When Chest CT Reveals a Forgotten Tuberculosis Surgery: Plombage, Pseudomonas Pneumonia, and the Limits of Radiology AI

How Historical Lucite Ball Plombage Complicates Chest Imaging Interpretation, Infectious Disease Assessment, and AI-Assisted Radiology

MediAI | Clinical Radiology Case Study · Thoracic Imaging · Diagnostic Risk · Healthcare AI

Author: Ph. D. GJ Lee

Executive Answer

Multiple spherical structures clustered in the upper hemithorax of an elderly patient may represent extrapleural plombage, an obsolete surgical treatment for pulmonary tuberculosis. Polymethyl methacrylate (PMMA), also known as Lucite, was historically implanted into the extrapleural space to compress diseased lung tissue.

This case involves a man in his 80s with remote tuberculosis treated by Lucite ball plombage who subsequently developed severe pneumonia, recurrent septic shock, and fatal Pseudomonas aeruginosa infection.

The central diagnostic challenge is recognizing historical surgical material while independently evaluating acute pulmonary infection.

For contemporary radiology, the case also exposes an important limitation of artificial intelligence: detecting an abnormal structure is not equivalent to understanding its clinical significance.

1. Why This Case Matters: Two Different Diseases in One Chest

A chest radiograph obtained during the evaluation of severe pneumonia may contain information extending far beyond the immediate clinical indication.

In this case, an elderly man experienced a complicated hospitalization involving pneumonia and recurrent septic shock.

The clinical course initially involved methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Subsequent deterioration was associated with Pseudomonas aeruginosa pneumonia and sepsis, ultimately resulting in death.

However, the patient's thoracic imaging also demonstrated an unusual finding: multiple rounded structures occupying the right upper hemithorax.

These were not pulmonary metastases, calcified granulomas, or conventional postoperative metallic devices.

They represented the residual material from a tuberculosis treatment performed approximately five decades earlier.

The patient had undergone extrapleural pneumolysis with Lucite ball plombage during the 1940s.

At autopsy, the implanted spheres measured approximately 3–4 cm in diameter and were surrounded by fibrous tissue. Pleural calcification and moderate inflammatory changes were also identified.

The distinction between the historical surgical findings and the acute infection is essential.

The presence of plombage material does not establish that the implanted spheres caused the patient's Pseudomonas pneumonia or bloodstream infection.

Instead, the case illustrates how remote surgical intervention, chronic structural changes, and acute infectious disease can coexist within the same diagnostic examination.

This distinction has practical implications for radiologists, emergency physicians, infectious disease specialists, thoracic surgeons, and developers of AI-assisted imaging systems.

2. Clinical Scenario: An Elderly Patient With Severe Pneumonia and a Forgotten Surgical History

The patient was a man in his 80s with a remote history of pulmonary tuberculosis.

During the 1940s, he underwent a form of collapse therapy involving the placement of acrylic spheres in the extrapleural space.

Following treatment, the clinical manifestations of tuberculosis resolved, and he remained without major infectious complications for approximately 50 years.

Decades later, he was hospitalized with severe pulmonary infection.

His clinical course included MRSA pneumonia, recurrent septic shock, and eventual fatal Pseudomonas aeruginosa pneumonia and sepsis.

The thoracic imaging demonstrated multiple spherical structures in the right upper chest.

These structures were associated with the historical plombage procedure rather than representing newly developed pulmonary lesions.

Important Clinical Information

Patient: Male, in his 80s

Historical diagnosis: Pulmonary tuberculosis

Historical treatment: Extrapleural plombage using PMMA/Lucite balls

Approximate interval: Five decades

Acute clinical condition: Severe pneumonia and recurrent septic shock

Microbiologic course: MRSA pneumonia followed by Pseudomonas aeruginosa pneumonia and sepsis

Outcome: Death

Autopsy findings: Multiple 3–4 cm acrylic spheres surrounded by fibrous tissue, pleural calcification, and moderate inflammatory changes

Specific laboratory values, antimicrobial susceptibility results, detailed antibiotic regimens, and the complete sequence of intensive care interventions were not reported in the available clinical information.

