Bronchopleural fistula with massive subcutaneous emphysema following early percutaneous drainage of lung abscess-a case report

Introduction: Lung abscesses develop from parenchymal necrosis secondary to pyogenic or anaerobic infection due to aspiration particularly with periodontal disease. Pyogenic lung abscesses mostly get successfully treated with antibiotics but may require percutaneous drainage or surgery (preferably lobectomy) in 10-20% of cases. Poor response to antimicrobial therapy could be related to virulence of organism, underlying lung disease or immunocompromised state. Bronchopleural fistula is a known complication after percutaneous drainage of lung abscess - early drainage or conservative therapy- which one to prefer as the initial choice for lung abscesses > 4-6cm? Case description: 68 year-old lady with COPD, scleroderma, pulmonary hypertension presented with fever, cough, and dyspnea at an outlying hospital. On admission she was found to have pneumonia with right lung abscess. Broad spectrum antibiotic was started and US guided thoracentesis with chest tube placement was done for drainage of lung abscess; abscess culture grew Streptococci and chest tube was removed 5 days later following which she developed swelling in neck, chest wall, abdomen, supraclavicular area with palpable crepitation. She was transferred to a tertiary care facility. Repeat CT showed massive subcutaneous emphysema involving neck, chest, back, upper extremities, right side of abdomen with 4.5x5.6 cm right middle lobe cavity with septations. The cavity was connected with multiple small airways causing bronchopleurocutaneous fistula. Trial of oxygen and broad spectrum antibiotic didn't impart any improvement in daily radiologic monitoring. She afterwards endured right thoracotomy with adhesiolysis along with right middle lobectomy. Bronchoscopy was unrevealing. She had an uneventful postoperative course and was discharged a week later. Discussion: Percutaneous drainage was routinely used in management of pyogenic lung abscess in pre-antibiotic era. Empyema, pneumothorax, hemothorax, bronchopleural fistula may develop as procedural complication. In a study of 184 patients by Mengoli et al, persistent bronchopleural fistula was reported in 8% patients. The above patient had US guided percutaneous drainage of pyogenic lung abscess soon after the diagnosis was made and subsequently developed bronchopleural fistula with massive subcutaneous emphysema which necessitated lobectomy with repair of fistula. Conclusion: There is no definitive indication for percutaneous drainage in management of lung abscess; only needed if medical therapy fails, as a substitute for thoracotomy/ lobectomy as reported by S.O. Wali et al. Patients with large abscess cavity measuring 4-6 cm could respond poorly to antibiotics and may require drainage, but randomized control trials are needed to establish definite role and optimal timing of percutaneous drainage. (Figure Presented).