Lack of mediastinal shift as a clue to delayed postpneumonectomy empyema

Delayed postpneumonectomy empyema is uncommon. The condition is usually elu sive and diagnosed late in the course of the disease, leading to increased morbidity. New air-fluid level on chest x-ray film or appearance of empyema necessitatis may enhance the index of suspicion and lead to early diagnosi s, but in many cases no clinical or laboratory clues are apparent, We descr ibe the case of a 60-year-old man with high fever and dyspnea 3 1/2 years a fter pneumonectomy, Diagnosis of postpneumonectomy empyema was delayed and finally suggested by the lack of expected mediastinal shift on chest film. Computed tomography (CT) of the chest showed a large quantity of fluid, whi ch later proved to be empyema, The patient was treated successfully by cont inuous cavity irrigation with neomycin and systemic antibiotics. We conclud e that in postpneumonectomy patients with septic fever, the only clue to di agnosis of delayed postpneumonectomy empyema may be hemithorax opacificatio n without mediastinal shift, confirmed by CT-guided thoracocentesis, Therap y with cavity irrigation and systemic antibiotics seems appropriate.