A 20-year-old girl came to our hospital for treatment because of "chest tightness with recurrent cough for 4 months". When she was born, she had a lung infection due to aspiration of amniotic fluid contaminated with meconium, so she was admitted to the neonatal intensive care unit for rescue. According to the patient's own recollection, she would be easily fatigued if she had done a little more physical work since she was a child, but she did not pay attention to it, thinking that her physique was weak and did not go to the hospital to see the situation.
In December 2020, the patient began to have chest tightness, with cough and expectoration, yellow sticky sputum, and the symptoms were obvious after activity, no chest pain, no nausea, vomiting, fever, palpitation and other accompanying symptoms. At that time, she thought it was a cold and did not pay attention to it. In February 2021, she went to the township hospital for antibiotic infusion treatment for more than 10 days. The symptoms did not improve significantly, while the patient began to have left shoulder pain. One week later, she went to the township hospital for chest CT examination and found the left lung huge lesion. At this time, the patient began to cough bloody sputum. On February 24, 2021, she rushed to the Nantong First People's Hospital for treatment, and was considered a diagnosis of "spontaneous hemopneumothorax". On the same day, the emergency left thoracic closed drainage was performed, and 1500ml of bright red bloody fluid was drawn. On February 26, 2021, at Nantong First People's Hospital, she underwent "thoracoscopic left chest exploration + thoracic adhesion separation + fibrous plate stripping + pulmonary bulla resection". During the operation, the left thoracic cavity was densely adhered, and the surface of the left lung was covered with a large amount of pale yellow jelly-like cellulose, which was densely adhered to the left chest wall. There was about 200ml of blood clot in the left chest cavity, which was removed. The upper lobe of the left lung was hypoplastic and the volume was obviously small. A bulla about 2 cm in size was seen at the top of the dorsal segment of the left lower lung. After the operation, the chest tube was left indwelling for more than 20 days for removal. After the chest tube was removed, the patient felt that there was still effusion in the left chest cavity, and the symptoms of cough with bloody sputum and chest tightness after exercise had not improved significantly. On April 14, 2021, due to "exacerbation of chest tightness with cough and shortness of breath", she went to Nantong First People's Hospital again, and improved the relevant examinations indicating left hydropneumothorax, and underwent emergent B-ultrasound-guided left thoracic closed drainage. After the drainage operation, 1100ml of light red liquid was drawn, and the chest CT was reexamined on April 16, 2021. It showed that the left encapsulated hydropneumothorax was absorbed than before, so the chest drain was removed and the patient was discharged. The patient felt that her symptoms did not improve significantly, so she went to our hospital for treatment on April 21, 2021.
On April 23, 2021, the chest contrast-enhanced CT results in our hospital showed a huge cyst in the left lung with the presence of air and liquid level. The height of the cyst is about 23cm, and the left lung was corresponding pressured. After enhancement, the cyst wall was slightly enhanced, and the cardiac shadow shifted to the right. (Fig. 1–5) After discussion in the department, it is believed that according to the results of imaging examinations, the possibility of cancerous cavities with pleural effusion cannot be excluded, and malignant pleural effusion must be excluded before surgical removal of the cyst can be considered. The patient's pleural effusion may continue to increase, and the condition may change rapidly. Pay close attention.
At 15:00 on April 24, 2021, the patient suddenly developed cough with hemoptysis without obvious incentive, poor spirit, and poor appetite. Considering that the left pleural effusion was poured into the bronchus, the left thoracic cavity was drained emergently. 750ml of bright red liquid was drawn out within 20 minutes after the operation, and the patient's symptoms, spirit and appetite were all improved. Then we perfected the PETCT and pleural effusion cytology examination for the patients.
PETCT (April 25, 2021, Shanghai Zhouxin Medical Imaging Diagnosis Center): The left lung was changed after partial resection of the bulla, and the left lower pleural fluid was being drained outside the cavity; the left lower lung was partially consolidated. On April 25, 2021, the pathological results of pleural effusion exfoliated cytology examination were reported (pathology number: T21-00384, T21-00385): (pleural effusion) routine smears saw more acute and chronic inflammatory cells and a few red blood cells, but none of malignant cells were found. On April 26, 2021, the pathological examination results of the pleural effusion sediment inspection were reported (pathology number: 21-05572): (pleural effusion sediment) saw more inflammatory cells and some fibrous exudates, but no clear tumor components were found; immunohistochemical markers: TTF-1, Villin, Pax-8, Calretinin, CD138, CK20 and GATA-3 negative; CK, CK7, CK5/6, CD45, CD3, CD20 and Ki-67 scattered in small foci.
After preliminarily ruling out the possibility of malignant tumor, elective surgical treatment is planned.
