Spontaneous Pneumothorax in a Young Female With Lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare disorder of abnormal proliferation of smooth muscle-like cells which results in the formation of thin-walled cysts and progressive lung destruction. It commonly presents with progressive dyspnea that is often associated with a history of pneumothorax or chylothorax particularly among females of reproductive age. In this report, we present a case of hydropneumothorax as the initial presentation of LAM in a 33-year-old woman, a rather rare presentation. We also discuss the pathogenetic mechanisms, the diagnosis, and treatment strategies using mTOR inhibitors like sirolimus.

Hydropneumothorax caused by complete rupture of a pulmonary hydatid cyst: A rare case report

Hydatid disease is a zoonotic disease endemic in developing regions. It is usually caused by infection with the tapeworm Echinococcus granulosus due to contaminated food or drinks or by close contact with dogs. The lungs are the second most affected organ (25%) after the liver (>65%). Cyst rupture is the most frequent complication. Enlarging pulmonary cysts are more vulnerable to rupture, with rupturing in the bronchial tree being the most common (20%-40%). Hydropneumothorax is a consequence of complete cyst rupture into the pleural cavity and occurs in rare cases (2%-4%). Superinfection is a common complication of the ruptured cyst, which might lead to empyema. A 26-year-old male presented to our clinic with dyspnea that had progressed recently and made him unable to walk a few meters. He had a history of cough and exertional dyspnea and was examined by three different clinics without performing a chest X-Ray. Physical examination revealed fever and a sick appearance. Chest X-ray revealed complete pneumothorax with an air-fluid level in the left hemithorax. Computerized tomography demonstrated two cysts, and one of them was ruptured, causing hydropneumothorax and empyema. The patient was treated with surgery, and follow-up showed recovery with a fully re-expanded lung. Rupture of pulmonary hydatid cyst is seen in the most of cases, the clinicians must be aware of such presentation and management of the pulmonary hydatid disease.

A Unique Case of Chylothorax Occurring Post-Chest Tube Insertion

Chylothorax is a relatively rare condition characterized by the accumulation of chyle, a milky lymphatic fluid, within the pleural space. It occurs because of disruption or obstruction of the thoracic duct or its tributaries, leading to chyle leakage into the pleural cavity. We present an interesting case of chylothorax that occurred as a complication post-chest tube insertion. A 66-year-old patient presented with hypotension and shortness of breath. Initial chest X-ray in the emergency room showed a right-sided hydropneumothorax requiring chest tube placement. Later on, the patient was transferred to the medical intensive care unit for respiratory failure. Chest tube drainage was initially serosanguineous but later changed to milky-white drainage. Pleural fluid analysis showed a triglyceride level of 208, confirming chylothorax. Conservative treatment was initiated with a low-fat diet and octreotide. The plan was to schedule the patient for thoracic duct embolization in view of continuous chylous drainage, but due to family preference, the procedure was deferred. This case report provides an overview of chylothorax, including etiologies and diagnostic options, and shows the importance of taking a multidisciplinary approach to finalize management strategies.

Malignant Pleural Mesothelioma (MPM) Presenting as Hydropneumothorax

An 86-year-old man presented with bilateral lower limb edema and was found to have hydropneumothorax on chest radiography. CT revealed a substantial pleural effusion and plaques. The patient had a history of working in a stone workshop, but the extent of asbestos exposure remained unknown. Thoracic drainage and subsequent thoracoscopic surgery confirmed the presence of biphasic malignant mesothelioma through pathological examination. Hydropneumothorax as a presentation of malignant pleural mesothelioma (MPM) is rare, with only a few similar cases reported. Remarkably, despite the coexistence of plural effusion and pneumothorax, the patient did not experience dyspnea. The examination also revealed tumor rupture and disruption of the pleura. Considering the possibility of MPM in patients with asymptomatic hydropneumothorax is essential for early diagnosis and appropriate management.

Pneumothorax Ex-vacuo or Trapped Lungs Appearing as Iatrogenic Hydropneumothorax: A Case Report and Review of Non-expandable Lungs (NEL)

Non-expandable lungs are usually diagnosed after a pleural intervention. It can be challenging to differentiate between an iatrogenic pneumothorax and a new diagnosis of non-expandable lungs following a pleural intervention. The correct assessment can save the patient from undergoing the insertion of an unnecessary intercostal chest drain, which often leads to catastrophe. Suspicion and early evaluation remain the keys, particularly in patients with chronic effusion. Often the diagnosis is reached through a combination of history, pleural fluid analysis, and radiological features such as the absence of a straight line in the chest X-ray, which is commonly found in a true hydropneumothorax, along with computed tomographic evidence of chronic effusion with thick pleural rind. Although not routinely performed, pleural manometry can confirm the diagnosis of trapped lungs. We present our case, where a 64-year-old woman with metastatic oesophageal cancer developed a right-sided effusion. The post-procedure chest X-ray following therapeutic aspiration of the pleural fluid gave an impression of iatrogenic hydropneumothorax, which on further careful assessment revealed a rather pneumothorax ex-vacuo along with effusion due to underlying trapped lungs. We present a review of non-expandable lungs.

Hydropneumothorax With Bronchopleural Fistula Following the Activation of Mycobacterium tuberculosis: A Case Report

Tuberculosis is not a disease of the current era; failure to eradicate it continues to cause unusual complications, which results in detrimental sequelae to the patients. It usually presents with respiratory symptoms such as shortness of breath, cough, and fever, in addition to extrapulmonary symptoms. While there have been a few published case reports on patients presenting with hydropneumothorax due to tuberculosis, its occurrence is relatively rare. Furthermore, to the best of our knowledge, this is the first published case of hydropneumothorax due to tuberculosis within the United Arab Emirates, as confirmed by a search on PubMed. Here, we present a case of a young farmer from Bangladesh who presented with shortness of breath and fever and was found to have decreased air entry along with hyperresonance sounds on examination. Fortunately, the patient was in a stable state, required minimum oxygen therapy, and was not escalated for further noninvasive or invasive mechanical ventilation. The patient was admitted to a tertiary hospital to receive initial medical therapy interim to transfer the patient to a facility where thoracic surgeons are found.

Hydropneumothorax as a Presentation of Birt-Hogg-Dubé Syndrome

Birt-Hogg-Dubé syndrome (BHDS) is a rare genetic disorder characterized by cutaneous, pulmonary, and renal manifestations. We present a unique case in which a combination of multiple chronic illnesses, genetic testing, and significant family history led to a diagnosis of BHDS. A 72-year-old male patient presented to their primary care physician with a persistent cough of four months and was admitted to the emergency department after the discovery of a left hydropneumothorax. The patient's medical history was significant for recurrent spontaneous bilateral pneumothoraces diagnosed over 20 years ago, chronic obstructive pulmonary disease (COPD), and many other systemic illnesses. A combination of the patient's significant past medical and family history led to a diagnosis of BHDS. Genetic testing was also done to confirm the diagnosis. Despite benign skin lesions being the most common finding, they are not always present, as seen in our case, which can result in missed diagnosis. Due to the autosomal dominant nature of BHDS, it is vital to make an accurate diagnosis to allow for proper genetic counseling, as the development of renal cancer is the leading cause of mortality.

Hydropneumothorax: A Presentation of Infected Bronchogenic Cyst

Bronchogenic cysts are closed sac-like cystic lesions resulting from abnormal budding of the primitive foregut during the early development of the alimentary and respiratory systems. We describe the case of a 54-year-old man who presented to the emergency department with complaints of fever, chills, shortness of breath, and a productive cough with intermittent hemoptysis for the past two to three months. Initial workup revealed a right lung hydropneumothorax with complete atelectasis of the right lung and a mass effect on the left lung. During intercostal drainage, pleural fluid analysis revealed empyema with E. coli treated with antibiotics. However, the symptoms persisted after five days of antibiotic treatment and drainage. A multidisciplinary team of thoracic surgeons, anesthesiologists, and pulmonologists was assembled due to the non-resolving nature of the lung abscess. The patient underwent a right middle lobe lobectomy with decortication via open thoracotomy, and a bronchogenic cyst, an uncommon cause of the lung abscess, was suggested by histopathological analysis.

