Year : 2005 | Volume
: 22 | Issue : 4 | Page : 119--121
Herniation of tuberculous cavity presenting as caverno-chest wall fistula
SP Rai, SK Kaul, SS Naware, M Kashyap
Department of Respiratory Medicine, Cardio-thoracic Surgery, Radiodiagnosis and Pathology, Military Hospital, Namkum, Ranchi-10., India
S P Rai
Classified Specialist Medicine & Respiratory Medicine, Military Hospital (CTC), Pune 411 040
Spontaneous drainage of a tuberculosis cavity by way of cavernochest wall fistula is an extremely uncommon occurrence. We describe a patient of cavitary pulmonary tuberculosis, whose cavity herniated into the chest wall and formed a caverno-chest wall fistula. The patient responded to antitubercular treatment.
|How to cite this article:|
Rai S P, Kaul S K, Naware S S, Kashyap M. Herniation of tuberculous cavity presenting as caverno-chest wall fistula.Lung India 2005;22:119-121
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Rai S P, Kaul S K, Naware S S, Kashyap M. Herniation of tuberculous cavity presenting as caverno-chest wall fistula. Lung India [serial online] 2005 [cited 2019 Oct 22 ];22:119-121
Available from: http://www.lungindia.com/text.asp?2005/22/4/119/44437
Herniation of lung is defined as protrusion of lung tissue beyond normal thoracic boundaries through an anomalous opening in the chest wall, diaphragm or mediastinum along the parietal and visceral pleura ,,, .Lung herniae can be cervical, thoracic, diaphragmatic or mediastinal according to the location  . Aetiologically, they are of two types, congenital and acquired. Acquired herniae are further classified as traumatic, spontaneous and pathological. Chest trauma is the commonest cause of acquired lung hernia, however, some of the pathological varieties of lung herniae have been recently reported, which are mainly following tuberculosis ,, .
Development of spontaneous caverno-chest wall fistula in cavitary pulmonary tuberculosis is an extremely rare phenomenon. Extensive review of literature revealed only four such case reports ,,,, . We report a case of thoracic, spontaneous acquired herniation of lung presenting as caverno-chest wall fistula due to underlying cavitary pulmonary tuberculosis who was managed successfully with antituberculosis drugs.
A 23-year-old soldier was admitted with left sided chest pain, low grade fever with evening rise and 6kg weight loss of two week duration and appearance of localized swelling over left axillary area along with nonproductive cough and breathlessness of one week duration. There was no history of trauma. He was a nonsmoker and non alcoholic. His father had died of pulmonary tuberculosis three years back. He had no other significant past illness.
Physical examination revealed averagely built and nourished patient. His pulse rate was 84/minute, blood pressure 130/80 mm Hg and respiratory rate was 24/minute. He was a febrile and had early signs of clubbing. Chest examination revealed an ill defined, smooth, soft swelling of 9x6cm size over left third and fourth intercostal spaces in anterior axillary line. It was tender, crepitant, manually reducible with expansile cough impulse. On auscultation, bronchial breath sounds were present in right infraclavicular area along with occasional crepitations. No other abnormality was found on clinical examination.
His hemoglobin was 12.2 gm/dl, TLC-9400/ cumm, DLC-P66, L-28, M1, E5 % and ESR 40 mm in first hour. His urine analysis, blood sugar, renal and liver function tests were within normal limits. Mantoux test with PPD 10TU showed induration of 14mm. 1gM tuberculosis ELISA was positive. HIV was nonreactive. Chest radiograph showed a large cavity in left hemithorax with presence of gas in subcutaneous/ soft tissue planes along with mottling in right upper and left mid zones suggestive of pulmonary tuberculosis [Figure 1]. His sputum was negative for acid fast bacilli by smear and culture. Fiberoptic bronchoscopy was normal. CT scan chest showed thick irregular walled, peripherally placed cavity with subcutaneous soft tissue planes showing presence of gas [Figure 2],[Figure 3]. There was absence of generalized involvement of pleura. He was treated with antituberculosis chemotherapy (daily therapy containing 3 months Isoniazid, Ethambutol, Rifampicin and Pyrazinamide, followed by 3 months Isoniazid and Rifampicin). Patient showed good response to anti-tuberculosis treatment. He became afebrile in one week, expansile cough impulse stopped in one month. He gained 9kg weight and repeat chest radiograph showed near complete resolution of the lesion [Figure 4]. There had been no recurrence during one year follow up.
A majority of lung herniae (82%) are acquired and only 1% of the acquired herniae are secondary to tuberculosis, inflammatory or neoplastic disease of the chest wall and pleurae ,, . For a lung hernia to develop there are two essential criteria: a). Weakness of thoracic wall and b) increase in intrathoracic pressure produced by protracted coughing, straining, weight lifting etc. ,, .
Diagnosis of lung hernia can easily be made in the presence of soft, crepitant protrusion which bulges forward on coughing, forced expiration or Valsalva's maneuver , . The defect in the chest wall can often be palpated. Chest radiograph shows pulmonary parenchymal tissue protrusion beyond the normal confines of thoracic cage on tangential exposure ,, . CT-chest confirms the protrusion beyond the thoracic cage. The development of caverno-chest wall fistula in our patient appears, probably to have resulted from the rupture of the tension cavity because of endobronchial lesion acting like a check-valve mechanism. The rupture of the cavity spontaneously to the exterior into chest wall was not associated with pyopneumothorax as a complication because of the pleural symphysis that must have taken place. Chronic tuberculosis of the lungs is usually accompanied by pleurisy and the dense adhesions between the visceral and parietal pleura obliterate the pleural space. Absence of evidences for other causes of the presence of air in soft tissues of chest wall as well as the prompt clinical response to anti-tuberculosis treatment confirm the tuberculous etiology.
Usually, conservative treatment is sufficient. Surgical repair is indicated when there is constant pain, recurrent infection, respiratory distress, progressive increase in size of hernia and impending lung rupture ,,, .
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