Case Report Pleural Effusion or Main Left Bronchus Mucus Obstruction: To Drain or Not to Drain? Decision-Making for Young Surgeon on Call Danilo Coco 1 and Silvana Leanza 2 1 Madre Teresa of Calcutta Hospital, Schiavonia, Padova, Italy 2 Carlo Urbani Hospital, Jesi, Ancona, Italy Correspondence should be addressed to Danilo Coco; [email protected] Received 8 October 2017; Accepted 31 December 2017; Published 28 January 2018 Academic Editor: Atsushi Komemushi Copyright © 2018 Danilo Coco and Silvana Leanza. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mucous plugs occur in a number of pulmonary conditions. Central right or leſt bronchus mucus plug causes complete pulmonary collapse making it an emergency life-threatening case. We describe the case of an 80-year-old man that, in postoperative period aſter a urological intervention, has had a progressive tachypnea and dyspnea during hospitalization for urological problems. Young surgeon on call was called. 1. Introduction Mucous plugs occur in a number of pulmonary conditions such as bronchial asthma, pulmonitis, cystic fibrosis, and bronchiectasis and in various types of obstructive pathology [1]. In the elderly, it can appear for restless situations such as long postoperative period of bed rest. It is difficult to recognize and has differential diagnosis with pleural effusion or pneumothorax. 2. Case Report An 80-year-old man hospitalized in urologic department for BPH with history of hypertension, diabetes mellitus, and severe obstructive pulmonary pathology. e interdivisional surgeon of surgery department was called because the patient had increasing shortness of breath and a cough productive of small amounts of yellow sputum, low blood pressure, discolored skin or nails, confusion and extreme tiredness, muscle fatigue, and general weakness. Physical examination of chest demonstrated normal tracheal breath sound, asymmetric thoracic movement, absent breath sounds, absent leſt bronchovascular breath sound, and increased vocal resonance. Arterial blood gas (ABG) demonstrated respiratory acidosis. A chest radiography showed opaci- fication of and volume loss in the leſt lung (Figures 1(a) and 1(b)). It was difficult to differentiate massive pleural effusion. A thoracic CT scan confirmed the complete lung atelectasis without pleural effusion (Figures 2(a) and 2(b)). e initial choice of chest tube placement was converted in a bronchoscopy. Bronchoscopy revealed a large mucous plug completely occluding the leſt main bronchus. It was necessary to remove the plug. e next X-ray showed leſt lung fully expanded aſter the plug was removed (Figure 3). e patient’s breathing also improved substantially. One month later, chest radiography showed a complete resolution (Figure 4). 3. Pathogenesis Mucus plug is an accumulation of desquamating mucus cells of bronchus and mucus that make an obstruction in the elderly and in all patients that have lost cough capacity. A sectorial atelectasis appears when the mucus plug occludes a peripheral bronchus. If it occludes the main bronchus a complete pulmonary collapse occurs. Hindawi Case Reports in Radiology Volume 2018, Article ID 3180575, 3 pages https://doi.org/10.1155/2018/3180575
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Case ReportPleural Effusion or Main Left Bronchus MucusObstruction: To Drain or Not to Drain? Decision-Making forYoung Surgeon on Call
Danilo Coco 1 and Silvana Leanza 2
1Madre Teresa of Calcutta Hospital, Schiavonia, Padova, Italy2Carlo Urbani Hospital, Jesi, Ancona, Italy
Correspondence should be addressed to Danilo Coco; [email protected]
Received 8 October 2017; Accepted 31 December 2017; Published 28 January 2018
Academic Editor: Atsushi Komemushi
Copyright © 2018 Danilo Coco and Silvana Leanza. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.
Mucous plugs occur in a number of pulmonary conditions. Central right or left bronchus mucus plug causes complete pulmonarycollapse making it an emergency life-threatening case. We describe the case of an 80-year-old man that, in postoperative periodafter a urological intervention, has had a progressive tachypnea and dyspnea during hospitalization for urological problems. Youngsurgeon on call was called.
1. Introduction
Mucous plugs occur in a number of pulmonary conditionssuch as bronchial asthma, pulmonitis, cystic fibrosis, andbronchiectasis and in various types of obstructive pathology[1]. In the elderly, it can appear for restless situations suchas long postoperative period of bed rest. It is difficult torecognize and has differential diagnosis with pleural effusionor pneumothorax.
