Fulminant Food Aspiration-Induced Pneumonia Leading to Tension Pyopneumothorax after Proctectomy: An Autopsy Case

Postoperative aspiration pneumonia is an uncommon but severe pulmonary complication, particularly in older adults with cognitive impairment. We report an autopsy case of fulminant aspiration pneumonia, caused by food aspiration following colorectal cancer surgery, that progressed to tension pyopneumothorax.

A male aged ≥75 years with dementia underwent laparoscopic high anterior resection for rectal cancer and resumed oral intake after passing a water-swallowing test. Shortly thereafter, he developed rapidly progressive pneumonia, hypoxemia, and septic shock, ultimately progressing to bilateral tension pneumothorax and death. Autopsy revealed multiple pulmonary abscesses, extensive lobular pneumonia, and subpleural fistulae in all lobes of both lungs. Grocott staining identified vegetable matter consistent with aspirated food, and colonies of Actinomyces species were also present, confirming aspiration pneumonia complicated by lung abscesses. Multiple pleural surface perforations from these abscesses likely caused substantial air leakage into the pleural space, culminating in uncontrolled tension pyopneumothorax. No histological signs of chronic aspiration were found.

In older adults with dementia, massive food aspiration can lead to fatal pneumonia with progression to pyopneumothorax, even in the absence of prior aspiration history. Vigilance is essential when resuming oral intake in such patients after surgery.