Consequently, the discussion of treatment principles below should be understood as a guideline-based clinical framework rather than a reconstruction of this patient's actual management.

3. Understanding Plombage: Why Physicians Once Collapsed Tuberculous Lungs

Before effective antituberculosis chemotherapy became widely available, pulmonary tuberculosis was frequently managed through procedures intended to collapse diseased portions of the lung.

The rationale was based on reducing ventilation and mechanical expansion of infected lung regions, particularly areas containing cavitary disease.

These interventions were collectively described as collapse therapy.

Historical approaches included artificial pneumothorax, thoracoplasty, phrenic nerve interventions, extrapleural pneumolysis, and plombage.

What Is Extrapleural Plombage?

Plombage is a surgical technique in which material is inserted into a surgically created extrapleural space to compress the adjacent lung.

The material occupies space between the chest wall and the underlying pleural structures, producing localized pulmonary collapse.

Historically, surgeons used several materials, including paraffin, mineral oil, fat, rubber, and acrylic substances.

PMMA spheres became particularly recognizable because they produced a distinctive radiographic appearance.

Unlike conventional pulmonary nodules, the spheres were manufactured objects with relatively uniform geometry.

When multiple spheres were inserted together, they formed clusters of rounded structures that could remain visible on chest imaging for decades.

Plombage Versus Thoracoplasty

These procedures are sometimes discussed together because both belong to the historical category of pulmonary collapse therapy.

However, they are anatomically and surgically different.

Thoracoplasty reduces thoracic volume through rib resection and alteration of the chest wall.

Plombage compresses the lung by introducing material into the extrapleural space.

This distinction matters during image interpretation.

A radiologist should not automatically describe clustered Lucite spheres as evidence of thoracoplasty.

The more accurate terminology is:

Remote extrapleural plombage for pulmonary tuberculosis.

4. Chest Radiograph Interpretation: Recognizing the Characteristic Pattern

Figure 1. Anteroposterior chest radiograph demonstrating multiple rounded Lucite plombage spheres clustered in the right upper hemithorax.

ALT text: Anteroposterior chest radiograph showing multiple spherical extrapleural Lucite implants in the right upper hemithorax following historical tuberculosis collapse therapy.

Radiographic Findings

The chest radiograph demonstrates multiple rounded or oval structures clustered in the right upper thorax.

Their relatively uniform configuration and organized distribution distinguish them from most naturally occurring pulmonary lesions.

The individual spheres demonstrate a characteristic radiographic appearance related to their acrylic composition and surrounding tissues.

Importantly, Lucite is not equivalent to metallic material or densely calcified tissue.

The spheres may appear relatively radiolucent, while their margins and surrounding fibrotic or calcified tissues contribute to the overall radiographic pattern.

This distinction prevents a common descriptive error: interpreting the entire cluster as multiple calcified pulmonary nodules.

Radiologist's Interpretation

The most important imaging features are:

Multiple rounded structures with similar morphology.
Clustering within the upper hemithorax.
An extrapulmonary or extrapleural distribution.
Associated chronic pleural or postoperative changes.
Compatibility with historical tuberculosis collapse therapy.

When these features occur together, extrapleural plombage becomes a strong diagnostic consideration.

Suggested Radiology Report

Findings:

Multiple rounded extrapleural structures are clustered in the right upper hemithorax, compatible with retained acrylic plombage material from historical tuberculosis treatment.

Impression:

Remote right-sided extrapleural plombage for pulmonary tuberculosis.

Any concurrent pulmonary infiltrates, consolidation, or other acute findings should be described separately according to their actual imaging appearance.

