Loculated Right-Sided Hydropneumothorax Mimicking Giant Pulmonary Bullae in a Post-Tuberculosis Patient: A Multimodality Imaging Diagnostic Challenge

Sidik Teghar Sanyadi, Bernard Sujijanto Suwito, Gandhi Estrada Atmanto — Mon, 27 Apr 2026 04:28:45 +0000

Introduction: Post-tuberculosis lung disease remains a significant public health challenge affecting millions of individuals globally, representing a substantial health burden in tuberculosis-endemic regions and in developed countries with immigration from endemic areas. Loculated hydropneumothorax as a late complication of successfully treated pulmonary tuberculosis is a rare but diagnostically challenging entity, particularly when imaging findings suggest alternative pathology such as giant pulmonary bullae. This case illustrates the complexity of post-tuberculosis complications and the essential role of multimodality imaging.

Case presentation: A 63-year-old retired woman presented to the emergency department with three days of progressive dyspnea accompanied by a productive cough with yellowish-white sputum. Physical examination revealed severe tachypnea (41 breaths per minute), clinically significant hypoxemia (SpO₂ 88 percent on room air), and diminished breath sounds over the right hemithorax with crackles in the right upper lobe. Chest radiography demonstrated a large thin-walled cavity (18 by 9.5 by 14 centimeters) with a horizontal air-fluid level in the right hemithorax, mediastinal leftward shift, and right costophrenic sinus obliteration. Thoracic point-of-care ultrasound revealed predominant gas throughout the right hemithorax with minimal pleural fluid in dependent zones and absence of identifiable lung tissue above the hemidiaphragm. Contrast-enhanced computed tomography definitively identified a loculated right-sided hydropneumothorax with a thin-walled pleural compartment, an air-fluid level, compressive atelectasis of the right lower and middle lobes, and post-tuberculosis fibrotic sequelae. This case illustrates the critical importance of multimodality imaging integration in differentiating loculated hydropneumothorax from mimicking entities, particularly giant pulmonary bullae. Individual imaging modalities—radiography, ultrasound, and computed tomography—each contributed essential diagnostic information, demonstrating that none is sufficient in isolation.

Conclusion: Loculated hydropneumothorax must be considered in the differential diagnosis of large cavitary lesions in post-tuberculosis patients. A multimodality imaging approach is essential for achieving diagnostic certainty and preventing unnecessary surgical intervention.

Sriwijaya Journal of Radiology and Imaging Research

Loculated Right-Sided Hydropneumothorax Mimicking Giant Pulmonary Bullae in a Post-Tuberculosis Patient: A Multimodality Imaging Diagnostic Challenge