Fluid-containing emphysematous bullae: a spectrum of illness

Abstract

Fluid-containing emphysematous bullae are an under-reported complication of chronic obstructive pulmonary disease. The roles of bronchoscopy in the work-up and of antibiotics in the treatment are undefined.This study reports the combined results from the analysis of 16 cases treated at the present authors' institution and 36 previously reported cases.The median age at presentation was 58 yrs and the median duration of follow-up was 60 weeks. A third of the patients were asymptomatic, while two-thirds presented with symptoms, including 10% who had evidence of a severe lung infection. Methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa and Bacteroides melaninogenicus were cultured from the bullae fluid in three symptomatic patients. Sputum and blood cultures were uninformative. Bronchoscopy, performed in two-thirds of the cases, added no diagnostic information. Antibiotic treatment did not result in a more rapid resolution of the air fluid level. Percutaneous drainage was safe and effective in four patients.In conclusion, patients with fluid-containing bullae present with a spectrum of illness. Antibiotic treatment does not hasten radiographic resolution and bronchoscopy has no diagnostic or therapeutic role.

MRSA infected emphysematous bullae in an asymptomatic COPD patient

“…Although strongly discouraged previously, percutaneous drainage is now emerging as a safe, high yield procedure that results in a rapid improvement in symptoms and assists with titrating antibiotic therapy to the specific microorganism 478. Current literature suggests that the causative microorganisms can vary widely and minimal or slow response to empiric therapy is seen, then obtaining biopsies is recommended 6. In this case, CT guided biopsies were obtained that cultured MRSA bacteria.…”

“…Because the benign presentation of this condition, Mahler et al proposed that the fluid accumulation was sterile and was as a result of reaction to the inflammation in the surrounding lung parenchyma 45. In the symptomatic patient, however, current speculation suggests that the infection arises from either the surrounding lung parenchyma or via haematogenous spread 6. Of Mahler's 10 patients, four were asymptomatic.…”

“…Prior imaging with evidence of an existing bulla greatly simplifies the management and all efforts should be made to obtain prior radiology of the chest 6. In the event prior radiology is not available, the presence of a thin-walled cavity with a disproportionate clinical picture would be suspicious of the diagnosis 47.…”

Spontaneous pulmonary haemorrhage into an existing emphysematous bulla

“…Pulmonary bullae are common in patients with COPD, and can be complicated by pneumothorax or more rarely by sterile or infected intrabullous fluid collection 1. Blood-containing pulmonary cavities or lesions are rare 6…”

“…Chronic obstructive pulmonary disease (COPD) is very common and can be complicated by emphysematous bullae; these can be of little consequence but often compound dyspnoea and occasionally precipitate pneumothorax or intrabullous infection 1. We describe a unique case of massive haematoma formation within a giant emphysematous bulla, preceded by infection and antiplatelet medication.…”