BRONCHO-PERICARDIAL FISTULA IN NECROTIZING PNEUMONIA

Abstract

CASE PRESENTATION: A 54-year old gentleman with history of hypertension, active IV drug use, and a gunshot wound to the antero-lateral part of chest in 1986, presented with one-week history of dyspnea, productive cough, severe weakness and fatigue. On initial examination, he was toxic-appearing, febrile and in moderate respiratory distress. Examination revealed diminished breath sounds bilaterally with rales and egophony on the left. Laboratory evaluation revealed WBC 7.6 with 57% bands, lactic acid 4.0 and procalcitonin 21.Computed Tomography with contrast revealed parenchymal necrotizing opacities in the left upper lobe communicating directly with pericardial sac, causing pneumopericardium without tamponade. Infectious work-up was negative, however our suspicion remained high. Broad spectrum antibiotics, along with fluid resuscitation was started. Despite respiratory distress, we avoided positive pressure ventilation. With rapid clinical improvement, surgical intervention was deferred. He underwent bronchoscopy with lavage. Copious amounts of culturenegative, predominantly PMN positive tenacious mucous were suctioned from his left upper lobe. He was discharged home with 4 weeks of antibiotics.