Visual Diagnosis: Tension Pneumothorax with Evolving Cysts in an Infant

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1. Ariel Stein, MD*,† 2. Helena Molero, MD*,† 3. Donavon Hess, MD, PhD*,‡ 4. Mark Luquette, MD*,§ 5. Michael B. Pitt, MD*,† 1. *University of Minnesota School of Medicine, Minneapolis, MN 2. †Department of Pediatrics 3. ‡Department of Surgery, and 4. §Department of Laboratory Medicine, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN * Abbreviations: CPAM: : congenital pulmonary airway malformation ED: : emergency department RSV: : respiratory syncytial virus A 5-month-old previously healthy term male infant presents to a rural emergency department (ED) for a 1-week history of increasing congestion, poor oral intake, and a temperature of 103°F (39.4°C). He is being treated with amoxicillin for presumed pneumonia. His examination in the ED is significant for scattered rhonchi and mild dehydration. His chest radiograph reveals inflammatory changes without a focal infiltrate (Fig 1). However, because this is his fourth presentation to the ED during this illness, he is admitted for observation. During the next 2 days his respiratory distress and tachypnea progressively worsen. On day 3 of his hospitalization he begins having episodes of desaturation and worsening retractions refractory to oxygen via low-flow nasal cannula. His examination at this time is significant for diffuse rhonchi throughout both lung fields with decreased air entry at the lung bases. Because his clinical status is deteriorating, he is transferred to a higher level of care. Figure 1. Anteroposterior and lateral chest radiographs on hospital day 1 show patchy, predominantly perihilar airspace opacities, consistent with viral inflammatory/reactive airway disease. No lobar consolidation. No pneumothorax. On arrival at the referral center he is lethargic, with decreased breath sounds and persistent desaturations. A respiratory swab polymerase chain reaction is positive for respiratory syncytial virus (RSV). His chest radiograph reveals a large right-sided tension pneumothorax (Fig 2). A pigtail chest tube is emergently placed, and his work of breathing improves. Within 2 days he is no longer requiring supplemental oxygen. The medical team is unable to successfully put the chest tube to water seal, however, because each time it is sealed there is a rapid re-accumulation of his pneumothorax. After several unsuccessful attempts, his chest tube is placed back to suction and he is airlifted, via helicopter, to a pediatric tertiary care center for further evaluation, now 11 …

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