A 32 year old man presents with a 4 day history of increasing right sided chest pain and associated shortness of breath. He has no fever, no cough and no sputum production. He is sitting back at 45 degrees.
You begin by exploring the 2nd interspace in the mid-clavicular line bilaterally. What do these images show?
- The first clip taken on the patient’s left side demonstrates normal lung sliding.
- The second clip taken on the symptomatic right side shows absence of sliding and features consistent with pneumothorax.
You then move to explore the right lower chest wall and costophrenic angle. What does this clip show?
Views of the right costophrenic angle show a complex, located pleural effusion. Within the effusion are small foci of air and areas of more solid appearing material.
The differential is large; ultrasound cannot determine the precise nature of the fluid.
In this case the fluid was blood, with locations and blood clot visualised. Spontaneous haemopneumothorax is uncommon, and in females would raise the question of thoracic endometriosis and catamenial haemopneumothorax.
The history is not typical for infection or malignancy, however infection with empyema and pneumothorax / bronchopleural fistula or malignancy with effusion and pneumothorax would be possible alternate diagnoses.
This is the patient’s chest x-ray.
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