CRA8 PNEUMOTHORAX OR LARGE BULLAE: A PRICE TO PAY

Zulkifli.S1
Hospital Pakar Sultanah Fatimah, Muar

Introduction

Pneumothorax and large bullae is confusing, especially in emergency cases. Pneumothorax mistaken as lung bullae would cause detrimental results and here we report a case of tension pneumothorax mimicking a large lung bullae in a case of smear positive tuberculosis. 

Case Report

A 15 year old lady presented to us for rapid breathing, hemoptysis, night sweats and chronic cough for 5 months. She was put on a High Flow Mask for a day, and suddenly deteriorated the next day requiring mechanical ventilation. Initial CXR documented as right sided large bullae with left side consolidations. Post intubation, she developed cardiac arrest and required chest compressions for 60 minutes. She regained her circulation after that and repeated Chest Xray shows enlarging bullae, at this point raised the suspicion of tension pneumothorax. Needle thoracocentesis was done and 800mls of air was aspirated. Chest tube was not inserted at this point due to profound coagulopathy. She further deteriorated while in ICU. She required two max dose inotropes and required high setting ventilator support. ETT AFB sent stat shows scanty AFB seen. She then started with an SEO regime. Repeated chest Xray shows expansion of the right lung with minimal residual pneumothorax. The next day, the patient developed another asystole episode and chest compression was started. She ROSC-ed after 5 minutes. Pupils both are dilated 6mm and another asystole episode happened. Chest compressions were done for 44 minutes however it was to no avail. The patient succumbed and was pronounced dead. 

Conclusion

The case highlights the importance of considering tension pneumothorax as a differential diagnosis, even in the setting of suspected large lung bullae, particularly in patients with sudden respiratory distress. Prompt diagnosis and appropriate management of tension pneumothorax is crucial, as a missed or delayed diagnosis can lead to catastrophic consequences.