What is the primary diagnosis for a patient with a cardiothoracic problem post right lung decortication (surgical removal of a restrictive layer of tissue around the lung), presenting with continuous air leak, leucocytosis (elevated white blood cell count), eosinophilia (elevated eosinophil count), and a skin drug allergy?

Primary Diagnosis and Differential for Post-Decortication Patient

Most Likely Primary Diagnosis

The patient most likely underwent right lung decortication for complicated parapneumonic effusion or empyema (pleural infection) that progressed to the organized stage with fibrinous peel formation restricting lung expansion. 1, 2

Indications for Lung Decortication

Decortication is performed to remove the restrictive fibrinous or fibrous peel from the visceral pleura when:

• Empyema reaches the organized stage (typically >2-3 weeks) with thick pleural peel preventing lung re-expansion 1, 2
• Medical management including chest tube drainage and intrapleural fibrinolytics has failed 1, 3
• Trapped lung syndrome develops with persistent pleural space and inability to achieve full lung expansion 1, 4
• Multiloculated empyema with significant pleural contamination not amenable to simpler drainage procedures 2, 5

The British Thoracic Society guidelines emphasize that decortication should be individualized based on patient fitness and empyema stage, particularly when the lung is trapped. 1

Differential Diagnosis of Lung Pathology Requiring Decortication

Primary Infectious Causes (Most Common)

Bacterial empyema is the leading indication, with:

• Gram-negative organisms predominating in recent series (38.5% culture-positive rate) 4
• Streptococcus pneumoniae, Staphylococcus aureus, and anaerobes as traditional pathogens 2, 4
• Progression through exudative → fibrinopurulent → organized stages over 2-4 weeks 2, 3

Fungal Causes (Less Common but Important)

Ruptured coccidioidal cavity requires prompt decortication and cavity resection when the pleural space is contaminated. 1 This presents with:

• Spontaneous pneumothorax (one-third of cases) or hydropneumothorax/empyema (two-thirds) 1
• Thick surrounding lung parenchyma with satellite nodules and fibrosis 1
• May require lobectomy in severe cases due to intense inflammation 1

Other Considerations

Tuberculous empyema - chronic fibrinous pleuritis requiring decortication in advanced cases 1

Post-pneumonic organizing pleuritis - sterile inflammatory reaction following pneumonia 2, 5

Malignant pleural disease - though less likely given the clinical presentation, should be excluded 1

Clinical Context of This Case

Persistent Air Leak Significance

The continuous air leak on day 12 post-decortication suggests:

• Incomplete lung re-expansion with residual pleural space 2, 3
• Possible bronchopleural fistula formation (6.8% complication rate) 2
• Inadequate pleural symphysis allowing persistent air communication 1

This is a recognized complication requiring prolonged chest tube drainage and potentially repeat intervention. 1, 2

Eosinophilia and Drug Allergy Context

The combination of leucocytosis, eosinophilia, and drug allergy raises important considerations:

• Drug-related pneumonitis can present with eosinophilia and various CT patterns including organizing pneumonia (23% of cases). 1, 6 However, this would be an unusual primary indication for decortication.

• Peripheral eosinophilia in empyema may indicate:

  • Allergic reaction to antibiotics used for empyema treatment 1
  • Parasitic infection (rare in typical empyema presentations) 1
  • Drug hypersensitivity pneumonitis superimposed on the primary process 1, 6

• The drug allergy likely represents a secondary complication from prolonged antibiotic therapy for the underlying empyema rather than the primary pathology. 1

Prognostic Factors

Patients requiring decortication typically have:

• Longer duration of preoperative symptoms (median >2-3 weeks) 2, 4
• Advanced disease stage at presentation (57.7% transferred from other hospitals) 4
• Higher ratio of frank empyema versus complicated parapneumonic effusion 2

Success rates for decortication:

• 86-100% definitive cure rate with open or VATS decortication 2, 3
• Perioperative mortality 3.4-5.6% 2, 4
• 6.8% require repeat surgery for persistent empyema or complications 2

Common Pitfalls to Avoid

Do not assume the eosinophilia indicates the primary diagnosis - it most likely represents drug hypersensitivity from treatment rather than eosinophilic lung disease requiring decortication. 1

Recognize that persistent air leak beyond 7-10 days post-decortication may require additional intervention including repeat VATS, pleurodesis, or prolonged drainage rather than expectant management alone. 1, 2

Consider fungal causes (especially coccidioidomycosis) in appropriate geographic regions or immunocompromised patients, as management differs significantly. 1