A colonic splenic flexure tumour presenting as an empyema thoracis: a case report
© Murphy et al; licensee BioMed Central Ltd. 2009
Received: 28 December 2007
Accepted: 13 January 2009
Published: 13 January 2009
The case report describes the rare presentation of a 79-year-old patient with a locally perforated splenic flexure tumour of the colon presenting with an apparent empyema thoracis in the absence of abdominal signs or symptoms.
Initial presentation was with a non-productive cough, anorexia and general malaise. An admission chest X-ray and subsequent computed tomographic image of the thorax showed a loculated pleural effusion consistent with an empyema. The computed tomography also showed a thickened splenic flexure. Thoracotomy was performed and a defect in the diaphragm was revealed after the abscess had been evacuated. A laparotomy was carried out at which point a tumour of the splenic flexure of the colon was found to be invading the spleen and locally perforated with subsequent collection in communication with the thorax. The tumour and spleen were resected and a transverse end colostomy was fashioned.
One must consider the diagnosis of pathology inferior to the diaphragm when an apparent empyema thoracis is encountered even in the absence of clinical signs or symptoms.
The case describes the rare presentation of a patient with a locally perforated splenic flexure tumour of the colon with an apparent empyema thoracis in the absence of abdominal signs or symptoms. This has been described once in the past by Teruuchi et al. .
The patient made an uneventful postoperative recovery and was discharged from hospital 15 days after the operation having received the relevant vaccinations. Pathological assessment showed a Dukes B moderately differentiated adenocarcinoma with the pathological staging of T4 N0 M1. The label of M1 is derived from the fact that the thorax was breached. Adjuvant chemotherapy has been scheduled.
The case highlights the rare presentation of an apparent empyema thoracis secondary to abdominal pathology. Technically, it is not a true empyema given that it originated and communicated with the abdominal cavity, hence its labelling as an 'apparent' empyema. The only previous example of this pathology was described by Teruuchi et al. , and was the case of a 63-year-old man who presented with chest pain and fever and was noted to have a pleural effusion and a pneumothorax on chest X-ray. In contrast, our patient had neither chest pain nor a pneumothorax. What was also interesting in this instance is that the patient had an insidious onset of symptoms and had no abdominal symptoms or signs. Possible alternative approaches would have been to perform a contrast enema or colonoscopy pre-operatively to further evaluate the detected colonic anomaly or to carry out a thoracoscopy to assess the diaphragm even though one could argue that neither was clinically indicated. The use of video assisted thorascopic surgery (VATS) may have been advocated in some centres. Invariably, thoracotomy with washout as well as laparotomy with tumour resection would have been required, as was the procedure in our patient. In the future management of empyema thoracis, one needs to remember the differential diagnosis of diaphragmatic perforation that has been outlined in this patient, and that the clinical absence of classical symptoms and signs does not rule out the aforementioned pathology.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank Mr M Corrigan for his substantial contribution with regard to drafting and acquisition as well as Mr A O'Donnell for cardiothoracic opinion.
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