5. Chest CT Interpretation: Establishing the Anatomical Relationship

Figure 2. Coronal chest CT demonstrating multiple spherical structures within the right upper extrapleural space, consistent with historical Lucite ball plombage.

ALT text: Coronal chest CT showing clustered spherical acrylic plombage implants in the right upper extrapleural space with surrounding chronic pleural and fibrotic changes.

Why CT Is More Informative Than Chest Radiography

A chest radiograph can suggest the presence of historical plombage material.

CT provides more precise anatomical localization and characterization.

In this case, coronal CT demonstrated multiple rounded, relatively low-attenuation structures arranged along the right upper extrapleural space.

Surrounding soft-tissue and fibrotic changes were also identified.

The relationship between the spheres, pleura, chest wall, and adjacent lung is central to interpretation.

Ten CT Features Worth Evaluating

1. Anatomical location

Determine whether the structures are intrapulmonary, pleural, extrapleural, or chest wall-based.

2. Number and distribution

Assess whether the structures form a localized cluster consistent with historical surgical implantation.

3. Internal attenuation

Evaluate the material's attenuation characteristics rather than assuming that all rounded opacities represent calcification.

4. Pleural thickening

Identify chronic pleural changes surrounding the implanted material.

5. Pleural calcification

Determine whether calcification involves the surrounding pleural tissues.

6. Adjacent pulmonary architecture

Evaluate chronic volume loss, fibrosis, distortion, and other structural changes.

7. Chest wall involvement

Look for abnormalities suggesting erosion, extension, or inflammatory complications.

8. Relationship to the bronchial tree

Assess for communication with the airway or findings that raise concern for fistula formation.

9. Relationship to vascular structures

Identify concerning proximity, displacement, or suspected erosion involving major vessels.

10. Evidence of superimposed infection

Evaluate for fluid collections, gas outside the expected implant configuration, abscess formation, or other findings suspicious for infection.

The last several findings represent potential complications to assess, not complications proven to have occurred in this patient.

Clinical Interpretation

The central advantage of CT is not simply that it reveals the spheres more clearly.

It establishes their anatomical context.

A collection of rounded structures within the lung parenchyma carries a different differential diagnosis from similarly shaped objects confined to an extrapleural compartment.

Correct localization can prevent unnecessary diagnostic workup for pulmonary nodules, metastatic disease, or other suspected abnormalities.

6. The Physical Appearance of Lucite Plombage Material

Figure 3. Acrylic Lucite sphere historically used for extrapleural plombage in the surgical treatment of pulmonary tuberculosis.

ALT text: Spherical polymethyl methacrylate implant historically used in extrapleural plombage for pulmonary tuberculosis.

PMMA is a synthetic polymer widely recognized for its relatively stable physical characteristics.

Historically, spherical acrylic implants were used to occupy the surgically created extrapleural space.

The spheres in this case measured approximately 3–4 cm in diameter.

Their physical geometry helps explain the imaging appearance.

Multiple similarly sized spheres placed together create a repetitive pattern that differs substantially from the irregular distribution of granulomatous calcifications or metastatic pulmonary nodules.

The appearance is best understood as a collection of manufactured implants rather than a collection of biological lesions.

This is an important principle in postoperative thoracic imaging.

Recognizing the physical design of a medical device can be as important as recognizing the imaging characteristics of a disease.

7. Differential Diagnosis: What Else Can Mimic Plombage?

The identification of multiple rounded structures in the thorax should trigger a structured differential diagnosis.

However, the differential becomes considerably narrower once their extrapleural location and regular arrangement are established.

Calcified Tuberculous Granulomas

Healed pulmonary tuberculosis may produce calcified granulomas.

These are generally smaller and demonstrate variable morphology and distribution.

They do not typically form a compact collection of similarly sized spherical implants within the extrapleural space.

Calcified Pleural Plaques

Pleural plaques often appear as localized areas of pleural thickening, sometimes with calcification.

