Presentation
Smoker, ICC inserted for treatment of pneumothorax elsewhere.
Patient Data
A large area of lucency within the left upper lobe has an atypical appearance for a pneumothorax given lung markings project into the inferior aspect of the lucency and an alternate etiology such as a large bulla or congenital lobar emphysema should be considered. Linear bands of atelectasis are present within the aerated left lower lobe. The right lung is clear. An intercostal catheter is present on the left. No mediastinal shift is demonstrated.
ICC not deflating. CT for ? pneumothorax or bulla in the left upper zone.
Left-sided ICC is noted with the tip located peripherally next to the horizontal fissure, with a small associated pneumothorax. Minor associated subcutaneous emphysema associated with the ICC.
A large emphysematous portion of the most of the left upper lobe is demonstrated with lung markings extending into the apex, consistent with congenital lobar emphysema. Adjacent portions of the lower aspect of the left upper lobe are collapsed. No mediastinal shift. A band of plate atelectasis traverses the apical segment of the left upper lobe. The lungs are otherwise normal.
Heart and mediastinum are within normal limits for non-contrast examination. No lymphadenopathy. Bones and upper abdominal viscera are normal.
Impression
Large emphysematous portion of most of the left upper lobe consistent with congenital lobar emphysema. ICC is well positioned and associated with a small pneumothorax which is most likely associated with insertion of the catheter.
ICC removed, check CXR.
The left-sided ICC has been removed. The large left upper and mid zone lucency persists, unchanged from the previous examination. The right lung remains clear. No mediastinal shift.
Case Discussion
Identifying a pleural edge and seeing lung markings extend to the pleural margin are important signs of pneumothorax that should be sought. In this case, the present of lucency in the left hemithorax simulated a pneumothorax that prompted the initial treatment of ICC insertion. However, there are several features that, in hindsight, contradict the diagnosis of pneumothorax.
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