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Bone Case 16 Answers

1) Describe the abnormalities

(i) There is a mild biconcave scoliosis with a few scattered areas of moderately raised uptake in the thoracolumbar and cervical spine; a typical pattern for degenerative change.
(ii) there is a marked deformity of the upper rib cage on the right
(iii) there is raised activity centred over the region of the upper left lung

 

2) What possible explanation is there for the major abnormalities?

The thoracic abnormalities are sequelae of surgery for pulmonary TB in the pre-antibiotic days. He underwent both right thoracoplasty with considerable resultant rib cage deformity and left apical plombage. The area of plombage shows considerable heterotopic soft tissue uptake.

Click here to see his conventional chest radiograph.

Before the discovery of antimicrobial drugs and development of techniques of pulmonary resection from 1940s to the early 1960s, collapse therapy was the mainstay of treatment for pulmonary tuberculosis. It evolved from the idea that artificial collapse would put the lung at rest, promote the healing process and prevent spread of tuberculous material to uninvolved parts of both lungs. A successful treatment resulted in formation of fibrosis with encapsulation of the diseased portion and containment of infection.

Methods to achieve and to maintain the collapse were many but most commonly included artificial pneumothorax, phrenic nerve crush, thoracoplasty, and plombage.

Thoracoplasty
By removing portions of the second to eighth ribs, the affected lung collapses. Whilst the procedure is disfiguring, irreversible and reduces pulmonary capacity, thoracoplasty is a powerful therapy for pulmonary tuberculosis. One recent study showed that 67% of >300 patients with bilateral pulmonary TB treated with plombage and thoracoplasty had inactive disease at 5-years. Thoracoplasty continues to remain a potent surgical technique for control of empyema (particularly post-pneumonectomy), closure of bronchopleural fistula, obliteration of fibrocavitary disease, sputum conversion and control of haemoptysis in patients with advanced pulmonary TB

Plombage
The method of plombage involved creation of an extrapleural space and filling it with one of many available materials. Usually this was with methyl-methacrylate (Lucite) balls or vegetable / mineral oil (oleothorax). Other materials used include fat (omentum, fresh lipoma), paraffin wax blocks, bone, gauze sponge, silk, gelatin or rubber balloons.

The advantages of plombage over thoracoplasty included selective collapse of the diseased part of the lung with less derangement of pulmonary function; also, it could be carried out in one stage and was cosmetically more acceptable.

 

3) Are we likely to encounter such patients in the future?

Many living patients treated by plombage are now dying of unrelated old-age diseases thus fewer and fewer will be seen in the future. Hence, many consider such cases to be purely historical and of little relevance. However, over the past 15 years, a significant and steady worldwide increase in prevalence of tuberculosis has been noted, including multiple-drug resistant organisms and atypical strains. Predictions show that both the incidence of tuberculosis and the number of multiple-drug resistant strains will continue to increase. There are already many patients for whom no combination of agents is of any use. In absence of adequate therapeutic agents, it has been postulated collapse therapy will return

 

4) Do these patients encounter complications?

Obviously, such deforming surgery can result in type 2 respiratory failure. Also, the original TB infection can reactivate at any stage. However, complications are encountered decades later, particularly with plombage. The presence of a foreign body for a prolonged period of time resulted in complications, most commonly, infection and migration but also malignant tumours , erosion of major vessels with bleeding and haemoptysis.

 

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The text is entirely the opinion of the author and does not necessarily reflect that of RUH NHS Trust or the Bristol Radiology Training Scheme. Website content devised by Paul McCoubrie.