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Case Report
DOI: 10.17354/cr/2015/159
Diagnostic Dilemma in a 70-Year-Old Man with
Fever and Air-fluid Level on Chest X-ray
Abhisheka Kumar1, Hanmant Ganpati Varudkar2, Arti Julka3, J C Agrawat4
Senior Resident, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, Bihar, India, 2Professor and Head, Department of
Pulmonary Medicine, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India, 3Professor, Department of Pulmonary Medicine, R. D. Gardi Medical
College, Ujjain, Madhya Pradesh, India, 4Associate Professor, Department of Pulmonary Medicine, R. D. Gardi Medical College, Ujjain,
Madhya Pradesh, India
1
Infected bullae are frequently confused with a pulmonary abscess. There recognition is important to avoid unnecessary interventions.
We describe a case of 70 years male patient, who came with complaints of breathlessness since 5 years, cough with a moderate amount of
mucopurulent expectoration, pain in back and right shoulder and low-grade intermittent fever all since 20 days. Past history was unremarkable.
There is a history of 100 pack-years. On examination, he was tachypneic, having oxygen saturation of 87% on room air. On respiratory
examination; the finding was consistent with emphysema with right sided cavitary disease. Chest X-ray showed thin walled cavity with fluid level
in the right upper zone with pneumothorax on the left side. Investigations revealed 17, 000 white blood cell with neutrophil predominance. He
was not responding adequately so high-resolution computed tomography (HRCT) was ordered which showed multiple thin-walled bullae in
both lung along with air-fluid level in one large bullae with surrounding pneumonitis on the right side. Infected emphysematous bullae should
be suspected when a fluid level appears in a patient with clinical finding suggestive of emphysema. We propose that symptomatic patients
with radiological signs of air-fluid level should be evaluated with HRCT to rule out similar condition and assessment of underlying condition
Keywords: Chronic obstructive lung disease, Emphysema, Infectious giant bullae, Lung abscess, Lung bullae
INTRODUCTION
Lung abscess is defined as necrosis of the pulmonary
tissue and formation of cavities containing necrotic debris
or fluid caused by microbial infection. The formation
of multiple small (<2 cm) abscesses is also referred as
necrotizing pneumonia or lung gangrene. Both lung
abscess and necrotizing pneumonia are manifestations of
a similar pathologic process. Failure or delay to recognize
and treat lung abscess is associated with poor prognosis.
Lung abscess was a devastating disease in the pre-antibiotic
era when one-third of the patients died, another one-third
recovered, and the remainder developed debilitating
illnesses such as recurrent abscesses, chronic empyema,
bronchiectasis, or other consequences of chronic pyogenic
infections. The treatment of lung abscess is guided by
the available microbiology with consideration of the
underlying or associated conditions. Lung abscess the most
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common runs a sub-acute course with an insidious onset
of non-specific symptoms, but it may present acutely with
aggressive toxic symptoms. The duration of symptoms
before diagnosis is extremely variable, ranging from
several days to around 6 weeks. Lung abscess appears as a
thick-walled; usually round cavity with irregular margins
that forms an acute angle with the chest wall. There are
no signs of compression of the surrounding lung. Infected
bullae are frequently confused with a pulmonary abscess.
Bullae are characteristically thin wall and are a more
common in the upper zone. The finding of fluid-containing
emphysematous bullae is underreported complication of
bullous lung disease Patient with infected bullae tend to
be less sick and toxic than those with lung abscess. Airfluid levels appearing in lung bullae are always considered
to indicate acute infection and, therefore, conservative
management with prolonged antibiotics and observation
until resolution is the recommended approach. The most
common therapeutic approach to infectious bullae of the
lung is the administration of systemic antibiotics. Surgical
resection was reported to be a contraindication in fluid-filled
bullae because of persistent post-operative air leakage due
to lung injury.1 We present a case in which Bullae were not
identified previous to this episode. Recognition of infected
bullae is important to avoid unnecessary diagnostic or
therapeutic interventions. Fluid-containing emphysematous
Corresponding Author:
Dr. Abhisheka Kumar, Flat No. 203, Gangotri Apartment, Behind Bhawani Market, Ambedkar Path, Patna - 800 014, Bihar, India.
