What’s the Diagnosis #6

A 39 year old male with a 1 pack per day smoking habit presents with acute onset of shortness of breath and right-sided chest pain. You obtain an x-ray that is shown below. What is the diagnosis?


If you said “pneumothorax”, you’re right.
You decompress the pneumothorax using a Cook catheter and Heimlich valve. You hear a rush of air through the needle as the patient breathes out. You obtain a second chest x-ray to confirm that the lung is re-expanded. The result is shown below. Now what is your diagnosis?


Scroll down for the answer.





Bullous Emphysema with Pneumothorax
When I initially saw the second x-ray, I was going to put in a second chest tube, suspecting that part of the pneumothorax had become walled off or loculated. Then I saw small septations in the right lung field and conferred with the radiologist who agreed that there was no further pneumothorax present.

Absence of lung tissue is noted in the right lower lung field in the first x-ray.
In the second chest x-ray, a small catheter can be seen in the right lateral 5th interspace. The remaining lung tissue is expanded, but multiple large bullae remain in the upper lung field, simulating a persistent pneumothorax.

See additional information about bullous emphysema here: Link #1, Link #2, Picture link

3 Responses to “What’s the Diagnosis #6”

  1. Jennifer says:

    My diagnosis was “whoa, that dude has fuzzy white stuff all up in his lungs. that can’t be good.”

  2. Chelsea says:

    Isn’t he a bit young for emphysema? I’d look for underlying causes.

    • Andrew says:

      39 years old with 1 ppd addiction he very likely has over 20 pk/years. Not young at all for that heavy history. There is no set age limit for emphysema though it is correlated with smoking intensity usually occurring over 10 pk/years though subtle smoking related changes can be identified in teenagers or people in their twenties with thorough pulmonary function tests and HRCT.

      It is a common misconception of young people, and a failure of the anti-tobacco efforts – that one has to be “old” to get emphysema.

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