A 67-Year-Old With a “Shrunken” Left Lung and Recurrent Pneu
The present case study has been discussed in the journal CHEST.

A 67-year-old woman was referred for nonresolving pneumonia and abnormal chest images. She was in her usual state of health until 1 month prior to referral when she started having fever, chills, dry cough, and chest pain. She presented initially to an urgent care facility that diagnosed her with bilateral pneumonia and left-sided volume loss on chest radiography.

She was given azithromycin, but her fever did not resolve in the weeks following the antibiotic course. Previous to these symptoms she was able to play tennis and worked full time as the director of a charter school.

At age 19 years, she was an unrestrained passenger in a high-velocity motor vehicle accident. She initially was dead on arrival to the ED but underwent lifesaving resuscitation. She remembered having two left-sided chest tubes, several broken ribs, and a prolonged recovery that required tracheostomy placement. She recalled that starting about 1 year after her accident, she was unable to maintain vigorous levels of exercise. She denied known exposure to TB and asbestos, had no relevant travel history, and a purified protein derivative test result was normal.

She was afebrile with a BP of 150/78 mm Hg and had an oxygen saturation of 92% while breathing room air as well as an unremarkable body habitus (BMI, 26.03 kg/m2). She was in no acute distress. Her examination was notable for a focal inspiratory squeak and turbulent air entry on forced inhalation as auscultated from the midchest anteriorly. A chest CT scan without contrast was obtained to further characterize the left lung abnormality (Fig 1).

Diagnosis: Delayed airway stenosis after blunt chest trauma with postobstructive pneumonia.

Diagnostic workup: Bronchoscopy.

Management: Airway dilation and airway stent placement.

Clinical Pearls
1. Delayed bronchial stenosis from remote blunt chest trauma is an important consideration for patients with otherwise cryptogenic airway obstruction and postobstructive pneumonia.

2. Bronchoscopy is required to characterize and confirm the diagnosis of bronchial stenosis.

3. Benign airway stenosis after trauma can be treated endoscopically or surgically, or both, depending on patient-specific factors, anatomy, and available expertise.

4. Benign central airway stenosis is the result of an exuberant healing reaction that often recurs after simple airway dilation techniques.

5. Silicone stent placement can be used to promote airway remodeling and achieve a more durable relief of stenosis.

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