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A Case of Fluid Filled Emphysematous Bullae: A Cause for Concern?
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A6786 - A Case of Fluid Filled Emphysematous Bullae: A Cause for Concern?
Author Block: J. Wong; Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, United States.
While emphysematous bullae are not rare in cases of chronic obstructive pulmonary disease, to find them fluid filled is unusual. Diagnosis on imaging can be difficult, and once diagnosed, the role of further workup or antibiotics remain uncertain. There are few case reports of these findings with varied interventions, hence the definitive treatment is unclear. This case involves a 59 year old female with a history of bullous emphysema (FEV1 2.2 L (77% predicted)) who presented to pulmonary clinic with left sided back and shoulder pain and found to have soft tissue opacity in left lung apex. PET scan was obtained that showed hypermetabolic uptake in the left apex. Biopsy of lesion showed poorly differentiated squamous cells and patient was diagnosed with stage IIIA T4N1 squamous cell lung cancer. After several rounds of radiation and chemotherapy, patient receives followup PET scan (7 months after initial presentation) which now shows fluid levels in the right apical blebs with hypermetabolic uptake. The initial left apex mass had decreased in size and now without hypermetabolic uptake. Patient did not have cough, fever, or shortness of breath. Patient was given 2 weeks of amoxicillin-clavulanic acid. Patient unfortunately could not provide sputum sample. Repeat chest CT one month later showed improvement of the fluid collections in the right apex. This case is novel given the scarcity of cases reported in literature of fluid filled emphysematous bullae. Patients have been described on a spectrum of being asymptomatic to severe lung infection, making it unclear if these fluid accumulations represent sterile reactions to inflammation in the lung or are true infections. There are case reports of patients having undergone aspiration of bullae with positive bacterial cultures, but these occurred in symptomatic patients. Role of bronchoscopy appears to be low yield in a retrospective study and role of percutaneous drainage and choice and duration of antibiotics, if they are necessary, need to be further studied.
Author Block: J. Wong; Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, United States.
While emphysematous bullae are not rare in cases of chronic obstructive pulmonary disease, to find them fluid filled is unusual. Diagnosis on imaging can be difficult, and once diagnosed, the role of further workup or antibiotics remain uncertain. There are few case reports of these findings with varied interventions, hence the definitive treatment is unclear. This case involves a 59 year old female with a history of bullous emphysema (FEV1 2.2 L (77% predicted)) who presented to pulmonary clinic with left sided back and shoulder pain and found to have soft tissue opacity in left lung apex. PET scan was obtained that showed hypermetabolic uptake in the left apex. Biopsy of lesion showed poorly differentiated squamous cells and patient was diagnosed with stage IIIA T4N1 squamous cell lung cancer. After several rounds of radiation and chemotherapy, patient receives followup PET scan (7 months after initial presentation) which now shows fluid levels in the right apical blebs with hypermetabolic uptake. The initial left apex mass had decreased in size and now without hypermetabolic uptake. Patient did not have cough, fever, or shortness of breath. Patient was given 2 weeks of amoxicillin-clavulanic acid. Patient unfortunately could not provide sputum sample. Repeat chest CT one month later showed improvement of the fluid collections in the right apex. This case is novel given the scarcity of cases reported in literature of fluid filled emphysematous bullae. Patients have been described on a spectrum of being asymptomatic to severe lung infection, making it unclear if these fluid accumulations represent sterile reactions to inflammation in the lung or are true infections. There are case reports of patients having undergone aspiration of bullae with positive bacterial cultures, but these occurred in symptomatic patients. Role of bronchoscopy appears to be low yield in a retrospective study and role of percutaneous drainage and choice and duration of antibiotics, if they are necessary, need to be further studied.
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