Tuberculous pulmonary gangrene: report of a case and review

A miner with No left lung: Extensive pulmonary destruction in delayed effective Multi-Drug-Resistant Tuberculosis treatment

We report a case of extensive pulmonary destruction due to delayed effective pulmonary tuberculosis (TB) treatment in an adult artisanal miner in eastern Democratic Republic of Congo. Xpert MTB/RIF was positive after his second rifampicin-susceptible TB treatment. Chest X-rays were suggestive of large cavity, fibrosis of remaining lung and air-fluid levels at the base of the destroyed lung. The patient passed away after delayed effective TB regimens. Clinicians should be aware that urgent surgical intervention is often required to prevent lethal acute respiratory failure and shock notwithstanding effective chemotherapy in such condition. Effort is needed to timely diagnose multidrug resistance TB and to implement thoracic surgery for TB in high burden countries.

Massive pulmonary tuberculosis cavity misdiagnosed as pneumothorax

Massive pulmonary cavity is a rare and serious complication of chronic reactivation tuberculosis. A 38-year-old gentleman had a history of tuberculosis treatment noncompliance 2 years ago. His presenting symptoms were cough, fever, and left-sided pleuritic chest discomfort for 2 months. Chest radiographs showed extensive lung destruction associated with large thick-walled cavities and severe fibrosis of the residual lung. In the emergency department, this was initially misdiagnosed as a large pneumothorax and a chest tube was inserted. Subsequently, this was misdiagnosed again as bronchopleural fistula when brisk air leak was seen. The chest tube did not lead to any radiological or clinical improvement and was removed without incident. This case demonstrates that massive pulmonary cavity can easily be misdiagnosed and tube thoracostomy is unnecessary. Although this condition was previously reported to be associated with a high mortality rate, our patient survived as a result of accurate diagnosis and prompt antituberculosis therapy.

Tuberculous damaged lung in a child

Tuberculosis (TB) remains the "great pretender." We report the case of a 10-year-old female, who presented with a mass in the left chest that was suspected initially to be a tumor. This was later confirmed to be tuberculous in nature, with dissemination to the liver. A large granuloma eventually replaced the left lung, leaving her with "tuberculous destroyed lung" (TDL), an extremely rare, life-threatening sequela of the disease. We review the pathophysiology, radiologic findings, and management options, which includes pneumonectomy, for this seldom seen but preventable condition.

Surgical management of acute necrotizing lung infections

BACKGROUND

Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk.

OBJECTIVE

To review results of resection in the setting of acute necrotizing lung infections.

METHODS

A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene.

RESULTS

Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n = 17), hemoptysis (n = 5), air leak (n = 7), septic shock requiring pressors (n = 8) and inability to oxygenate adequately (n = 7). Twenty-four patients were ventilated preoperatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n = 4), thoracoscopic decortication (n = 4) and open decortication (n = 2). Procedures included pneumonectomy (n = 4), lobectomy (n = 18), segmentectomy (n = 2), wedge resection (n = 4) and debridement (n = 7). There were three (8.5%) postoperative deaths--two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent.

CONCLUSIONS

Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.