Abstract Introduction Bronchopleural fistula (BPF) with empyema is a dangerous post-pneumonectomy complication. While most declare early, BPF can arise decades later sustained by chronic infection. Management priorities are source control, drainage, and reconstruction post-infection. We report a decades-delayed BPF after pneumonectomy, outlining the importance of an Eloesser flap thoracostomy window to clear the infection and the complicating presence of a plasma cell granuloma. Case Report A 37-year-old male, originally from Venezuela, non-smoker with PMH of supposed recurrent Pseudomonas PNA s/p right pneumonectomy in 2005, initially presented to our ER for cough, fever, and left-sided chest pain. CT chest showed absence of the right lung, pleural calcifications compatible with prior pleurodesis, a small chronic ex-vacuo pneumothorax, and an 8 × 6 mm opacity in the left lower lobe (LLL), favored to represent air-space opacity rather than a nodule. He was discharged with antibiotics and surveillance. In clinic, he reported a productive cough with intermittent hemoptysis. AFB×3 and QuantiFERON were negative; sputum culture grew E. coli. Cardiothoracic surgery recommended a repeat CT, which showed possible communication between the right bronchial stump and an abscess with intrapleural air. Bronchoscopy showed purulence from the right bronchial stump and papillomatous tissue on the right lateral tracheal wall, negative for HPV (Image). Pathology revealed plasma cell granuloma. After re-presenting with hemoptysis, CT angiography excluded pulmonary embolism but revealed ill-defined centrilobular LLL nodules concerning infection; he was admitted and a large-bore chest drain was placed with thick, purulent output. He underwent right thoracostomy with the creation of Eloesser flap thoracostomy window with chronic packing to treat his persistent BPF. Fiberoptic bronchoscopy and right VATS exploration were performed; the cavity was debrided. Endobronchial valves were not attempted as the fistulas were small. The cavity gradually obliterated and the flap was closed. Patient now awaits plastic surgery eval for correction of chest concavity deformity. Discussion This case underscores multiple clinical pearls. First, in any patient with new hemoptysis, post-pneumonectomy, there needs to be a high suspicion for delayed BPF. Second, in chronically contaminated spaces, source control and dependent drainage are paramount but attempts at closure should be deferred until the cavity is sterile and tissue biology is favorable. Third, endobronchial valves have limited utility for proximal stump defects within infected post-pneumonectomy cavities; Eloesser flap thoracostomy window offers reliable drainage with potential planned closure. Fourth, incidental airway lesions such as HPV-negative plasma cell granuloma can complicate evaluation. This abstract is funded by: None
Bicalho et al. (Fri,) studied this question.