Surgical surprise in a case of loculated empyema

Abstract

Cases of massive benign pleural effusion, presenting later as chronic empyema are a known entity. Surgical intervention in the form of tube thoracostomy, thoracotomy/video-assisted thoracoscopic evacuation of pus and decortication are needed as a routine. But sometimes a surgical surprise on the table, gives the tell-tale evidence of a missed aetiology for pleural effusion. We present here a rare case of chronic empyema left hemi thorax which turned out to be ruptured dermoid cyst of anterior mediastinum with massive pleural effusion which got infected on repeated thoracocentesis. A 23-year-old female, computer engineer presented with dyspnoea and dry cough of 3 months duration, associated with loss of appetite and weight. No history of fever. On examination, thin built, mild clubbing, tracheal shift to right with dullness/absent breath sounds on entire left chest. On investigation, image studies revealed massive left pleural effusion, repeated thoracocentesis done, recurrent effusion turned into pyothorax, tube thoracostomy done and empirical anti-tuberculous therapy started by chest physician. Finally, came for decortication, thoracotomy on table revealed evidence of ruptured dermoid cyst confirmed by histopathology. Patient recovered well and 6 months follow-up revealed no recurrence. Investigations did not give any clue for preoperative diagnosis in our case. Aetiology for chronic empyema is multifactorial. Ruptured anterior mediastinal benign cystic teratoma revealed on thoracotomy for empyema is a rare entity and only three cases are reported so far. We report another such rare case from south India.

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