OLEOTHORAX: PULMONARY PLOMBAGE

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plombage (extra-pleural pneumonolysis) is a surgical treatment method used to treat cavitary lesions of the lung in patients with pulmonary tuberculosis (TB) during 1930–50s before the introduction of anti-TB chemotherapy by creating a cavity surgically under the ribs in the chest wall and filling the space with inert material [1]. The materials used in this procedure are acrylic balls, fat, wax, rubber, and mineral oil (Oleothorax). Rarely, Plombage is used to seal a large bronchopleural fistula that causes refractory pneumothorax, with only one reported case in the literature [2]. We present another case of Pulmonary Plombage (Oleothorax) used in successfully treating refractory pneumothorax. CASE PRESENTATION: A 62-year-old man with a history of hypertension and symptomatic bradycardia requiring a permanent pacemaker came in with worsening shortness of breath associated with decreased exercise tolerance and orthopnea. The examination was remarkable for pan systolic murmur at the apex, jugular venous distention, and decreased breath sounds in the right lung base. Chest radiograph (Image 1) revealed cardiomegaly and a pleural-based rounded mass in the right pleural space inferiorly. Computed tomography (Image 2) showed a loculated cystic mass (label A) (13x9x10 cm) measuring slightly above water density and apical bullae. An echocardiogram revealed severe left atrial and left ventricular dilation with an ejection fraction of 55% and prolapse of the anterior leaflet of the mitral valve (MV) with severe mitral regurgitation (MR). Pulmonary service was consulted for loculated cystic mass in the lung, upon further questioning, the patient mentioned he had lung surgery in 1993 due to recurrent pneumothorax, which was found to be Pulmonary Plombage. He was started on intravenous loop diuretics for congestive heart failure secondary to MR with improvement in symptoms. DISCUSSION: We presented the modern imaging description of a Plombage thoracoplasty performed to treat refractory pneumothorax with an uncomplicated outcome 28 years after surgery. A new method to treat pneumothorax due to a large cavity with a bronchopleural fistula. The utility of Pulmonary Plombage to seal a large bronchopleural fistula causing refractory pneumothorax has not been studied, with only one case report [2] in the literature where they used pericardial fat pad as Plombage to successfully treat refractory pneumothorax without complications after 48 years. This technique involves complications like hemorrhage, infection, fistulization to the skin. Radiographic characters depend on the material used in the Plombage treatment. The cystic mass measuring slightly above water density seen in our patient was filled with mineral oil (Oleothorax). CONCLUSIONS: Pulmonary Plombage, a historical treatment used to treat cavitary lesions in tuberculosis patients, can be used effectively in treating refractory pneumothorax. REFERENCE #1: Namana V, Gupta SS, Sarasam R, Mathur P: Historical TB treatment—Plombage. QJM An Int J Med. 2017, 110:191. 10.1093/qjmed/hcw213 REFERENCE #2: Nakano T, Tsubochi H, Minegishi K, Endo S: Pericardial fat pad plombage for pulmonary cavity causing massive air leakage. Surg Case Reports. 2020, 6:156. 10.1186/s40792-020-00917-7 DISCLOSURES: No relevant relationships by Akshay Avula, source=Web Response No relevant relationships by Elias Chuki, source=Web Response No relevant relationships by Raja Jadav, source=Web Response No relevant relationships by Harry Sequeira gross, source=Web Response