Tension Hydropneumothorax Caused by a Ruptured Hydatic Cyst in the Pleural Cavity: Case Report

Hydatid disease is a zoonosis caused by a larva of the tapeworm Echinococcus. All organs can be involved, but it is frequently located in liver for adults and lung for children. The clinical features are nonspecific. Imaging findings has an important place in the diagnosis and the follow-up. Rupture is the most common complication of a hydatic cyst and has a variety of imaging findings depending on the ruptured layer, the amount of air within the cyst and the type rupture. We report the case of a 10-year-old boy presenting shortness of breath and fever among other symptoms revealing by chest X-ray and thoracic CT scan, a lung ruptured hydatic cyst to the pleural cavity causing a tension hydro-pneumothorax and a superadded infection.

Late-presenting congenital diaphragmatic hernia in a child with gastric perforation and acute pancreatitis

BACKGROUND

Late-presenting congenital diaphragmatic hernia occurs beyond the neonatal period, and is relatively rare, presenting with nonspecific respiratory and gastrointestinal symptoms.

CASE

We report a rare case of late-presenting congenital diaphragmatic hernia in a 7-year-old girl, who presented with abdominal pain, shortness of breath and fever on admission. Work-up revealed intrathoracic gastric perforation, acute pancreatitis and septic shock with a diaphragmatic defect. Due to the high content of amylase in pleural effusion, we suspected the presence of a pancreaticopleural fistula, and we were also puzzled whether the gastric perforation was caused by a pleural indwelling catheterization, but this was ruled out. We about performed a laparotomy to reposition the herniated organs, repair the hernia and the gastric perforation, and undergo the gastrostomy. The girl had an uneventful post-operative recovery.

CONCLUSIONS

Late-presenting congenital diaphragmatic hernias are often misdiagnosed. Clinicians should combine multiple imaging modalities to make a definite diagnosis and perform surgery as soon as possible to avoid severe complications.

A Case of Bronchopleural Fistula and Hydropneumothorax in a Patient With Necrotizing Pneumonia Complicated by Mycobacterium avium Complex

A bronchopulmonary fistula is a pathological connection that develops between the bronchi and the pleural cavity as a result of etiologies including surgery, infection, blunt or penetrating trauma, radiation, chemotherapy, and chronic obstructive pulmonary disease sequela. Diagnosis and treatment are challenging for intensivists. We present a case report of bronchopulmonary fistula resulting in hydropneumothorax caused by necrotizing pneumonia and complicated by mycobacterium avium complex that resolved spontaneously. The aim of this case report is to discuss the presentation and treatment of bronchopleural fistulas.

A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema

Spontaneous hydropneumothorax (HP) and mediastinal emphysema (ME) are infrequently presented complications of pulmonary tuberculosis (TB). A-34-year-old Pakistani male presented with dyspnea, productive cough, and right-sided pleuritic chest pain. He had no history of any surgery, TB, comorbid disease, or other serious pulmonary diseases. Chest radiography revealed a right-sided HP and parenchymal infiltration. The laboratory results of pleural effusion showed elevated adenosine deaminase levels with the empyema features. Acid-fast bacilli were detected and Mycobacterium tuberculosis without any drug resistance grew in the culture both in the sputum and pleural fluid. A chest tube was inserted immediately. A prolonged airway leak was detected. Hepatotoxicity protocol has been initialized (due to increased hepatic enzymes in the initial presentation) and followed without observing any complications associated with the treatment. On the 25^th day of the standard TB treatment protocol, we observed hepatic enzymes in the normal range. Around 40-days of a hospitalization period, he started developing fever and methicillin-resistant Staphylococcus aureus was detected in the pleural fluid culture. We introduced linezolid to the treatment regimen in addition to the antituberculosis protocol. Although spontaneous ME is a benign disease, it might be life-threatening and difficult to manage when complicated with HP and active TB infection. Active TB should be considered a differential diagnosis once ME or HP was detected, and treatment should be started immediately for both diseases.

Tension Fecopneumothorax

Fecopneumothorax causing tension (hemodynamic compromise) is an extremely rare situation, mostly as a result of blunt trauma. Here, we present an 86-year-old gentleman who presented with tension fecopneumothorax, with an interesting backstory as to the development of fecopneumothorax.

