Usefulness of the double-wall sign in detecting pneumothorax in patients with giant bullous emphysema

Differentiating Giant Bullous Emphysema From Tension Pneumothorax: A Case Report

Giant bullous emphysema (GBE) is a progressive disease that commonly presents with severe progressive dyspnea attributed to the progressive destruction of alveolar walls and the formation of large air pockets, resulting in impaired gas exchange. This presentation is most commonly seen in young, thin male smokers. GBE poses an interesting and unique clinical challenge due to its radiologic findings, which can be easily mistaken for tension pneumothorax. Despite the decreased acuity of GBE as compared to tension pneumothorax, inadequate treatment in a severe case can lead to spontaneous pneumothorax, infection, and/or respiratory failure. In this report, we highlight a case of severe GBE that presents similarly to tension pneumothorax in both symptomatology and radiologic findings. The case at hand is of a 50-year-old male patient with a history of chronic obstructive pulmonary disease (COPD) with complaints of dyspnea and subsequent findings of tachycardia, tachypnea, and hypoxemia with significantly decreased breath sounds in the right lung. Radiologic findings showed increased lucency of the right hemithorax and a mass effect with a mediastinal shift to the left. History and further imaging with CT led to an ultimate diagnosis of severe GBE and COPD exacerbations. The patient was treated with non-invasive medical management. With the challenges of overlapping presentations, landing on the correct diagnosis is imperative to accurately and adequately treat the patient since GBE and tension pneumothorax significantly differ in acuity and overall management, hence the need for a high level of suspicion based on the clinical picture and the use of high-resolution CT.

Giant Bullous Emphysema Mimicking Spontaneous Pneumothorax

Emphysema is a progressive and degenerative lung disease that most commonly occurs due to many years of smoking or exposure to smoke and irritants. It is also seen in the congenital absence of the alpha-1-antitrypsin enzyme. Bullous emphysema is an advanced stage of the disease where strictures of the bronchi permit the inspired air to enter the bronchi but close on expiration, causing air retention and alveolar dilation, destruction, and atrophy. Multiple small bullae coalesce to form a giant bulla (defined as occupying more than one-third of the hemithorax), which causes respiratory symptoms and mediastinal shifting and leads to a poor general condition of the patient. Here, we present the cases of two patients diagnosed with bullous emphysema who presented within three months of each other. This article details the similarities and differences in the approach to both cases and the learning experience from these presentations, especially in acute symptomatology. Bullous emphysema is usually confused with a pneumothorax on a simple chest X-ray; hence, it is imperative to look for the lung margins and confirm the diagnosis using computed tomography of the thorax.

Unilateral Giant Bullae: Pulmonary Placental Transmogrification Should Be Kept in Mind: Case Reports

Placental transmogrification is a peculiar clinical entity of the lung of uncertain etiology. We report 2 cases of pulmonary placental transmogrification in 2 patients of different nationalities. Both of them had no history of smoking or chronic lung disease. The main presentations were dyspnea and chest pain. Radiologic studies showed a unilateral giant bulla in both patients; additional pneumothorax was present in only 1patient. They underwent surgical bullectomy. Histopathologic studies revealed the presence of intracystic placenta-like villous structures and a diagnosis of placental transmogrification was made. Placental transmogrification should be considered in cases of unilateral bullae.

Please do not put a chest drain in my chest! Vanishing lung syndrome

Introduction

Vanishing lung syndrome, also known as giant bullous emphysema is a condition usually reported in young male thin smokers. There are numerous case reports that have added to the body of evidence. There are also case reports of the giant bulla being misinterpreted for a pneumothorax.

Case report

A 61 year old male with severe chronic obstructive lung disease presented to Accident and Emergency with progressive breathlessness. A chest radiograph showed a giant right sided bulla that was initially misinterpreted as a tension pneumothorax. Further review of his imaging and lung function pointed to him having vanishing lung syndrome. He was referred for a cardiothoracic opinion but was eventually managed conservatively.

Discussion

Vanishing lung syndrome is characterised by a slowly enlarging upper lobe bulla that compresses normal lung parenchyma and causes mediastinal shift, with the patients experiencing increasing dyspnoea and reduced exercise tolerance. Smoking cessation is the mainstay of treatment. If they are relatively asymptomatic, patients are managed conservatively. Otherwise a variety of lung volume reduction techniques can be considered. A large bulla can look the same as a pneumothorax but the former does not have a lung edge and has a more rounded appearance. A CT scan is very useful in differentiating between the two pathologies. Bullae are predominantly caused by smoking. Bullae will cause high total lung volumes and residual volumes, but low alveolar volumes. Bullae can be observed or treated by surgical techniques

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The relevance of the differential diagnosis of pneumothorax is important within the African context (tuberculosis, etc.).

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Obstructive and bullous lung disease is often a challenging diagnosis.

Vanishing Lung Syndrome in a Patient with HIV Infection and Heavy Marijuana Use

Vanishing lung syndrome (VLS) is a rare and distinct clinical syndrome that usually affects young men. VLS leads to severe progressive dyspnea and is characterized by extensive, asymmetric, peripheral, and predominantly upper lobe giant lung bullae. Case reports have suggested an additive role of marijuana use in the development of this disease in young male tobacco smokers. We herein report a case of a 65-year-old Hispanic male previously diagnosed with severe emphysema and acquired immune deficiency syndrome (AIDS), with a history of intravenous heroin use and active marijuana smoking who presents to the emergency department with severe progressive shortness of breath he was found to have multiple large subpleural bullae occupying more than one-third of the hemithorax on chest computerized tomography (CT), characteristic of vanishing lung syndrome. The patient was mechanically ventilated and later developed a pneumothorax requiring chest tube placement and referral for surgical bullectomy. Surgical bullectomy has shown high success rates in alleviating the debilitating symptoms and preventing the life threatening complications of this rare syndrome. This case further emphasizes the importance of recognizing VLS in patients with severe emphysema and heavy marijuana smoking.

Core curriculum illustration: pneumothorax

This is the fourth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Giant bulla mimicking pneumothorax

It is usually thought by emergency physicians that the diagnosis of a pneumothorax is straightforward and easy to make and to treat, but the diagnosis may sometimes pose a challenge. The present report describes a case of a giant pulmonary bulla in a 40-year-old man that progressed to occupy almost the entire left hemithorax and also subsequently ruptured to produce a large left pneumothorax. The giant bulla was diagnosed only as a pneumothorax, and initially managed with a chest tube only. The differentiation between pneumothorax and a giant bulla can be very difficult, and often leads to inaccurate diagnosis and management. This case report demonstrates the clinical presentation of giant bulla and its complications such as pneumothorax and also highlights the difficulty in making this diagnosis and appropriately treating it. In this article, we emphasized how to differentiate between giant bulla and pneumothorax utilizing history, physical examination, and radiological studies including computed tomography (CT) scan.