Size doesn't matter!

An 18-year-old male patient with a known history of Crohn's colitis was admitted for further management of his symptoms. He was treated with anti-tumour necrosis factor (anti-TNF) adalimumab and intravenous steroids in addition to azathioprine. He developed sudden onset pleuritic chest pain. Ventilation/perfusion (V/Q) scanning was reported as normal. A computed tomography pulmonary angiogram (CTPA) showed evidence of a small peripheral wedge shaped area of consolidation in the left lower lobe. He was treated with oral antibiotics but the chest pain persisted for the next 2 weeks. A repeat chest x-ray performed 2 weeks later revealed evidence of a large hydro-pneumothorax which was promptly drained. A chest CT later showed evidence of lower lobe consolidation. Sputum cultures grew Staphylococcus aureus. It was felt that a broncho-pleural fistula due to the peripheral cavitating lesion led to the pneumothorax.