Case Report

A 70 year old male, farmer by occupation presented with the complaint of increased breathlessness and cough with minimal expectoration for 5 days. He was a chronic smoker (28 pack years) with no alcohol and drug abuse. The patient was also a known case of chronic obstructive pulmonary disease (COPD) for last 5 years for which he was taking irregular bronchodilator therapy. Physical examination revealed a soft, crepitant bulge in the right infra-axillary region with volume of the bulge increasing during coughing or Valsalva's maneuver. Previously, he had tuberculous empyema on the same side which was drained with chest tube along with adequate antitubercular treatment. On auscultation rhonchi were audible on left side with decrease in breath sound on right side. Examination of other systems was unremarkable. A chest radiograph showed loculated pneumothorax on right side communicating with a large subcutaneous air collection which was also confirmed by computed tomography scan (figure1-3).

Figure 1

Figure 1: Chest radiograph showing loculated pneumothorax along with subcutaneous air collection

Figure 2

Figure 2: CT thorax showing pneumothorax necessitans in full inspiration

Figure 3

Figure 3: CT thorax showing increase in size of pneumothorax necessitans after Valsalva's maneuver

He was given inhaled bronchodilator to control COPD exacerbation. After controlling symptoms of COPD exacerbation, the patient was refereed to the department of surgery.

Discussion

Pleural thickening₂, empyema thoracic and empyema necessitans₃ are the well known complication of tuberculous pleural effusion and the Intercostal hernia₄ are the known complication of tuberculous empyema drained with chest tube, but pneumothorax necessitans as a complication of tuberculous empyema drained with chest tube has not been reported previously. Decreased resistance of the thoracic wall as a result of previous intercostal chest tube drainage and abnormally high intrathoracic pressure as a result of uncontrolled COPD may be the cause of pneumothorax necessitans in our case.