A case of chronic tuberculous empyema and chest wall abscesses following extrapleural Lucite ball plombage 52 years before

Abstract

A 71-year-old diabetic man, who underwent left extrapleural Lucite ball plombage for pulmonary tuberculosis 52 years before, presented to our hospital complaining of left axillary swelling and tenderness. He was febrile and also had two other chest wall protrusions. Chest x-ray and contrast-enhanced CT scan films revealed empyema in the dead spaces made by the Lucite balls and chest wall abscesses communicating through intercostal spaces. No tuberculous lesions were detected in either lung field. Incision and drainage were performed, but the thin, yellowish, creamy pus revealed no organisms at first. Extirpation of the plombs and fenestration with removal of the dorsal part of his left 7^th and 8^th ribs was performed through left thoracotomy, and eighteen hollow Lucite balls of three different sizes, 3 to 5 cm in diameter and weighing 350 g altogether, were removed. Most of them contained creamy pus inside, and some of them were partially fractured or divided at midline seams. We inserted sterilized gauze pads immersed in povidone iodine in the dead spaces of his left thoracic cavity. Based on the positive acid-fast bacilli culture and polymerase chain reaction (PCR) confirming this organism as Mycobacterium tuberculosis, which had become evident after the first surgery, we diagnosed this case as tuberculous empyema with chest wall abscesses, and antituberculous multi-drug regimen was initiated. At the second surgery a month later, curettage of the left thoracic cavity and decortication of the left lung surface was carried out. The previously removed and preserved left 7^th and 8^th ribs were autologously re-implanted, but later showed minor complication of periosteal tissue necrosis and sterile effusion.
Before the advent of antituberculous drugs in the 1950s, surgical treatment for pulmonary tuberculosis played a very important role, especially the collapse therapies, like thoracoplasty or plombage. Extrapleural Lucite ball plombage was one of them, but soon disappeared because of its various life-threatening complications. Survivors, as seen here, are also annoyed by its late complications such as empyema or hemothorax. However, it is also true that this patient had been free of tuberculosis and asymptomatic for about a half century. It is of interest to discuss the bright and dark side of this histological technique and therapeutic options for its late complications, and we found this successfully treated case worth reporting.