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This is a 32 year old man who comes into the ED complaining of shortness

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of breath and cough that's been going on for quite a bit of time,

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with a history of weight loss.

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Portable x-ray was obtained. And again, going through in our standard approach,

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what we see when we look at the left lung, is that there's a large pneumothorax.

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We can measure the air gap here.

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The apical portion is about 5cm.

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The lateral portion, we can call that 3.5cm.

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The patient is a little rotated.

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You could argue that there's a little bit of shift of the mediastinum to the right.

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And you see that with the splaying of the rib slightly, you also have the trachea that's

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to the right of midline, as well as the other mediastinal structure.

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So, the heart has also shifted over.

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So there's a little bit of tension secondary to this large pneumothorax.

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The right lung is clear.

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As you're going through looking at the soft tissues and the bone below

0:59

the diaphragm, all of those structures look pretty well in order.

1:04

I will draw your attention back to the lung.

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As we're kind of looking at the attenuation of the lung,

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we noticed that the upper lobe just looked a little denser and busy than it should

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have, even with some degree of atelectatic change because of the pneumothorax.

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And there was a little bit

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of heterogeneity that just didn't seem correct.

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So we did recommend a CT just to look at the lung parenchyma,

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to make sure that there wasn't anything else going on.

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The patient was waiting for the chest tube

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to be placed and we were able to just whip them over really quickly to CT.

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The patient was stable, so we were able to get that in quick succession.

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So I've got the CT to show you.

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Really what I'll draw your attention to is just the scout view again,

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which is the same finding that we saw on the radiograph.

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There's a little bit of shift. You can see midline here.

1:56

Shift of the midline, you've got some tension, you've got a large pneumothorax.

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You see that increasing opacity here in the upper lobe.

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And I'll just share with you really

2:04

quickly some of the characteristics and some of those cavitary lesions

2:08

that are seen in the upper lobe of the atelectatic lung.

2:12

And so given the history of cough that's been going on for a while,

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weight loss that was reported, and the upper lobe predominant cavitary

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lesion, TB certainly becomes much more of a concerning factor.

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So let's take a look to see if we see

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other findings that may support or kind of lead us in a different direction.

2:31

So, going back to the axial images, you again see the very large pneumothorax.

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On the left,

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you see a number of cavitary apical lesions.

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Some are thick walled, some are a little bit thinner.

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There are some other areas of consolidation.

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They're seen in the left upper lobe.

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Atelectatic changes are seen

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in the lower lobe and the right side looks pretty normal with the occasional, you know,

2:58

smaller, very subtle cystic changes. Shifting to the soft tissue windows.

3:05

This patient did not get contrast, but we're going to look for any evidence

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of adenopathy which we don't see any significant adenopathy,

3:14

which we don't see any significant adenopathy.

3:20

And then below the diaphragm looks unremarkable.

3:26

Take a quick look at the bones.

3:31

Just kind of looking at the spinal canal,

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the vertebral components, the ribs, the sternum, the clavicles.

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We've taken a look at the scapula,

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we've taken a look at...

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Just going to run through everything.

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I don't see any aggressive osseous lesions.

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I always like to take a look at the sagittal.

3:58

As we switch this back to lung windows

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on the sagittal, we're able to nicely see how large the pneumothorax is.

4:04

All of this space along here,

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you can see really nicely these thickened cavitary areas in the apex.

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So we did raise the concern

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of tuberculosis in this patient, given the symptoms.

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What we did find out in talking more

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to the clinicians is that this is a gentleman who did have an issue

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with housing security and so he was living in a number of halfway houses at times,

4:31

was staying with friends, but really didn't have a stable place to call home.

4:37

Certainly, that put him at risk and he was

4:40

actually lost the follow up before full testing could take place.

4:45

However,

4:46

he did return to the ED six months later with an x-ray that looked like this.

4:52

So again, his lung has re expanded.

4:55

He does have a pick line that was placed,

4:58

but he does have, you know, again, by apical, at this point, cavitary lesions.

5:05

There's no large adenopathy that we can see, no large pleural effusions.

5:09

The bones and the soft tissues otherwise look good.

5:12

But this is someone that we again flagged

5:14

as concern for TB, and this time he was kind of brought back in,

5:18

did get looped in with social services and a care regimen that actually allowed

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for him to get the treatment that he needed and deserved.

5:27

So this is a case, through sequential imaging,

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both x-ray and CT, of a patient who incidentally was seen to have evidence

5:36

of TB with cavitary lesions, but also had a pneumothorax with tension,

5:40

which is really, I think, what brought him in.

5:42

The pneumothorax itself lost the follow up,

5:45

came back with more extensive disease now, bilateral, upper lobe regions involved.

5:52

But this time we're able to really flag

5:54

and tag and get him connected with social services.

5:56

So, TB is something that we don't see frequently, but it certainly is something

6:01

that we need to be aware of because we will see it.

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Depending on where you're practicing with enough frequency that you want to be

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able to see it and recognize it when you see it.