Thoracic D&C Pres 19 April 2012

61 yoM s/p CABG, Mitral Valve and MACE procedure 2010 Developed a RLL lung abscess approximately 4 months prior to presentation which was managed with IV antibiotics For the last two months he has had hemoptysis, coughing up old blood, particularly after lying down for long periods of time

PMH: Inclusion body myopathy, XOL, HTN, CAD, DM, hypothyroidism PSH: Pacemaker, appendectomy, RIHR, elbow surgery, CABG, MACE, mitral valve repair ALL: NKDA Meds: levothyroxine,glimepride, methylpred, ropinorole,azathioprine, spironolactone,lasix,coreg, ramipril,Klor-con,nasonex, janumet SH: Retired FF, no smoking, no EtOH ROS: otherwise negative PE 109/ HEENT: No LAD PULM: CTA B COR: RRR ABD: Soft, NTND

Bronchoscopy- Blood and bloody secretions emanating from the RLL

CT Scan 1. Volume loss and consolidation within the right lower lobe with associated bronchiolectasis and bronchiectasis with multiple bronchials communicating with a large loculated hydropneumothorax. Favor complicating empyema and bronchopleural fistula. This is associated with endobronchial spread of infection with multifocal regions of diffuse tree- in-bud and centrilobular nodules within the right middle lobe, and right lower lobe. Right upper lobe to lesser degree.

Pt was taken to the OR on 6 April for a RVATS, decortication Extensive lower lobe decortication was performed Fluid within the cavity was bloody Pleural biopsies were taken from within the cavity The entire cavity and surrounding lung were resected with Endo GIA stapler

An additional small broncho-pleural fistula was discovered after inflating the lung, this was oversewn with a chromic suture The entire staple line and surface of the lung was coated with ProGel

Pathology – –Surgical Pathology Microscopic Interpretation – –Pleura, right (specimen #1); biopsy: – –- Acute and chronic pleuritis with necrotic tissue and numerous fungal hyphae (see Comment). – –Cavity wall, right lung (specimen #2); biopsy: – –- Inflamed fibrous tissue with necrosis and fungal hyphae. – –Right lung, lower lobe (specimen #3); wedge resection: – –- Portions of lung with bronchiectatic cavity, necrotizing granulomas, and patchy organizing pneumonia (see Comment).

Pt was left intubated due to inclusion body myositis and poor tidal volumes He was extubated on POD#1 Pt was discharged home on POD#10 and had no hemoptysis during his hospital stay

Inclusion Body Myopathy Inclusion body myopathy (IBM2) is characterized by slowly progressive distal muscle weakness that begins in the late teens to early adult years with gait disturbance and foot drop secondary to anterior tibialis muscle weakness. Unknown cause, thought to be either autoimmune or degenerative (there are both hereditary and sporadic types) Affected individuals are usually wheelchair bound about 20 years after onset

Bronchopleural Fistula Most commonly seen after pulmonary resection but the incidence is low (1-2%) Spontaneous fistulas usually occur in association with TB, bacterial pneumonia or lung abscess

Bronchopleural Fistula Symptoms – –Coughing up of serosanguinous fluid or pus – –Fever – –Malaise – –General symptoms of toxicity – – Newly formed air-fluid level on chest radiograph

Bronchopleural Fistula Management – –Post-resection fistulas   Chest tube suction   Fibrin sealants placed through the bronchoscope – –Spontaneous Fistulas   Definitive bronchial closure with possible muscle flap   Acutely ill patients should be stabilized and empyema should be allowed to become chronic