Bilateral pneumothorax due to unexpected cause

Case Presentation: A 51-year-old male with a past medical history of alpha-1 antitrypsin deficiency with severe emphysema status post bilateral lung transplantation presented to the pulmonary transplant clinic for follow up. On evaluation, he was found to have declining FEV1 and FVC levels. A chest x-ray was performed to evaluate underlying abnormalities and revealed bilateral large pleural effusions. He was admitted to the hospital for bilateral chest tube placement. He tolerated the procedures well, chest tubes had good transudative output, and his respiratory status remained stable. Daily follow up chest x-rays showed continued deacreasing size of his pleural effusions, however after several days showed a new finding of bilateral apical pneumothoraces. A chest CT scan was done for better evaluation. This showed appropriate placement of both chest tubes with new bilateral pneumothoraces measuring up to 1 cm with only minimal residual bilateral pleural effusions. Cardiothoracic surgery was contacted and recommended continuing negative pressure suctioning. Daily chest x-rays did not show improvement, so the decision was made to remove the chest tubes. The patient’s respiratory status remained stable and his pneumothoraces did not increase in size but he was noted to have re-accumulation of small bilateral pleural effusions. He was discharged home in a stable condition without requiring any supplemental oxygen therapy. Discussion: Our patient underwent bilateral pulmonary transplantation for end stage emphysema secondary to alpha-1 antitrypsin deficiency and had bilateral pleural effusions post-operatively which were drained. On follow up, re-accumulation was noted and he was admitted for repeat drainage which was complicated by what was thought to be bilateral pneumothoraces in the presence of bilateral chest tubes. On evaluation by cardiothoracic surgery, this was determined to be secondary to size difference between the patient’s chest cavity compared to the smaller transplanted lungs. His chest tubes were removed, which resulted in re-accumulation of his pleural effusions and disappearance of the space around the lungs, proving that this was secondary to size discrepancy. Conclusions: Donor-to-recipient organ size matching is a critical component of lung transplantation. Currently, donor height is used as a surrogate for lung size. While this is an important predictor for lung size, it is a crude surrogate that fails to incorporate several factors, including sex, on organ size. We present a case where a patient received bilateral transplantation of smaller lungs. This resulted in an appearance similar to bilateral pneumothoraces due to the empty space surrounding the lungs resulting in recurrent pleural effusions. It is always important to remember that the first step in evaluating the cause of any pathological finding is for the clinician to revisit the patient’s history and keep a wide range of differential diagnoses