A 76-year-old lady with chronic cough and a discharging chest wall sinus.

A 76-year-old lady was referred to the respiratory clinic with a 6-month history of a discharging left chest wall sinus. She also had a 6-month history of dry cough, left chest wall pain and breathlessness. There was no history of fever, haemoptysis, weight loss or night sweats. She was a lifelong non-smoker and there was no history of asbestos exposure. Investigations showed elevated white blood cell count of 14.5310/l (neutrophil count 11310/l) and C reactive protein 87 mg/L; renal and liver function tests were normal. Sputum cultures were negative. She had a laparoscopic Nissen fundoplication 12 years earlier, complicated by perforation of the oesophagus. Subsequently, 6 years later, she developed dyspnoea; a chest x-ray at this time revealed a left-sided pleural-based abnormality. A thoracoscopic biopsy suggested benign pleural thickening/fibrosis. After thoracoscopy, she developed a discharging sinus around the access port site, which was excised. The patient then relocated to the region and presented with a persistent discharge from the original chest wall sinus. Oral penicillin was commenced, although with only partial response and incomplete resolution of the discharge. Chest x-ray revealed a mass lesion in the left hemithorax, which was confirmed by a CT scan (figures 1 and 2).