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Endgames Picture Quiz

An ominous cough

BMJ 2010; 340 doi: (Published 05 May 2010) Cite this as: BMJ 2010;340:c1994
  1. Harpreet Ranu, specialist respiratory registrar,
  2. Shelley Srivastava, specialist respiratory registrar,
  3. Brendan Madden, professor of cardiothoracic medicine
  1. 1Department of Cardiothoracic Medicine, St George’s Hospital, London SW17 0QT
  1. Correspondence to: B P Madden brendan.madden{at}

    A 55 year old woman with bronchiectasis, lobe sequestration, and recurrent respiratory infections failed to respond to medical treatment. Pulmonary function tests showed forced expiratory volume in one second of 2.3 l/ (85% of predicted) and diffusion lung capacity for carbon monoxide (a test of the integrity of the alveolar-capillary surface area for gas transfer) of 5.56 mmol/min/kPa (66% of predicted). She underwent right lower lobectomy, but four weeks later she developed fever, cough with frothy serosanguinous sputum, and right pleuritic chest pain. She was admitted to hospital and chest radiography was performed (fig 1).

    Fig 1 The patient’s chest radiograph


    • 1 What is the most likely diagnosis?

    • 2 What risk factors are associated with the diagnosis?

    • 3 How should this patient be managed?


    1 What is the most likely diagnosis?

    Short answer

    The chest radiograph shows an air fluid level at the right intermediate bronchus close to the site of the bronchial stump. In addition, opacification of the right lower zone of the hemithorax is obscuring the right hemidiaphragm and right heart border, probably because of a right pleural effusion (fig 2). This radiograph combined with the clinical history suggests the presence of a postoperative bronchopleural fistula.

    Fig 2 Chest radiograph showing an air fluid level close to the bronchial tree at the level of the bronchial …

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