Giant Bullae With Air Fluid Level Causing Fungal Empyema

Abstract

INTRODUCTION: A bullae occupying more than one third of affected lung is considered a giant bullae. Risk factors of giant bullae include HIV, COPD, smoking, and illicit drug use. Giant bullae can develop air fluid levels. Air fluid levels in giant bullae should raise the concern for infection until proven otherwise. Giant bullae with air fluids levels are at risk for rupture and propagating infection to healthy lung parenchyma or rupture into pleural space. There are no clear guidelines for the treatment of large bullae with infection. CASE PRESENTATION: 53 year old African American Male presents with 1 week history of body aches, cough, chills, fevers, and yellow sputum production. Past medical history is significant for cerebrovascular accident with no residual deficits and asthma. Patient is active smoke and denies illicit drug use. Patient was febrile with diminished breath sounds in the right Chest. Laboratory data was significant leukocytosis. Chest X-ray revealed a large right air fluid level with concerns for pleural involvement. A CT scan of the chest revealed emphysematous changes in the left lung. Right lung imaging showed giant right upper lobe bullae with air fluid level and thickened pleura. Small cavities were present. The patient was treated with Vancomycin and Piperacillin/Tazobactam antibiotics. Blood and sputum cultures where unrevealing. Fever and leukocytosis persisted despite antibiotics. DISCUSSION: Due to the amount of fluid within the giant bullae and a risk of rupture, the bulla was drained via percutaneous pigtail catheter. Three hundred ml of maroon cloudy appearing fluid was removed. The patient subsequently underwent video assisted thoracoscopy with right upper bullectomy. Culture of the fluid within the bullae and pleural fluid grew Aspergillus fumigatus. Surgical pathology of resected bullae revealed multiple micro abscesses with fungal hyphae, diffuse chronic interstitial pneumonitis with focal organization, and chronic pleuritis. Voriconazole was administered with complete resolution of symptoms. Chest X-ray 2 weeks post operatively shows no new airspace disease CONCLUSION(S): There are no published guidelines for treatment of giant bullae with air fluid levels. Although infection with bacterial organisms is most common, infection with fungal organism may occur. Surgical intervention should be considered in patients that have minimal perioperative risk. If conservative management is chosen patient should be followed closely and consideration for percutaneous drainage undertaken as blood and sputum cultures may be unrevealing. If a patient with this underlying pathology exhibits clinical deterioration antifungal therapy should be strongly considered.