Dr. Pepe’s Diploma Casebook: Case 46 – SOLVED!


Dear Friends,

Today I am presenting the case of a 52-year-old man who underwent a bilateral lung transplant two years ago. He developed chest pain following bronchoscopy and endobronchial biopsy.

Examine the images below and leave your thoughts in the comments section.

What do you see?
It is significant?

52-year-old man, PA chest

52-year-old man, PA chest

52-year-old man, lateral chest

52-year-old man, lateral chest

Click here for the answer

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    32 Responses to : Dr. Pepe’s Diploma Casebook: Case 46 – SOLVED!

    1. Tesi says:

      Bilateral pneumothorax, suspecious also for a small pneumopericardium. Not yet significant.

    2. Ann says:

      Bilateral pneumothorax

    3. Nicky jay says:

      Bilateral pneumothorax with pneumomediastinu

    4. Ather Radwi says:

      Bilateral pneumothoracies, and pneumopericardium.

    5. vilma says:

      1.pneumothorax, pneumopericardium.
      2.i dont like the inner contour of the main bronchus, because they are irregular (stenosis?granulation tissue?).
      3.thickening of the interstitium.

    6. Diana Baptista says:

      Bilateral pneumothorax and pneumopericardium. Significant in right hemithorax

    7. Priyank says:

      bilateral pneumothorax more severe on the right side

    8. Priyank says:

      bilateral pneumothorax more severe on the right side.
      Needs CT to look for bronchial dehiscence

    9. mohammad alshafie says:

      bilateral pneumothorax,pneumopericardium. and I notice few cystic
      spaces in inner region of right middle field ? bullae.

    10. Marine says:

      Bilateral pneumothorax
      corpus alienum ?

    11. Marcy says:

      Bilateral yatrogenic pneumothorax and pneumopericardium (because the lucent band terminates at the hilar level), suggest a penetrating injury of trachea/barotrauma/broncial tree(?). It could be solved placing a drainaje tube.

    12. gus says:

      Indirect signs of bronchial dehiscence include the presence of a new or persistent air leak, pneumothorax, and pneumomediastinum

      • gus says:

        Indirect signs of bronchial dehiscence include the presence of a new or persistent air leak, pneumothorax, and pneumomediastinum (in the early postoperative period..(
        Pneumothorax may also occur after
        transbronchial biopsy

      • gus says:

        Bilateral-lung and heart–lung transplantations frequently result in a single communicating pleural space. Therefore, fluid and gas collections are often bilateral.
        Is necessary a prior study.

    13. Maria says:

      Pneumothorax bilateral and pneumomediastinum.

    14. Dr Watson says:

      Pneumothorax and pneumocardium seems too easy. There must be something more. One can’t be satisfied by the first finding. We can’t forget important clinical data: can we see the cause of performing bronchoscopy and biopsy?

    15. Sara says:

      Bilateral pneumothorax and pneumomediastinum

    16. Hossam says:

      Bilateral pneumothorax, pneumomediastinum

    17. takis limiatis says:

      pneumopericardium & pneumopericardium

    18. sameh khodair says:

      Bilateral pneumothorax and pneumomediastinum,……But I think that there is another thing as your cases are not easy from the first impression…..:)

    19. genchi bari italia says:

      …scusa per il ritardo:ero a Congresso.Tante risposte significa che in tanti ti seguono ! Si vede chiaramente un pn.torace, bilaterale ed un pnpericardio…..ma gli esami precedenti, per confronto, cosa hanno evidenziato? Il trapianto, bilaterale, di polmone porta inevitabilmente a pn.torace, post-operatorio.Perchè non è stato fatto anche un rx in pronda espirazione?

      • Dr. Pepe says:

        Since the pneumothorax was obvious, expiratory films were not considered. I believe that the appearance is typical of pneumomediastinum; pneumopericardium is much more unusual and does not follow endoscopic biopsy.

    20. gus says:

      I like to know what is the reason of the lung heart operation.
      could be a recurence of a prior pathology.
      If pneumopericardium is not follow endoscopic biopsy…
      i think we have two options.
      -bronchial dehiscence (but that is in the early postoperative period)
      -Bronchomediastinal fistlas is rare complication of the lung-heart transplantation.

      • Dr. Pepe says:

        You are assuming that the patient have pneumomericardium.
        Better think of oneumomediastinum, a common occurence after endoscopic biopsy. Follow the KISS method.

    21. Chris says:

      Obviously the patient has an bilateral pneumothorax, pneumomediastinum and pneumopericardium. The mainbronchus on the left side seems tho be constricted, so they did the bronchoscopie for dilatation by a ballon and caused a iatrogenic Pneu. Obstructive airway complications (OACs) effect 5-25% after LTX.

      • Dr. Pepe says:

        My information is that no balloon dilatation was performed. Will check the chart and get back to you. Personally, I don’t see any sign that suggests pneumopericardium, which is very rae in my experience.

    22. Chris says:

      Sorry, its the right bronchus constricted!

      • Dr. Pepe says:

        Checked the clinical history and at bronchoscopy there was a 30% stenosis of intermediate bronchus and 50% of middle lobe bronchus. No dilatation was performed. Biopsy was made because bronchiolitis obliterans was suspected.
        Air dissapeared on March 30 2011, fifteen days after the biopsy was performed.

    23. genny federer says: