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From the EMDaily Archives: What’s the Diagnosis? By Dr. Eric Chavis

A 27 year old male with a history of osteosarcoma with numerous lung metastases s/p left upper lobe wedge resection 1 year ago presents with dyspnea on exertion and “abnormal findings on outpatient CT scan”. Vitals include HR 135, RR 18, SpO2 93% on room air. On exam, he has diminished but present breath sounds bilaterally. A chest x-ray is obtained and shown below. What’s the diagnosis?

Answer: Hydropneumothorax (see pleural line in periphery of left lung and pleural effusion)

  • Defined as the presence of both air and fluid in the pleural space
  • Can be either atraumatic or traumatic (hemopneumothorax)
  • Underlying etiologies can include: COPD (due to presence of blebs), pneumonia, TB, malignancy, prior lung instrumentation
  • Most common presenting symptoms are SOB and cough
  • Diagnosis can be made on CXR, US, or CT
  • In the event of tension physiology, treat as tension PTX with needle decompression, tube thoracostomy
  • For more stable cases, treatment is supplemental O2 to help with lung re-expansion, tube thoracostomy, and pulmonology consultation
  • Ultimately, requires admission for further workup, treatment of underlying condition
  • The etiology of this patient’s hydropneumothorax was unknown, but possibly related to underlying malignancy


Kasargod V, Awad NT. Clinical profile, etiology, and management of hydropneumothorax: An Indian experience. Lung India. 2016;33(3):278-280. 

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