Abstract Introduction Occult pneumothorax (OP) is a pleural air collection unidentifiable on supine chest X-ray (CXR). OP can occur with any process causing pleural disruption including trauma and cystic lung disease. We present a case of an anterior OP in a patient with severe Pneumocystis jirovecii pneumonia (PJP), where the underlying pathology was masked by falsely improving serial CXRs, necessitating bedside ultrasound (US) for diagnosis and life-saving intervention. Case Presentation A 41-year-old man with AIDS, bronchiectasis, and PJP was admitted for bilateral pneumothoraces requiring chest tubes. On hospital day 7, he developed severe respiratory distress with tachycardia and hypoxemia. Examination showed a right sided chest tube with appropriate tidaling and the left tube with a persistent, intermittent air leak as before. Despite this clinical worsening, the supine CXR was falsely reassuring, reporting a small, unchanged pneumothorax on the left and complete resolution on the right. Given the clinical-radiological disconnect, bedside thoracic US was performed, which showed loss of lung sliding along the left anterior hemithorax. An anterior chest tube was inserted with immediate resolution of symptoms and vital sign instability. Discussion This case illustrates the significant limitations of CXR in identifying clinically relevant OP, particularly in critically ill patients where anterior pockets cannot be visualized. Upright positioning allows for visualization of the visceral pleural line to identify a pneumothorax; this sign is rarely visualized in a supine patient without a large pneumothorax present (1). Use of CXR and ultrasound to detect pneumothoraces has been compared in ventilated patients and the ED setting with a higher sensitivity with ultrasound use (2,3). Ultrasound evaluation of the anterior parasternal borders and along the mid-axillary line of the fourth or fifth intercostal space pneumothoraces can promptly assess for OP (4). While CT imaging can confirm an OP, the time and risk of transport are often prohibitive in the decompensating patient. Thus, in patients with a clinical change, bedside ultrasound should be utilized for rapid evaluation of acute respiratory distress. Conclusion Occult pneumothoraces can occur in patients at risk for pleural disruption. OP should be suspected in high-risk patients who acutely decompensate regardless of unremarkable CXR findings. Bedside thoracic ultrasound is a quick, safe, and highly sensitive diagnostic modality that should be utilized as the first-line assessment tool to detect OP, preventing the delays and risks associated with transportation to CT in unstable patients. This abstract is funded by: none
Phan et al. (Fri,) studied this question.
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