A 71-year-old woman, 10 days ago due to "left anterior thoracic pain with chest tightness after activity" in other hospitals, line fiberoptic bronchoscopy suggests that "the left lower lobe of the outer basal section of the mucous membrane is swollen, hypertrophied, lumen narrowing "Chest computed tomography (CT) showed "inflammation of both lungs, medium volume of fluid in the left pleural cavity, cavity formation in the lower lobe of the left lung, and lung abscess was possible". Closed chest drainage of hemorrhagic pleural fluid, relieved after treatment.One day before admission, the patient gradually coughing sputum, white foamy, small amount, with fever, body temperature 37.7 degrees Celsius, accompanied by decreased appetite.He was hospitalized in the Department of Respiratory Medicine with a pulmonary infection.
The left lung was turbid by percussion and the chest tube was unavailable. Computed tomography (CT):atelectasis of the left lung, structures in the left hilar region were poorly displayed, and soft tissue shadows appeared to be seen in the hilar region.There was a large amount of fluid and air in the pleural cavity on the left side, with a drainage tube placed in it, and there was a small amount of fluid in the pleural cavity on the right side. Pneumothoracic changes on the right side. Small amount of pericardial effusion(Fig. 1A,B). Blood count: leukocytes 16.36*10/L, hemoglobin 105g/L, neutrophil ratio 80.50%, lymphocyte ratio 8.10%, albumin 26.2g/L, albumin/globulin 0.91, calcitonin 0.569ngmL. Diagnosis: 1. left sided fluid pneumothorax 2. left hilar tumor? 3.pericardial Treatment: anti-infection treatment was given after admission, placement of a large tube of closed chest drain(Fig. 1C,D), a small amount of yellowish liquid was drained.Pathological diagnosis of pleural fluid: found most of the inflammatory cells mainly neutrophils, did not see the exact tumor cells.
Thoracoscopy was performed, suggesting extensive dense adhesions in the thoracic cavity, which led to the cessation of exploration.The drug sensitivity culture of pleural fluid suggested Enterococcus faecalis infection, and the patient was transferred to our department. The patient developed hypoproteinemia, nutritional deficiency, anemia, weight loss and other complications. The patient's condition improved after being actively given anti-infective and nutritional supportive treatment. After repeated communication with the patient's family, he was prepared to undergo pyothorax removal with fibrous plate debridement.
During surgery, extensive adhesions were found in the right thoracic cavity, with thickening of the dirty pleura and the wall pleura, up to about 1 cm. Food debris was seen in the thoracic cavity(Fig. 1E). There were multiple septated and encapsulated pus cavities. The diaphragm showed a 3*5cm fissure, and the gastric fundus entered the thoracic cavity and became embedded and ischemic necrosis.There were three necrotic perforations in the gastric wall of about 1×1cm, 3×3cm and 3×4cm respectively(Fig. 1F). Surgical method: lung decortication + diaphragmatic repair + partial gastrectomy. Surgical incision: left posterior lateral sixth intercostal incision of about 20cm. Chest pus culture showed Candida glabrata.Postoperatively, she was given parenteral nutrition, blood transfusion, anti-infection, correction of liver function, antifungal and other symptomatic treatment. After surgery, her heart function failed, with positive treatment, her condition improved. She was discharged from the hospital 2 weeks after the operation(Fig. 1G,H,I).