A 53-year-old man with hypertension, anxiety, and active alcohol abuse presented to the emergency room with increasing lethargy and shortness of breath. He reported a 9-day history of left-sided chest pain and erythema, which had worsened over the 4 days prior to admission. Review of systems was positive for fever, chills, fatigue, cough, chest tightness, and malaise. Notably, 12 days prior to his presentation, he was admitted after an assault and sustained facial fractures and lacerations; physical examination and CT of the chest/abdomen/pelvis at that time were negative for other injuries.
On re-presentation, he was tachycardic and normotensive. His left chest wall was warm, erythematous, and diffusely tender with crepitus that extended into the axilla. Initial laboratory data demonstrated hyponatremia (serum sodium 130 mEq/L (135–145 mEq/L)), an anion gap of 20 mEq/L (3–11 mEq/L), and hypovolemia, with a blood urea nitrogen (BUN) of 42 mg/dL (7–20 mg/dL) and a creatinine of 0.9 mg/dL (0.5–1.2 mg/dL). He had a leukocytosis of 17 500 cells/μL (4500–10 000 cells/μL) with a marked left shift (15% bands, 56% neutrophils). Blood cultures were collected. A CT of the chest/abdomen/pelvis was obtained and demonstrated a 23 cm×10 cm×18 cm collection of air and fluid in the left chest wall extending into the left axilla. A second collection was identified in the mediastinum and pleural space with concomitant collapse of the left lower lobe and almost the entire left upper lobe (figure 1).
CT scan on the day of presentation. There is a 23×10×18 cm heterogeneous collection containing air in the subcutaneous soft tissues. There is extension of the collection into the thoracic cavity, involving the pleural space as well as the upper mediastinum. The left lower lobe and lingula are collapsed, and only the upper left lung remains aerated. The tracheobronchial tree is unaffected.
