A Young Man With Apical Fibrotic Changes on Chest Imaging and History of Pneumothorax

A 37-year-old man, who actively smoked with a 15 pack-year history, working in a greenhouse, was referred for evaluation of intermittent, nonpleuritic chest pain without specific characteristics. He reported no dyspnea, weight loss, hemoptysis, or fever. His medical history was unremarkable except for a left spontaneous pneumothorax 3 years earlier that failed to resolve with chest-tube drainage and required surgical bullectomy with apical and pleural biopsy, for which no diagnosis was established despite thorough evaluation. A chest radiograph during the patient's first hospitalization demonstrated a large, left-sided pneumothorax with partial lung collapse (Fig 1A), for which a chest tube was inserted; however, the lung could not be fully reexpanded (Fig 1B). A subsequent chest high-resolution CT scan (Fig 2) revealed bilateral apical pleural thickening and persistent left pneumothorax with subpleural parenchymal collapse. Because of the incomplete expansion, the patient underwent left apical bullectomy and pleurectomy through a limited thoracotomy. He recovered uneventfully and was discharged after a few days. Surgical specimens included an apical cap and visceral pleura. Histologic examination revealed dense pleural and subpleural fibrosis with an abrupt transition to relatively preserved underlying alveolar parenchyma (Fig 3). These findings were interpreted as nonspecific chronic pleuritis, and a definitive diagnosis could not be established at that time. He was not taking any medications, and no occupational exposure was mentioned. There was no family history of interstitial lung disease. The patient was referred to our hospital to investigate and manage his long-standing condition.