The Hippocratic Splash

Abstract

Although the current medical literature is limited, hydropneumothorax was described as far back as the 5th century BC. It is characterized by the presence of air and fluid in the pleural cavity and is an infrequent finding. Causes include trauma, iatrogenesis following thoracentesis, the presence of gas-forming organisms, tuberculosis and malignancy. Diagnosis is based on clinical and radiological features. We report a case of hydropneumothorax and present radiological images showing the distinctive features of this entity.

Learning points: Hydropneumothorax is defined as the presence of air and fluid in the pleural cavity and is an infrequent finding.Clinical features may present as breathlessness and chest pains with decreased breath sounds, dullness in a straight line, shifting dullness, a succussion splash and a positive coin test on physical examination; supine radiography demonstrates a distinctive pleural line with increased density lateral in the pleural cavity.Hydropneumothorax is managed by chest tube insertion for intercostal drainage.

Keywords: Hydropneumothorax; Mycobacterium xenopi; pneumothorax; radiology.

Figure 1

Chest radiography showing left-sided hydropneumothorax with contralateral deviation of the left mediastinum and the presence of multiple thin-walled cavitated lesions on the right side

Figure 2

Computed tomography (CT) showed hydropneumothorax on the left side of the lung, not loculated, with a maximum thickness of 4 cm (blue arrows), resulting slight contralateral deviation of the mediastinum, a cavitated lesion (green arrow) and irregular densities on the base

Figure 3

Post-drainage chest radiography showed re-expansion of the left lung with significant reduction of the hydropneumothorax and resolution of the deviated mediastinum. Left hemi-diaphragmatic elevation suggests a collapsed left lung