At 19:00 in the evening of April 28, 2021, the patient suddenly developed symptoms of hemoptysis, accompanied by chest tightness. About 100ml of bright red liquid was drawn from the chest drainage tube within 1 hour, and blood clots were visible. The ECG monitoring showed that the heart rate was 170 beats/min, SpO2 100% (nasal cannula oxygen, oxygen flow 5L/min) breathing 24 times/min, blood pressure 81/53mmHg. Urgent blood routine examination indicated: Hb 80g/L, urgent blood gas analysis indicated: Hb 80g/L, urgent bedside chest X-ray indicated: left pleural effusion. Considering intrathoracic hemorrhage, an emergency exploratory thoracotomy was performed on the same day.
The operation lasts 195 minutes (from 22:30 on April 28, 2021 to 01:45 on April 29, 2021). During the operation, extensive dense adhesions in the left thoracic cavity were detected, and the adhesions were carefully separated. The exploration revealed a huge thick-walled cyst in the thoracic cavity with a length of about 22 cm, and a large number of blood clots were seen in the cyst cavity. The blood clot was sucked by the suction device, and the cyst cavity was rinsed, and active bleeding spots were seen. The adhesions were carefully separated along the cyst wall, and the cyst was completely freed. The cyst was incised with a domestic linear cutting suture where the cyst invaded the lower lobe of the left lung. Remove the cyst. The lungs were bulging, and the upper and lower lobes of the left lung were bulging well, and no obvious air leakage was found. The operation was smooth and the anesthesia was satisfactory. The intraoperative blood loss was about 2500ml, the blood transfusion was 2300ml, and the infusion was 2700ml. The patient was returned to the intensive care unit after the operation. Surgical specimens were sent for pathology. Postoperative pathological results report (pathology number: 21-05830): General description: left thoracic cyst, 2 cyst wall-like tissues, a total of 13.5*9.5*3.7cm, wall thickness 0.4-1.0cm, inner wall gray-yellow, gray-red, rough, and the contents have been lost; the rest of the lung tissue is gray-red and soft. Diagnosis: (left thoracic) cyst wall-like tissue, partially covered by bronchociliated columnar epithelium, inflammatory necrosis with peripheral suppurative inflammation, atrophy of lung tissue around the cyst wall, widened alveolar septa, local solid degeneration, interstitial fibers collagenization, calcification, local alveolar epithelial hyperplasia with bronchial metaplasia, infiltration/aggregation of small lymphocytes in the interstitium, fibroblast proliferation and thick-walled vascular proliferation, please consider the diagnosis based on clinical and imaging studies, and pay attention to follow-up. Immunohistochemical results: F slice AE1/AE3 epithelium (+), TTF-1 epithelium (+), P63 epithelium (+), CD20 lymphocytes (+), CD3 lymphocytes (+), Cyclin D1 (-), CD23 Follicular dendrites (+), Ki-67 epithelium (+) 5%; in situ hybridization: EBER (-); special staining: acid-fast staining (-); silver hexamine (-) (Fig. 6, 7).
The patient recovered smoothly after surgery (see Fig. 8 for the bedside chest X-ray on May 04, 2021). The chest CT scan on May 6, 2021 showed that: the left thoracic tube is in the process of drainage; left hydropneumothorax with local consolidation and cord in the left lung (Fig. 9, 10). Then on May 7, 2021, closed drainage operation of the left thoracic cavity was performed again to improve the drainage. On May 10, 2021, two thoracic drainage tubes were removed, and she was discharged from the hospital on May 13.
On August 20, 2021, the patient was readmitted to the hospital due to "chest tightness for 1 week after activity". The chest CT examination in the outpatient clinic before admission showed: left pneumothorax, multiple left pulmonary bullae, and left lung volume reduction (Fig. 11, 12). On the day of admission, closed drainage operation of the left thoracic cavity was performed emergently. A large number of air bubbles were seen after the operation, and the patient felt the chest tightness was significantly improved compared previously. After the operation, the patient continued to have left lung air leakage. The chest X-ray on August 25, 2021 showed poor recruitment of the left lung (Fig. 13). Considering that the rupture of the bullae was difficult to heal, after the contraindication of surgery was ruled out, on September 1, 2021, the thoracoscopic left lung repair was performed. The operation lasts for 125 minutes (from 10:10 on September 1, 2021 to 12:15 on September 1, 2021). Intraoperative exploration could see extensive adhesions in the pleural cavity, no effusion, fissure hypoplasia. The intrathoracic adhesions were carefully dissected with an ultrasonic scalpel. After intrathoracic irrigation, bulging the left lung, air leakage on the surface of the lung can be seen, and carefully sutured. After suturing, the lungs were bulged well, and no obvious air leakage was found. The patient's vital signs were stable after operation. On the 6th day after the operation, the chest CT was re-examined, and the left lung recruitment could be considered (Fig. 14). Then to be extubated and discharged.
After 3 months (December 22, 2021), the patient came to our hospital again for a re-examination of the chest CT scan. The left lung showed good recruitment and the mediastinum has shifted from the right to the left (Fig. 15, 16).