Bronchopleural fistula and bilateral pneumothorax in a patient with COVID-19

COVID-19 pneumonia causes several complications that include pneumothorax, hydropneumothorax, empyema, and rarely leads to bronchopleural fistula (BPF). BPF is a communication between the pleural space and the bronchial tree. We report a case of 24 years man with pneumothorax, hydropneumothorax, and BPF that appeared after COVID-19 infection.

Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock

Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.

Management of necrotizing pneumonia with bronchopleural fistula caused by multidrug-resistant Acinetobacter baumannii

We report the case of a 53-year-old male that presented to our hospital with a history of a brain tumour. He was hospitalized 10 days prior in another hospital. Before surgery, he complained of mild cough. Routine chest radiography demonstrated right upper lobe consolidation which was diagnosed as hospital-acquired pneumonia. Broad-spectrum empirical antimicrobial was initiated. After surgery, his clinical condition deteriorated and he felt breathlessness. Chest radiography and computed tomography (CT) scan without contrast revealed necrotizing and cavitating pneumonia complicated by bronchopleural fistula (BPF) and hydropneumothorax. Sputum culture revealed infection of multidrug-resistant Acinetobacter baumannii (MDRAB). Despite optimal antibiotic therapy, BPF and hydropneumothorax failed to resolve and surgical approach was performed to debride the necrotic area and seal the fistula. After a month in the hospital, he was discharged and the serial chest X-ray showed good recovery of the lung.

Hydropneumothorax as a complication of necrotizing pneumonia in a young girl

Bronchopleural fistula with subsequent hydropneumothorax is an important complication of necrotizing pneumonia. Chest X-ray is an excellent diagnostic tool which can suggest hydropneumothorax. When present, this requires admission for drainage. If discharged after necrotizing pneumonia, follow-up should include a chest X-ray to rule out this complication.

Pulmonary endometriosis: a rare cause of hydropneumothorax

Pulmonary involvement in endometriosis is well described in the literature but asymptomatic significant hydropneumothorax is considered an unusual presentation. It classically coincides with a menstrual cycle and can be a cause of recurrent disease. We present a young lady who was found to have an incidental asymptomatic right hydropneumothorax on a pre-employment health screen. She comes from an endemic area of tuberculosis, thus we pursued several diagnostic tests to rule it out. A diagnosis of catamenial hydropneumothorax was reached through a pleural biopsy. This case highlights the importance of adopting a systematic approach in managing uncommon presentations.

Gastropleural Fistula: A Rare Complication of a Common Procedure

Weight loss surgeries are evident to be highly beneficial in patients with morbid obesity (body mass index (BMI) ≥40.0 kg/m²) and severe obesity (BMI between 35.0 and 39.9 kg/m² with co-morbidities). While this results in significant mortality benefit, there is always the possible risk of postsurgical complications. Gastrobronchial and gastropleural fistulas are two rare, post-operative pulmonary complications associated with these surgeries. Our patient is a 54-year-old female who underwent a biliopancreatic diversion with a duodenal switch. A few weeks later, she started developing a cough, fever, and shortness of breath. Computed tomography (CT) chest showed the presence of a loculated right sided hydropneumothorax. A gastrointestinal fluoroscopic contrast study performed showed a large fistula originating from the distal end of the stomach and ending towards the right pleural cavity. The fistula was successfully closed with the endoscopic fulguration of fistulous opening with argon beam coagulation and orthoscopic clipping, resulting in complete obliteration of the fistula tract. The right-sided hydropneumothorax was initially treated conservatively with antibiotics and chest tube drains followed by video-assisted thoracoscopic decortication with chest tube placement. Gastropleural fistula formation is rare but is nonetheless a serious postoperative complication of bariatric procedures and mimics pneumonia clinically. It is, therefore, essential to obtain detailed imaging work-up to rule out fistula formation, which, in turn, can be timely treated without causing further devastating results to the patient.