Phone: +91‑9472246900. E-mail: [email protected]
IJSS Case Reports & Reviews | November 2015 | Vol 2 | Issue 6
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Kumar, et al.: Diagnostic Dilemma in a 70-Year-Old Man with Fever and Air-fluid Level on Chest X-ray
bullae are an unusual complication of chronic obstructive
pulmonary disease (COPD). As patients with COPD can
develop a variety of cavitary lung lesions, identifying the
correct diagnosis can be challenging.2-5 The diagnosis of
fluid-containing emphysematous bulla can only be made
with certainty if there is interval development of a fluid
level in a pre-existing emphysematous bulla.5,6
CASE REPORT
We describe a case of 70 years male patient, who came
with complaints of breathlessness (Grade 3, mMRC) since
5 years (increased since 20 days), cough with a moderate
amount of mucopurulent expectoration, pain in back and
right shoulder and low-grade intermittent fever all since
20 days. Past history was unremarkable except for history of
benign prostatatic hypertrophy. He was chronic smoker with
history of 100 pack-years. In general examination, he was
tachypneic, having oxygen saturation of 87% on room air and
poor dental hygeine. On respiratory examination, positive
finding includes emphysematous shape of chest, decrease air
entry in left infra-axillary region and fine crept in right infraclavicular region. Chest X-ray showed thin walled cavity
with fluid level in right upper zone with small pneumothorax
on left side. Laboratory investigations revealed 17,000 white
blood cell with neutrophil predominance. Broad-spectrum
antimicrobials were administered including ceftriaxone
along with metronidazole for anaerobic coverage. Intercostal
tube was inserted for pneumothorax. He was not responding
adequately so high-resolution computed tomography
(HRCT) was ordered which showed multiple thin-walled
bullae in both lung along with air-fluid level in one
large bullae with surrounding pneumonitis on the right
side with an emphysematous change in rest of the lung.
Ultrasonography guided Percutaneous drainage was
performed in addition to intravenous antibiotic therapy
(Figures 1-3).
Figure 1: Chest X-ray PA view showing cavity with air-fluid level in the right upper
zone with left sided pneumothorax
Figure 2: X-ray right lateral view showing cavity with fluid level in the upper
zone anteriorly
DISCUSSION
Bullae are usually associated with varying degrees of
emphysema. Recent advances in high-HRCT add to our
knowledge of bullous emphysema. Most bullae increase in
size slowly over time. However, there are instances when
bullae enlarge rather quickly. Bullae also can rupture or
deflate either spontaneously or following an infection or
cough.
Although the most common cause for localized air fluid
level is lung abscess. Air fluid levels can also be seen in
malignancy and in tuberculous cavities from rupture of
Rasmussen’s aneurysm. Infected emphysematous bullae
should be suspected when a fluid level appears in a patient
with clinical finding suggestive of emphysema. A CT scan
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Figure 3: Computed tomography showing multiple bullae with single bullae with
air-fluid level on right side
is more appropriate and required to determine the exact
size and to better localize the fluid collection, especially if
percutaneous drainage is planned.5
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Kumar, et al.: Diagnostic Dilemma in a 70-Year-Old Man with Fever and Air-fluid Level on Chest X-ray
Mahler et al., have hypothesized that the fluid in bullae
is sterile and is a result of the reaction to inflammation
in the surrounding lung.1,7 However, this is conflicting as
there are other reports, where the fluid culture has grown
organisms. There are very few studies regarding isolation
of microorganism from fluid. Culture results from the
aspirated fluid are available only in four previously reported
cases of bullae containing air-fluid levels; three out of these
four cases showed Pseudomonas aeruginosa, Staphylococcus
aureus, and Bacteroides melaninogenicus, respectively, while
one was culture negative.8 The fluid aspirated from the bulla
in our patient grows pseudomonas. However, the patient
had received antibiotics for 1 week prior to the aspiration.
CONCLUSION
To conclude patients with severe symptoms like fever and
respiratory distress with radiological signs of air-fluid level
should be evaluated with high HRCT to rule out similar
condition and assessment of underlying condition. In
addition, benefit from percutaneous drainage, in addition,
to antibiotics. This would not only detect the causative
organism if present, but would also decrease the bacterial
load.
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3. Rothstein E, Harley BF Jr. Fluid levels in emphysematous bullae.
Dis Chest 1962;42:620-5.
4. Sanford HS, Green RA. Air-fluid levels in emphysematous bullae.
Dis Chest 1963;43:193-9.
5. Chandra D, Soubra SH, Musher DM. A 57-year-old man with
a fluid-containing lung cavity: Infection of an emphysematous
bulla with methicillin-resistant Staphylococcus aureus. Chest
2006;130:1942-6.
6. Leatherman JW, McDonald FM, Niewohner DE. Fluid-containing
bullae in the lung. South Med J 1985;78:708-10.
7. Mahler DA, Gerstenhaber BJ, D’Esopo ND. Air-fluid levels within
lung bullae associated with pneumonitis. Lung 1981;159:163-71.
8. Chandra D, Rose SR, Carter RB, Musher DM, Hamill RJ. Fluidcontaining emphysematous bullae: A spectrum of illness. Eur
Respir J 2008;32:303-6.
How to cite this article: Kumar A, Varudkar HG, Julka A, Agrawat JC.
Diagnostic Dilemma in a 70-Year-Old Man with Fever and Air-fluid Level on
Chest X-ray. IJSS Case Reports & Reviews 2015;2(6):27-29.
Source of Support: Nil, Conflict of Interest: None declared.
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