A 16-year-old with left-sided pneumothorax.

(CHEST 1999; 115:881–882) A 16-year-old boy with features of Marfan’s syndrome, previously in good health, had left sided chest pain and dyspnea of 6 days’ duration, which had worsened considerably on the day of admission. A posteroanterior chest radiograph showed complete pneumothorax on the left side and a partial pneumothorax on the right side. A chest tube was inserted on the left side and connected to an underwater seal drain. The patient became more dyspneic immediately. A repeat chest radiograph showed air space shadowing over the entire left lung field and an increase in the size of the pneumothorax on the right side (Fig 1). Subsequently, another chest drain was inserted on the right side and connected to an underwater sealed drainage. No negative pressure was applied to either of the drains. Over the next 30 min, the patient’s BP dropped to 70/50 mm Hg, and his oxygen saturation was recorded at 70% by pulse oximetry. Arterial blood gas analysis showed a PaO2 of 7.7 kPa and saturation of 90% while breathing 35% oxygen via face mask. Further chest radiographs revealed increasing air space shadowing over the rest of the left lung field with complete expansion of both lungs. Arterial BP initially responded to transfusion of IV fluids, but the patient remained hypotensive despite the administration of 1.5 L of IV gelatin solution. Video-assisted thoracoscopy was performed to exclude intrathoracic bleeding. On intubation of the trachea, copious amounts of frothy secretions were noted through the endotracheal tube; the patient became hypotensive and tachycardic. He required inotropic support to maintain hemodynamic stability. During operation, no bleeding was found in the chest cavity. Postoperatively, the patient was admitted to the ICU. A pulmonary artery flotation catheter was inserted; the pulmonary artery wedge pressure was 10 mm Hg, the cardiac index was 3.26 L/min/m, and the systemic vascular resistance index was 1,427 dyneszszcm/m. The patient was treated with positive end-expiratory pressure (PEEP), IV fluids, and inotropic support (epinephrine 0.2 mg/kg/min). The patient was weaned off inotropic support within 8 hs, and gas exchange improved over the following 12 h. The patient required ventilatory assistance for 36 hs. He was discharged home on the seventh day with complete resolution of his pulmonary edema. What is the diagnosis? *From the Birmingham Heartlands and Solihull Hospital NHS Trust, Birmingham, UK. Manuscript received May 22, 1998; revision accepted June 2, 1998. Correspondence to: Cyprian Mendonca, MD, Directorate of Anaesthesia, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK Figure 1. roentgenogram of the month