A case of malignant mesothelioma detected hydropneumothorax

A 61-year-old man was admitted to the emergency room because of sudden right chest pain and dyspnea. A chest X-ray and chest computed tomography (CT) revealed severe right pneumothorax with massive pleural effusion. Chest drainage was performed and approximately 1.2 L of pleural fluid was removed. Hemothorax was suspected based on the imaging findings, but the pleural effusion was serous. Active air leakage continued for 4 days after chest drainage, thus we decided to surgically control the air leakage and performed video-assisted surgery. A thoracoscopic examination revealed a large number of nodule parietal pleural and epiphrenic pleural nodule lesions. A pathological examination of frozen sections of the nodules indicated malignant pleural mesothelioma (MPM). Continuous air leakage was observed from the pleural surface of the right lower lobe. The air leak developed from the visceral pleura and the point of visceral pleura had a normal macroscopic appearance. The patient was treated with wedge lung resection and pleurodesis.

Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage due to Empyema

A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

Kirschner wire migration from subcapital humeral fracture site, causing hydropneumothorax

Migration of wires or pins around the shoulder is a known complication, though their migration within the chest is uncommon. We report an unusual case of hydropneumothorax due to migration of a bent Kirschner wire from the right proximal humerus in a 63 year-old man. We reviewed his clinical history, physical examination, imaging findings, surgical method and outcome. We also reviewed the literature on orthopaedic wire migration and latest technique in removal of the wires. Chest radiographs and chest computerized tomography are useful in detection and diagnosis of this disorder. Regular radiographic follow-up is needed for patients with internal fixation devices; any fractured or migrated pins or wires must be removed immediately to prevent dangerous complications. It is always important to remove the wires at the end of the treatment. Early removal of fixation wires and regular follow-up if wires are retained are essential to prevent serious complications.

Two cases of paragonimiasis westermani diagnosed after eosinophilic pleural effusion-induced hydropneumothorax

Our hospital is located in the Tono region in the southeastern district of Gifu Prefecture in which there are forests and inhabitants who still hunt and eat game meat. Therefore, boar meat increases the risk of contracting paragonimiasis. We treated two patients who were infected by Paragonimus westermani after eating boar meat. They developed hydropneumothorax in association with eosinophilic pleural effusion. For patients who have pneumothorax with concomitant pleural effusion and eosinophilia in the pleural fluid analysis, it is necessary to take a detailed history, which includes flesh food consumption and travel to an endemic area, and to make a careful examination while taking into consideration parasitic infections such as paragonimiasis.

Boerhaave's syndrome - tension hydropneumothorax and rapidly developing hydropneumothorax: two radiographic clues in one case

Boerhaave's syndrome is a rare and severe condition with high mortality partly because of its atypical presentation resulting in delayed diagnosis and management. Diagnostic clues play an important role in the approach to this syndrome. Here, we report a 48 year‐old male patient hospitalized with fever and left chest pain radiating into the interscapular area. Two chest radiographs undertaken 22 h apart showed a rapidly developing tension hydropneumothorax. The amylase level in the pleural fluid was high. The fluid in the chest tube turned bluish after the patient drank methylene blue. The diagnosis of Boerhaave's syndrome was suspected based on the aforementioned clinical clues and confirmed at the operation. The patient recovered completely with the use of antibiotics and surgical treatment. In this case, we describe key findings on chest radiographs that are useful in diagnosing Boerhaave's syndrome.

Chest X-ray findings in late-onset congenital diaphragmatic hernia, a rare emergency easily misdiagnosed as hydropneumothorax: a case report

INTRODUCTION

Late-onset congenital diaphragmatic hernia is a rare anomaly with misleading symptoms and signs.

