Abstract Introduction A persistent air-leak (PAL) is defined as an air leak lasting more than 5 to 7 days postoperatively and is often caused by abnormal communications between the bronchial tree and pleural space or between the alveoli and pleural space. These fistulous tracts can arise from various etiologies, including surgical complications, infectious processes, or mechanical ventilation. A case of a 50-year-old female who developed PAL after bronchoscopy and transbronchial biopsy complicated by pneumothorax and chest tube placement is described here. Case Presentation A 50-year-old woman, recently immigrant from Haiti, presented with left facial paralysis initially diagnosed as Bell’s palsy, along with a seven-month history of dry cough, night sweats, and weight loss. Chest CT showing a miliary nodular pattern and multiple bilateral nodules, suspicious for disseminated infection. Further workup revealed HIV infection with a viral load of 1 million RNA copies/mL and a CD4 count of 110 cells/mm. A diagnostic bronchoscopy with transbronchial biopsy and bronchoalveolar lavage (BAL) was performed. All other infectious studies were negative. Pathology from the left upper lobe biopsy revealed non-specific findings, including septal fibrosis, chronic inflammation, and type II pneumocytic hyperplasia, while BAL cytology demonstrated a few pigmented macrophages and mixed inflammatory cells. Immediately following the procedure, the patient developed a left-sided pneumothorax, which progressed to a large size measuring 6.5 cm on repeat chest X-ray on post-procedure day one despite chest tube placement, with PAL that had improved only on continuous suction. Follow-up CT did not reveal a bronchopleural or alveolopleural fistula as the source of the leak. However, patchy ground glass opacities in the left lung suggesting underlying pneumonia were present (blue arrow). The air, graded as level 1 with coughing or expiration, persisted for 5 days. Endobronchial valve placement was considered; however, the air leak resolved on day 5, and the chest tube was removed on day 6. Discussion This case illustrates a refractory PAL in a newly diagnosed HIV patient without typical risk factors. While PAL in HIV are commonly linked to Pneumocystis jirovecii pneumonia, tuberculosis, or cystic lung disease, this patient had no infectious or structural abnormalities, suggesting that HIV-related lung fragility alone may contribute. However, the pneumothorax and air leak may also have arisen secondary to bacterial pneumonia suggested by her CT scan findings. Clinicians should consider both HIV-associated lung changes and bacterial pneumonia when evaluating PAL in HIV patients, even in the absence of classic risk factors. This abstract is funded by: None
Mohamed et al. (Fri,) studied this question.