2. Case Report
An 80-year-old man hospitalized in urologic departmentfor BPH with history of hypertension, diabetes mellitus, andsevere obstructive pulmonary pathology. The interdivisionalsurgeon of surgery department was called because the patienthad increasing shortness of breath and a cough productiveof small amounts of yellow sputum, low blood pressure,discolored skin or nails, confusion and extreme tiredness,muscle fatigue, and general weakness. Physical examinationof chest demonstrated normal tracheal breath sound,asymmetric thoracic movement, absent breath sounds,absent left bronchovascular breath sound, and increased
vocal resonance. Arterial blood gas (ABG) demonstratedrespiratory acidosis. A chest radiography showed opaci-fication of and volume loss in the left lung (Figures 1(a)and 1(b)). It was difficult to differentiate massive pleuraleffusion. A thoracic CT scan confirmed the complete lungatelectasis without pleural effusion (Figures 2(a) and 2(b)).The initial choice of chest tube placement was converted ina bronchoscopy. Bronchoscopy revealed a large mucous plugcompletely occluding the leftmain bronchus. It was necessaryto remove the plug. The next X-ray showed left lung fullyexpanded after the plug was removed (Figure 3).The patient’sbreathing also improved substantially. Onemonth later, chestradiography showed a complete resolution (Figure 4).
3. Pathogenesis
Mucus plug is an accumulation of desquamating mucus cellsof bronchus and mucus that make an obstruction in theelderly and in all patients that have lost cough capacity. Asectorial atelectasis appears when the mucus plug occludesa peripheral bronchus. If it occludes the main bronchus acomplete pulmonary collapse occurs.
HindawiCase Reports in RadiologyVolume 2018, Article ID 3180575, 3 pageshttps://doi.org/10.1155/2018/3180575
2 Case Reports in Radiology
(a)
(b)
Figure 1: Complete left pulmonary opacification.
(a)
(b)
Figure 2: Chest CT scan: left bronchus mucus plug.
Figure 3: Chest radiography after bronchoscopy.
Figure 4: Chest radiography two months later.
4. Clinical Features
The most urgent clinical features are tachypnea, dyspnea,alteration pressure or frequency, and alteration of PO2 PCO2in EGA; accessory respiratory muscles evidence; reductionof pulmonary sound being dull on percussion. Differentialdiagnosis is between pleural effusion or pulmonary massiveatelectasis.
5. Diagnostic Evaluations
Thoracic X-ray is the first diagnostic evaluation. It demon-strates complete pulmonary hypodiaphania. Thoracic CTscan is useful when the doubt exists. It has more sensibilityand specificity to prove mucus plug. Bronchoscopy withflexible and rigid instruments is diagnostic and resolutive[2, 3].
6. Treatment
Treatment with antibiotics, corticosteroids, hydration, andchest physiotherapy often produces improvement. In emer-gency situation it is the first choice. Bronchoscopy is requiredto achieve lung expansion [4, 5].
Case Reports in Radiology 3
7. Conclusions
Mucus plug in central pulmonary bronchus is a pathologythat can occur in the elderly with restlessness associated withpulmonary or cardiologic pathology. For the surgeon it isimportant to distinguish it from pleural effusion to avoidchest tube drain.
Conflicts of Interest
The authors declare that there are no conflicts of interestregarding the publication of this article.
References
[1] S. R. Nair and S. B. Pearson, “Mucous plug in the bronchuscausing lung collapse,” The New England Journal of Medicine,vol. 347, no. 14, p. 1079, 2002.
[2] D. N. A. Puentes and et al, “Massive atelactasis of the left lung ina patient with cranial trauma,” Case report, CASOSCLINICOS.
[3] J. M. Rezende and B. R. Silveira, “Acute Respiratory Failure dur-ing Pediatric Anesthesia: Atelectasis and Hypertensive Pneu-mothorax: Case Report,” Revista Brasileira de Anestesiologia,vol. 62, no. 1, pp. 80–87, 2012.
[4] V. Kong, L. Naidoo, D. Jeetoo, G. Oosthuizen, G. Laing, andD. Clarke, “Chest X-Ray appearance of total opacificationof the hemithorax following central venous line insertion:A cautionary tale,” International Journal of Case Reports andImages, vol. 4, no. 12, p. 686, 2013.
[5] I. Salamone, B. Mondello, M. C. Lucanto, S. Cristadoro, M.Lombardo, and M. Barone, “Bronchial tree-shaped mucousplug in cystic fibrosis: Imaging-guided management,” Respirol-ogy Case Reports, vol. 5, no. 2, Article ID e00214, 2017.
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