CASE PRESENTATION

We describe the case of a 7-year-old Middle Eastern girl who presented with acute nonspecific abdominal symptoms and respiratory distress of 2 days' duration after sustaining a blunt trauma on her left chest wall on a background of chronic ill-defined left chest pain of 2 weeks' duration. Her initial chest radiograph showed an air-fluid level, which was thought to be a hydropneumothorax, so a chest tube was inserted and was shown to be positioned between the chest wall and the air collection; therefore, a nasogastric tube was inserted and it was positioned in the left chest cavity so the diagnosis of late-onset congenital diaphragmatic hernia was made. On retrospective analysis of the first abdominal X-ray, it showed a subtle lucent area that was triangular in shape and continued with the chest cavity, which indicates a sign of diaphragmatic hernia. In addition, the next unusual point was the nonvisualization of the diaphragm, which should be reported in any abdominal X-ray. An exploratory laparotomy was performed on our patient using a left-sided subcostal incision; the operative findings revealed a very small posterior rim of the diaphragm and a hypoplastic left lung. Her stomach, spleen, and left colon with the omentum were in the left side of her chest. She made an uneventful recovery postoperatively and was discharged after 1 week.

CONCLUSIONS

Gastric and intestinal gas shadow distribution provides an important marker in the diagnosis of late-onset congenital diaphragmatic hernia and should be sought for in every case of suspected congenital diaphragmatic hernia in addition to noting the position of the nasogastric tube in the chest cavity.

Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial

Boerhaave's syndrome (BS), also known as "spontaneous rupture of the esophagus", constitutes an emergency that requires early diagnosis if death or serious morbidity are to be prevented. First described in 1724, BS is thought to be more common than once thought. Its true incidence remains unknown. Mortality ranges between 20-40% with timely treatment but this rises to virtually 100% if treatment is delayed by more than 48 hours. This is unfortunately a common occurrence due to delayed diagnosis. The commonest precipitating factor is vomiting but BS can be truly "spontaneous". The classical clinical presentation described consists of vomiting, chest pain, and subcutaneous emphysema. However, and contrary to popular belief, this triad is actually uncommon accounting for the frequently delayed diagnosis. A less recognised presenting feature of BS is with pneumothorax due to associated rupture of the parietal pleura. Pneumothorax has been shown to be present in more than 20% of cases of BS-sometimes with a coexistent pleural effusion (hydropneumothorax). This article aims to raise awareness about pneumothorax as the sole initial presenting feature of BS and alert clinicians to consider BS in the differential diagnosis of any patient with respiratory symptoms and a recent history of vomiting.

Angiosarcoma presenting with spontaneous hydropneumothorax: report of a case and review of the literature

Angiosarcoma is a rare malignant tumor of soft tissue. Because angiosarcoma originates from endothelial cells, it can occur in any organ and shows aggressive clinical features. Most commonly, angiosarcoma initially presents as a cutaneous lesion. Lung metastasis from scalp angiosarcoma can develop pneumothorax. We report a case of multiorgan involvement of an angiosarcoma, including the scalp, initially presenting with hydropneumothorax. Immunohistochemistry analysis of the cells obtained from the study confirmed the pleural invasion of the angiosarcoma.

Pleural Aspergillosis in an otherwise healthy individual

Pleural Aspergillosis is a rare entity, with most of the cases occurring on a background of lung disease or surgery. We report a case of a 16-year-old boy who developed pleural Aspergillosis in the absence of any obvious pre-disposing factors. Patient presented with fever, dry cough and left sided chest discomfort of 6 weeks duration. A chest radiograph revealed features of the left pyopneumothorax. Despite being started on presumptive antituberculous treatment and intercostal drainage his symptoms failed to resolve. The sputum and pus were then subjected to fungal smears and culture, which indicated growth of Aspergillus fumigatus. We report this case in view of the extreme rarity of pleural Aspergillosis occurring in a young healthy individual with no evidence of prior lung pathology. Furthermore, the source of infection was traced back to a very unusual possible focus - a decayed tooth infected with A. fumigatus, thus making the case even more interesting.

Peri-operative course of peritonitis following tube thoracostomy: A misdiagnosed case of congenital diaphragmatic hernia

A young adult presented with signs of peritonitis following tube thoracostomy for suspected acute hydropneumothorax. Attempted decompression of the chest by tube thoracostomy had caused gastric perforation, and on surgical exploration, he was found to have a congenital diaphragmatic hernia with herniation of the stomach, spleen and colon. All intensive care doctors and emergency room physicians dealing with the care of patients with acute respiratory failure should be taught to recognize and keep the possibility of a Bochdalek hernia in mind, especially in young adults presenting with unusual respiratory and gastrointestinal symptoms.