Their morphology is generally linear, plaque-like, or irregular rather than uniformly spherical.

Chronic Pleural Calcification

Previous infection, hemorrhage, or inflammatory disease can produce extensive pleural calcification.

However, pleural calcification usually follows pleural surfaces rather than forming multiple discrete spheres.

Postoperative Foreign Bodies

Previous thoracic surgery may leave metallic clips, prosthetic materials, or other implanted devices.

Their location, shape, and attenuation characteristics may help establish the diagnosis.

Pulmonary Metastases

Multiple pulmonary metastases may appear as rounded nodules.

However, metastatic lesions occur within the pulmonary parenchyma and generally lack the uniform extrapleural arrangement characteristic of plombage.

Fungal Disease

Aspergilloma can produce a rounded intracavitary mass.

The characteristic finding is a fungal ball within a preexisting pulmonary cavity, sometimes separated from the cavity wall by an air crescent.

This differs anatomically from multiple implanted acrylic spheres.

Practical Differential Diagnosis Table

Imaging Feature	Plombage	Calcified Granuloma	Pleural Plaque	Pulmonary Metastases
Typical location	Extrapleural	Lung parenchyma	Pleural surface	Lung parenchyma
Shape	Spherical	Variable	Plaque-like	Rounded or irregular
Size uniformity	Often similar	Variable	Variable	Variable
Distribution	Clustered	Scattered	Pleural	Pulmonary
Historical association	Tuberculosis surgery	Prior granulomatous infection	Chronic pleural disease	Malignancy
CT diagnostic clue	Implanted spheres	Calcified parenchymal lesions	Pleural thickening	Parenchymal nodules

Diagnostic principle: Anatomical location and spatial organization are often more informative than the apparent density of a rounded lesion.

8. Pseudomonas Aeruginosa Pneumonia: A Separate Acute Diagnostic Problem

The historical plombage finding is visually striking.

However, the immediate clinical threat in this case was severe pulmonary infection complicated by sepsis.

Pseudomonas aeruginosa is a gram-negative organism associated with serious infections, particularly among hospitalized or critically ill patients and individuals with relevant pulmonary or healthcare-associated risk factors.

Its clinical importance reflects several biological characteristics.

These include antimicrobial resistance mechanisms, biofilm formation, toxin production, secretion systems, and other virulence-associated processes.

Clinical Presentation

Severe Pseudomonas pneumonia may present with fever, cough, purulent sputum, dyspnea, hypoxemia, and pleuritic chest discomfort.

In older adults, the presentation may be less typical.

Altered mental status, tachypnea, increasing oxygen requirements, hypotension, and functional deterioration may be prominent.

The absence of a high fever does not exclude severe bacterial infection.

Imaging Findings

Chest radiography and CT may demonstrate:

Pulmonary consolidation
Ground-glass opacities
Bronchopneumonia
Centrilobular nodules
Tree-in-bud opacities
Cavitation
Pleural effusion
Pulmonary abscess
Necrotizing pneumonia

These findings are not specific to Pseudomonas aeruginosa.

Other bacterial pathogens and noninfectious pulmonary conditions may produce overlapping appearances.

Consequently, the organism cannot be reliably identified from chest imaging alone.

Microbiologic testing and clinical correlation remain necessary.

The Most Important Diagnostic Separation

Two distinct questions must be answered.

Question 1: What are the multiple spherical structures in the right upper hemithorax?

They are compatible with historical extrapleural Lucite ball plombage.

Question 2: What caused the patient's severe pneumonia and sepsis?

The clinical course identifies Pseudomonas aeruginosa infection as the fatal infectious process.

The imaging appearance of the implanted spheres does not establish that the spheres were infected.

This separation prevents a visually unusual but chronic finding from dominating the interpretation of an acute life-threatening illness.

9. Can Plombage Cause Complications Decades After Surgery?

Although plombage material may remain clinically silent for decades, delayed complications have been documented.

