off, meaning that repeat pneumothorax could cause the fistula to reappear.…”

“…PCF has also been described in cases of malignancy, including pleural squamous cell carcinoma and following radiation therapy of breast cancer [ 2 , 7 ]. The clinical presentation of PCF is typically a non-specific palpable subcutaneous thoracic mass [ 8 ]. An audible high-pitched squeak during a sustained Valsalva maneuver may be heard as an indicator of an air leak [ 9 ].…”

“…An audible high-pitched squeak during a sustained Valsalva maneuver may be heard as an indicator of an air leak [ 9 ]. Diagnosis of PCF is made radiographically, usually via computed tomography (CT) imaging and in some cases via ultrasound [ 2 , 8 ]. In this report, we present a case of post-traumatic PCF formed following a motor vehicle crash and fully resolved after the placement of a tube thoracostomy.…”