PMC5341304_01
88-year-old male presents with several weeks of cough and fatigue. His medical history is notable for endovascular aortic aneurysm repair at an unknown date. An axial postcontrast computed tomography image from 2014 demonstrates normal appearance of the graft.
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F1
Past medical history was notable for endovascular prior stent-graft placement in a thoracoabdominal aneurysm, 2 years before current presentation [Figure 1].
88-year-old male presents with several weeks of cough and fatigue. (a) Axial noncontrast computed tomography image of the chest demonstrates air and soft tissue thickening (arrow) at the level of the aorta, in proximity to the adjacent stomach. There appears to be continuity between the gastric fundus and pleural space, with no intervening diaphragm. There is high-attenuation material layering in the pleural space (arrowhead). (b) Axial computed tomography image demonstrates a heterogeneous left pleural collection (arrow) with thick-wall, air, fluid, and high-attenuation material.
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F2
A noncontrast computed tomography (CT) of the chest was obtained, which demonstrated air and soft tissue thickening abutting the descending thoracic aorta, wall thickening of the adjacent stomach, as well as a heterogeneous, thick-walled left pleural air and fluid containing collection with layering intermediate to high-density material [Figure 2].
88-year-old male presents with several weeks of cough and fatigue. (a) Axial computed tomography image of the chest and abdomen after administration of dilute water-soluble oral contrast demonstrating clear extravasation of oral contrast from the stomach into the left pleural space through a large defect in the gastric wall and diaphragm (arrow). (b) Sagittal computed tomography image demonstrating similar finding (arrow).
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F3
The pre-IV contrast image confirmed a large gastropleural fistula as the cause for patient's empyema [Figure 3] with a clearly visualized diaphragmatic defect.
88-year-old male presents with several weeks of cough and fatigue. Axial computed tomography image of the chest after administration of dilute water-soluble oral contrast demonstrating extension of the contrast from the stomach, through the pleural space, and between the struts of the aortic vascular stent (arrow).
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F4
However, the oral contrast extended to the level of the patient's vascular graft struts, concerning for intramural involvement [Figure 4].
88-year-old male presents with several weeks of cough and fatigue. (a) Axial computed tomography image of the chest and abdomen after the administration of intravenous contrast demonstrates extension of the periaortic soft tissue thickening into the abdomen (arrow). (b) Axial computed tomography image of the abdomen demonstrating anterior displacement of the aorta (arrowhead). (c) Axial computed tomography image of the abdomen demonstrating the contained extravasation of contrast (arrow) from the right lateral wall of the abdominal aorta.
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F5
The post-IV contrast images demonstrated the extensive periaortic soft tissue thickening extending to the infrarenal abdominal aorta and displacing it anteriorly [Figure 5]. There was also evidence of pseudoaneurysm formation below the ostium of the right renal artery and below the level of patient's vascular stent [Figure 5] suggestive of an infectious pseudoaneurysm formation.