Lack of mediastinal shift as a clue to delayed postpneumonectomy empyema

Delayed postpneumonectomy empyema is uncommon. The condition is usually elusive 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 diagnosis, but in many cases no clinical or laboratory clues are apparent. We describe the case of a 60-year-old man with high fever and dyspnea 3(1/2) years after 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, which later proved to be empyema. The patient was treated successfully by continuous cavity irrigation with neomycin and systemic antibiotics. We conclude that in postpneumonectomy patients with septic fever, the only clue to diagnosis of delayed postpneumonectomy empyema may be hemithorax opacification without mediastinal shift, confirmed by CT-guided thoracocentesis. Therapy with cavity irrigation and systemic antibiotics seems appropriate.