Although a hydropneumothorax is not frequently mentioned in the medical literature [1], its non-specific clinical appearance has been attributed to several conditions. Tumors, such as malignant pleural mesotheliomas (MPMs) and angiosarcomas, are documented as potential causes, whereas tuberculosis is designated as the most common infectious etiology of a hydropneumothorax, but hydatid lung disease caused by echinococcus granulosus is also reported as a possible cause [1] [2] [3] [4]. On the other hand, invasive procedures of the lungs - thoracocentesis, placement of chest tubes and even a transbronchial biopsy all carry a risk for a post-procedural hydropneumothorax, suggesting their important role in the pathogenesis of this condition [5]. The clinical presentation starts with an acute onset of respiratory insufficiency characterized by dyspnea, breathlessness and an overall decline in respiratory function, whereas additional signs of fever and constitutional symptoms (weight loss, malaise, anorexia) are often seen if tuberculosis is the underlying cause [1]. Chest pain aggravated by deep breathing and a cough is reported in patients who suffer from hydatid disease, in whom cystic penetration into the pleural space causes hydropneumothorax [4]. In a small number of cases, an urticarial reaction and even anaphylaxis can occur once immune cells interact with the echinococcal cysts [4].

• Constitutional Symptom

  The clinical presentation starts with an acute onset of respiratory insufficiency characterized by dyspnea, breathlessness and an overall decline in respiratory function, whereas additional signs of fever and constitutional symptoms (weight loss, malaise [symptoma.com]

  All the patients were enquired regarding symptoms such as breathlessness, fever, cough, chest pain, constitutional symptoms such as loss of appetite and loss of weight. [ncbi.nlm.nih.gov]

• Dyspnea

  CASE REPORT: A 97-year-old woman complained of acute dyspnea without prior vomiting. Chest x-ray study showed a large right pneumothorax with associated effusion. [read.qxmd.com]

  It is typically diagnosed after patients present with nonspecific symptoms of chest pain, dyspnea, and cough with initial imaging most commonly showing unilateral pleural effusion. [ncbi.nlm.nih.gov]

  The clinical presentation starts with an acute onset of respiratory insufficiency characterized by dyspnea, breathlessness and an overall decline in respiratory function, whereas additional signs of fever and constitutional symptoms (weight loss, malaise [symptoma.com]

  Case contributed by Dr Aditya Shetty Diagnosis certain Diagnosis certain Presentation h/o dyspnea Patient Data Age: 30 Gender: Male From the case: Hydropneumothorax X-ray Frontal A large radiolucent area noted in the left upper and mid zone with a sharply [radiopaedia.org]

  Abstract A 61-year-old man was admitted to the emergency room because of sudden right chest pain and dyspnea. A chest X-ray and chest computed tomography (CT) revealed severe right pneumothorax with massive pleural effusion. [jtd.amegroups.com]

• Prolonged Expiration

  However, vesicular breath sound with prolonged expiration was detected in the left hemithorax. Heart sound was normal. Abdomen was scaphoid with epigastric tenderness and sluggish peristaltic sound. [atmph.org]

• Hyperresonance

  On percussion, hyperresonant note was elicited along the midclavicular line up to the right fourth intercostal space (ICS) in sitting position and also over the right supra scapular and the upper interscapular and upper axilla. [atmph.org]

• Subcutaneous Crepitus

  Subcutaneous crepitus was palpated over the swollen area. Both the trachea and cardiac apex were shifted to the left side. [atmph.org]

Although a hydropneumothorax is principally diagnosed through imaging studies, physicians can include it in the differential diagnosis of respiratory symptoms only after a thorough patient history and a physical examination focused on lung auscultation. Tachypnea, signs of cyanosis and an "inconclusive" lung sound heard at the level of hydropneumothorax formation should prompt the physician to order a plain chest X-ray, a procedure that will undoubtedly reveal an air-fluid level lined almost perfectly at a horizontal level, mimicking pleural effusion [6]. Furthermore, signs of lung collapse and pleural effusion may be shown on plain radiography and computed tomography (CT), which is also recommended during workup, especially if radiography is not conclusive [6]. However, transthoracic sonography (TS) has shown to be an equally useful method in detecting pleural pathologies [7]. In fact, its cost-effectiveness and the ability to perform the procedure bed-side, favor its use over plain radiography, especially when only supine X-rays can be carried out due to the overall condition of the patient [7].

• Air Bronchogram

  Remaining 22 [Table 1] patients required CT thorax in which cavitary consolidation with V-Y pattern was seen in 15 patients (26.3%) suggestive of TB, consolidation with air-bronchogram was seen in 15 patients suggestive of acute bacterial infection, emphysematous [ncbi.nlm.nih.gov]

• Decreased Oxygen Saturation

  Twenty minutes after an uneventful left lung lavage, the patient experienced increased peak airway pressure, decreased oxygen saturation and hypercarbia, despite ventilation with 90 per cent oxygen. [ncbi.nlm.nih.gov]

• Ovarian Mass

  Her medical history included infertility, an ovarian mass (in study), biliary diskinesia and protein C deficiency. The CT showed a bleb in the right inferior lobe and a pleural effusion. [ncbi.nlm.nih.gov]

• Wuchereria Bancrofti

  A pleural fluid report also showed eosinophilia and a few motile microfilaria of Wuchereria bancrofti. Microfilaria was also documented in peripheral blood. There was no evidence of other organ system involvement. [ncbi.nlm.nih.gov]

  A pleural fluid report also showed eosinophilia and a few motile microfilaria of Wuchereria bancrofti... [read.qxmd.com]

• Nocardia Asteroides

  A case of hydropneumothorax due to Nocardia asteroides in a patient with diabetes mellitus is reported. [ncbi.nlm.nih.gov]

• Coccidioides Immitis

  The only organism grown from cultures of the lung and pleural fluid was Coccidioides immitis, confirmed by exoantigen testing. [ncbi.nlm.nih.gov]

1. Kasargod V, Awad NT. Clinical profile, etiology, and management of hydropneumothorax: An Indian experience. Lung India. 2016;33(3):278-280.
2. Fayed HE, Woodcock VK, Grayez J. Simultaneous bilateral spontaneous hydropneumothorax: a rare presentation of bilateral malignant pleural mesothelioma. BMJ Case Rep. 2013;2013:bcr2013009350.
3. Chang JH, Kim JH, Hong S-H, et al. Angiosarcoma Presenting with Spontaneous Hydropneumothorax: Report of a Case and Review of the Literature. Open Respir Med J. 2014;8:48-54.
4. Zefov VN, Almatrooshi MA. Chest X-ray findings in late-onset congenital diaphragmatic hernia, a rare emergency easily misdiagnosed as hydropneumothorax: a case report. Journal of Medical Case Reports. 2015;9:291.
5. Boland GW, Gazelle GS, Girard MJ, Mueller PR. Asymptomatic hydropneumothorax after therapeutic thoracentesis for malignant pleural effusions. AJR Am J Roentgenol. 1998;170(4):943-946.
6. Atay AE, Oruc M, Sayin T, Gullu MN. Urticaria and hydropneumothorax as an exceptional cause of ruptured hydatid cyst of lung. J Postgrad Med. 2013;59(4):328-330.
7. Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol. 2005;53(3):463-470.