Empyema necessitans: very late complication of pulmonary tuberculosis

Abstract

Empyema necessitans is a rare clinical finding nowadays. We report the case of a patient admitted in our ward for investigation of an unknown onset anterior chest wall mass, with no accompanying signs or symptoms. It is noteworthy that the patient had had pulmonary tuberculosis submitted to thoracoplasty more than 60 years before. Thoracic MRI showed a large heterogeneous mass, with a thick wall and internal septations located at the right anterior chest wall, as well as a heterogeneous content inside the right pleural cavity, with direct communication between both. An aspirative puncture of both masses was performed, with positive cultures for Mycobacterium tuberculosis, thus leading to the diagnosis of pleural tuberculosis with anterior chest wall empyema necessitans. A drain was inserted and antibiotics started. This case draws our attention to a very rare complication of pulmonary tuberculosis and its surgical treatment, though it aroused many decades after primary infection.

Figure 1

Right chest wall mass, with no local inflammatory signs.

Figure 2

Chest X-ray, showing thoracic asymmetry with right-hand side retraction, extensive pleural calcification, right mediastinal deviation and old rib fractures.

Figure 3

MRI, T1 with contrast.

Figure 4

MRI, T2.

Figure 5

A CT-guided aspirative puncture (intrapleural mass). Arrow indicates possible communication path between intrathoracic and extrathoracic masses.

Figure 6

A CT-guided aspirative puncture (extrapleural mass). Arrow indicates possible communication path between intrathoracic and extrathoracic masses.

Figure 7

CT scan, sagital view.

Figure 8

CT scan, coronal view.