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Weekly Chest CasesArchive of Old Cases

Case No : 602 Date 2009-05-11

  • Courtesy of Dae Hee Han, Jung Im Jung, Myeong Im Ahn, Seok Hee Park. / The catholic University of Korea, Seoul St. Mary's Hospital.
  • Age/Sex 71 / M
  • Chief ComplaintAsymptomatic. The patient received a surgical treatment of pulmonary tuberculosis 30 years ago.
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Plombage (or paraffin plombage) with probable migration of the plombage material through the chest wall
Radiologic Findings
Chest PA shows a mass in the apex of the left hemithorax. The mass is of heterogeneous density, and is relatively lucent condering its large large. The cortical margin of the 3rd left rib is indistinct where it is projected upon the mass shadow.

Noncontrast scan through the upper thorax shows a large mass in the posterior chest wall causing expansion and erosion of the adjacent rib. The mass is largely of fat density, with small islands of soft tissue mixed with it. There are nodular calcifications along the inner surface of the mass. Contrast-enhanced scan shows no enhancing portions within the mass. The mass seems to have extended posteriorly (arrow) to form a thick layer of fatty tissue between the paraspinal and chest wall muscles, with nodular calcifications adjacent to the subscapularis muscle.
Brief Review
In the belief that collapsing the lung around the foci of tuberculous infection provided for anatomic healing of the lesions, physicians in the first half of the 20th century performed artificial extrapleural pneumothorax. If the patient tolerated artificial pneumothorax well, the surgeon injected or implanted plombe, a space-filling substance, during a second operation in order to compress the lung. Many substances were tried as substrate for plombe, and they included fat, gauze packing, oil, paraffin wax, bone, rubber bag, muscle, and synthetic materials, such as methylmacrylate spheres, fiberglass, polyethylene sheeting, and polystan sponge. There were complications resulting from collapse therapy including infection of the plombage space, blood vessel erosion, hemorrhage, and breach of the underlying parenchymal cavitation. It is said that paraffin wax, the material presumably used as plombe in this patient, were more prone to infection and extrusion, and thus was largely replaced by methylmacrylate, or lucite balls. With time, it became apparent that lucite also causes complications such as migration into adjacent structures and erosion of overlying ribs. Plombage thoracoplasty were also known to cause neoplastic complications to the chest wall, including epithelioid angiosarcoma, lung carcinoma, and non-Hodgkin's lymphoma. Performing extrapleural plombage for collapse therapy eventually fell out of favor as an optimal treatment for tuberculosis, largely due to introduction of antimicrobial therapy. It is reserved for patients with multi-drug resistance tuberculosis not eligible for surgical excision of infected lung tissue due to severe extension of disease or poor lung function.
References
1. Mathews J, Vrablik MC, Paniagua MA.Plombage migration outside the thoracic cavity: a complication of tuberculosis treatment.
J Am Med Dir Assoc. 2009 Feb;10(2):138-40.
Keywords
Chest wall, Iatrogenic lung disease, Postoperative complication, Tuberculosis,

No. of Applicants : 91

▶ Correct Answer : 44/91,  48.4%
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
  • - DCA, , India Rajesh Gothi
  • - Osaka University , Japan Osamu Honda
  • - CHU caen , France nicolas gautier
  • - Assam medical college , India Karunakaran M
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - MD SKNMC & GH,Pune,Maharashtra, INDIA , India Sushant Bhadane
  • - CHRU lille , France manuel toledano
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - hospital Sao Paulo , Brazil israel missrie
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - CHUV , Switzerland Andrea Ojanguren
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) YOOKYUNG KIM
  • - Gumi Kangdong hospital , Korea (South) Ju Ae Kim
  • - Yashoda Superspeciality hospital , India Pravin Mahadevappa
  • - Shinchon Severance Hospital , Korea (South) Ho-Joon Lee
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Private Clinic , Bahamas Trupti Dabholkar
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Barnard Institute of Radiology, Madras Medical College , India Iyappan Ponnuswamy
  • - The Armed Forces Daegu Hospital , Korea (South) Hyungwoo Oh
  • - Shinchon Severance hospital , Korea (South) Hye Mi Kim
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - sunder lal jain hospital,delhi , India sanjeev vachher
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Gimpo Woori Hospital , Korea (South) Son Youl Lee
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Catholic medical center, College of Medicine, The Catholic University of Korea , Korea (South) Soo Kyung Yoon
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Yonsei University Health System , Korea (South) Injoong kim
  • - Ewha Womans University , Korea (South) Eun Ju Ha
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - NASA SCANS , India RAKESH BHATIA
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - PITTWATER RADIOLOGY , Australia Saurabh Khandelwal
  • - PITTWATER RADIOLOGY , Australia Julie Arora
  • - govt royapettah hospital , India gopinathan kathirvelu
  • - Kangnam Sacred Heart Hospital , Korea (South) Jaewon Kim
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
▶ Correct Answer as Differential Diagnosis : 3/91,  3.3%
  • - kims,narkatpally , India k bhaskar
  • - ROHINI Scan Center. Ambattur, Chennai , India Umapathi Mahesh
  • - McGill University Health Center , Canada Alexandre Semionov
▶ Semi-Correct Answer : 2/91,  2.2%
  • - Institute of Chest Diseases,Calicut , India sijith raghavan
  • - KKUH , Saudi Arabia NABIL GHALEB
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