81. A new case.
- Which technology?
(Click here for the answer) Maximum-intensity-projection: in this way, a larger number of CT slices is totalled up. This addition concerns merely the densest image-points, so that bones, chalk (calcium) and various contrast agents are stressed.
We may see a large plombage with an irregular calcified wall. The shape shows us that the plombage content is oily, i.e. Fluid and not solid. The Densitometry permits an unambiguous diagnosis of the oleothorax, but is unable to properly differentiate between oil and paraffin.
A thick, circular formation is to be found in the caudal section of the plombage. In the case of a fluid content, these bodies may move freely = i.e. Dipping down to the lowest spot.
Karl Gürtler (Bielefeld) described such a "Plombage Mouse”and documented this incident from different angles and positions by means of fluroscopy.
82. Patient already displayed in 81. CT- transversal cut - in the lower part of this plombage. Strong and significant irregular wall calcification.
Oil is a little less dense as fat cells, but significantly denser than air: quite typical, therefore, for an oleothorax.
Within the plombage itself may be found the already-described , spherically rounded, homogen-calcified image: a "Plombage mouse”.
Bild 82
83.Installation of a plombage in 1939 cause of a therapy-resistant, open lung tuberculosis in the left upper region. a83.Installation of a plombage in 1939 cause of a therapy-resistant, open lung tuberculosis in the left upper region.
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- What, then, precisely, is so typical? What is not totally normal? What known complication has already commenced?
(Click here for the answer) First of all, we shall document what is typical: foreign-bodies' reaction to the wall leading to calcification: a complication which occurs regularly after several years.
What is noteworthy is the shrinking of the left thorax with all of the inherent signs.
- This expiration posture is typical for a shrinking process.
- Diminishing and reducing "intercostal spaces” (only a swelling and thickening of the ribs is not yet proven).
This shrinkage is atypicaly for oleothorax; it is much more common in fibrithorax (with or without chronical empyema). We suppose the shrinkage is a result of primary toberculous infection and nor a complication of therapy.
84. Same case.
Another uncommon but typical complication is:
Exsudat influx in the plombage content.
(Hutton, 1983; Mullin,1986)
Remark the mirror between fat above and exsudat below.
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- To repeate: which additional and rare complications are not detectable here as a threat, but are here as part of this combination ?
(Click here for the answer) The rare plombage perforation
- in the soft areas*
- in the bronchial system** (Mullin 1986 , Tsou 1978)
- in the mediastinum (Deck 1969)
- the rare infection case
*Pleurocutane Fistula is described by Howlett (1937) and by Hayes (1933) .
** Twersky (1972) observed a post-traumatic , provoked fistula.
85. Further oleothorax with Paraffin.
The commonplace, reactionary wall-thickening is very clear. The calcification tends to be especially thick . The inner regions of the caverns show there to be a three-layered structure.
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- What, in all likelihood, are the pertinent composite parts in this formation?
(Click here for the answer) Top: fat
Middle: exsudat
Bottom: exsudat with cell-damage
At the time of the examination, there was no clinical proof or evidence of an infection.