Visual Diagnosis: Tension Pneumothorax with Evolving Cysts in an Infant

Abstract

A 5-month-old previously healthy term male infant presents to a rural emergency department (ED) for a 1-week history of increasing congestion, poor oral intake, and a temperature of 103°F (39.4°C). He is being treated with amoxicillin for presumed pneumonia. His examination in the ED is significant for scattered rhonchi and mild dehydration. His chest radiograph reveals inflammatory changes without a focal infiltrate (Fig 1). However, because this is his fourth presentation to the ED during this illness, he is admitted for observation. During the next 2 days his respiratory distress and tachypnea progressively worsen. On day 3 of his hospitalization he begins having episodes of desaturation and worsening retractions refractory to oxygen via low-flow nasal cannula. His examination at this time is significant for diffuse rhonchi throughout both lung fields with decreased air entry at the lung bases. Because his clinical status is deteriorating, he is transferred to a higher level of care. On arrival at the referral center he is lethargic, with decreased breath sounds and persistent desaturations. A respiratory swab polymerase chain reaction is positive for respiratory syncytial virus (RSV). His chest radiograph reveals a large right-sided tension pneumothorax (Fig 2). A pigtail chest tube is emergently placed, and his work of breathing improves. Within 2 days he is no longer requiring supplemental oxygen. The medical team is unable to successfully put the chest tube to water seal, however, because each time it is sealed there is a rapid re-accumulation of his pneumothorax. After several unsuccessful attempts, his chest tube is placed back to suction and he is airlifted, via helicopter, to a pediatric tertiary care center for further evaluation, now 11 days after his initial presentation. His chest radiograph just before transfer reveals a well-positioned chest tube with interval decrease in the size of the pneumothorax. On arrival at the tertiary care center he is well appearing, with no increased work of breathing, and is saturating 97% to 100% on room air. His lung sounds are clear bilaterally, but an air leak is auscultated on inspiration. He has no crackles, wheezes, or rhonchi. Chest radiography is repeated to verify the position of the chest tube and incidentally reveals a large cystic-appearing lesion in his right lung that has not been previously described (Fig 3). Computed tomography of the chest is performed that reveals multiple air-filled cystic lesions in the right upper lobe of the lung as well as a persistent right-sided pneumothorax (Fig 4). Surgery and pulmonology are consulted for co-management. On day 17 of his cumulative hospitalization he undergoes wedge resection of the right upper lobe of his lung without complications. Samples of the cystic lesions are sent to the pathology laboratory to confirm the diagnosis. AUTHOR DISCLOSURE Drs Stein, Molero, Hess, Luquette, and Pitt have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an un...