CRA53 “DOUBLE TROUBLE : EXTENSIVE PNEUMATOCELES WITH PNEUMOTHORAX IN AN IMMUNOCOMPROMISED PATIENT”

Deepa Priya Naidu Subramaniam1, Nor Syamimi Mohd Isa1, Irfhan Ali Hyder Ali1, Lalitha Pereirasamy1
1 Respiratory Department, Hospital Pulau Pinang, Pulau Pinang, Malaysia

INTRODUCTION:

Pneumatoceles are air-filled cysts that can rupture and cause a pneumothorax. In immunocompromised patients, these cysts often form due to opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP), as a result of damaged lung parenchyma. In-fact presence of bilateral pneumatoceles is a marker of advanced disease that increases risk of pneumothorax.

CASE SUMMARY:

A 38-year-old man was rushed to the emergency room with worsening dyspnea. He had ten-months history of cough, occasional hemoptysis, fever, and weight loss. A chest X-ray revealed bilateral parenchymal infiltrates with a left-sided pneumothorax, necessitating chest tube placement. Tuberculosis work-up were negative. Given the clinical and radiological findings, PJP was suspected. The patient tested positive for HIV, with CD4 count of 24/μL and viral load of 446,725 copies/mL. Empirical treatment with Bactrim and steroids was initiated for PJP. The patient showed clinical improvement until his chest drain dislodged 10 days later, leading to subcutaneous emphysema and persistent air leak. A computed tomography scan of the thorax showed multiple pneumatoceles and a left pneumothorax. Sputum culture grew Klebsiella pneumoniae, which was treated accordingly. The patient was not a surgical candidate and planned for talc pleurodesis. Unfortunately, he succumbed to sepsis and respiratory failure before the procedure.

DISCUSSION:

Managing pneumothorax secondary to pneumatoceles in immunocompromised patients is challenging due to multiple possible etiologies. Further complications such as subcutaneous emphysema, persistent air leaks, and secondary bacterial infections may complicate the clinical course.

CONCLUSION:

This case illustrates the complexity of managing advance disease. Early recognition and aggressive management are crucial, but secondary infections and mechanical complications can significantly impact outcomes. A multidisciplinary approach and vigilant monitoring are essential to improve the prognosis in similar high-risk cases.