Reported complications include infection, migration, chronic empyema, extrusion through the chest wall, erosion into adjacent structures, and fistula formation.

Historical surgical literature describes patients who developed complications many years after their original tuberculosis treatment [1]–[4].

Potential Mechanisms

Long-term implantation can lead to a chronic foreign-body response.

Fibrous encapsulation develops around the material.

Additional changes may include chronic inflammation, pleural thickening, calcification, and distortion of surrounding structures.

In selected cases, mechanical pressure or inflammatory processes may contribute to erosion or migration.

Does Every Patient Need Implant Removal?

No.

The presence of asymptomatic historical plombage material does not automatically justify surgical removal.

Management depends on symptoms, imaging findings, suspected complications, the patient's physiological reserve, and the risks of intervention.

An elderly patient with stable implants and no evidence of implant-related complications may be managed differently from a patient with empyema, fistula formation, or suspected vascular erosion.

The distinction is particularly important in patients with substantial comorbidity.

Application to This Case

The autopsy demonstrated fibrous encapsulation, pleural calcification, and moderate inflammatory changes.

These findings establish a chronic tissue response.

They do not, by themselves, prove that the Lucite spheres were the source of Pseudomonas sepsis.

A causal conclusion would require additional evidence linking the implanted material to the acute infectious process.

10. Diagnostic Risk Perspective: When an Unusual Finding Distracts From the Emergency

This case illustrates a recognizable vulnerability in diagnostic imaging.

An uncommon, visually dramatic abnormality may attract attention and influence interpretation.

The challenge is to identify that abnormality without allowing it to obscure the primary clinical problem.

Risk 1: Anchoring on Historical Tuberculosis

The presence of old tuberculosis treatment may lead clinicians to interpret new pulmonary abnormalities through the framework of prior disease.

However, chronic postoperative changes and acute bacterial pneumonia require separate assessment.

Risk 2: Misclassifying Plombage as Pulmonary Nodules

Failure to recognize the extrapleural location of the spheres may result in an incorrect differential diagnosis.

This can generate unnecessary recommendations for nodule surveillance, additional imaging, or invasive investigation.

Risk 3: Assuming the Implants Are the Infection Source

A chronic foreign body can become infected.

However, the possibility of infection is not equivalent to evidence of infection.

The radiologist should evaluate for complications rather than assume causality.

Risk 4: Satisfaction of Search

Once the unusual spherical structures have been identified, the reader may prematurely consider the examination explained.

This can reduce attention to additional findings such as consolidation, pleural fluid, or other acute abnormalities.

Risk 5: Incomplete Clinical Communication

A report that describes only multiple rounded thoracic opacities may fail to communicate the historical surgical explanation.

Conversely, a report focused entirely on plombage may inadequately address the patient's acute respiratory deterioration.

A Better Reporting Strategy

The radiology report should separate chronic findings from acute abnormalities.

For example:

Chronic finding:

Multiple right upper extrapleural spherical implants compatible with remote Lucite ball plombage for pulmonary tuberculosis.

Acute findings:

Describe the actual pulmonary parenchymal and pleural abnormalities, including their location, extent, and complications.

Clinical correlation:

Correlate suspected pneumonia with microbiologic findings and the patient's clinical course.

This structure improves diagnostic clarity and supports communication between radiology and the treating team.

11. Diagnostic Workflow: From Chest X-Ray to Clinical Decision

A practical approach to unusual rounded thoracic structures can be organized into five stages.

Stage 1: Identify the Morphological Pattern

Determine whether the structures are spherical, irregular, linear, or plaque-like.

Assess their number, size, and spatial arrangement.

Stage 2: Establish Anatomical Location

Distinguish pulmonary parenchymal lesions from pleural, extrapleural, and chest wall abnormalities.

Use CT when localization or assessment of suspected complications requires additional anatomical detail.

Stage 3: Reconstruct the Relevant Clinical History

Review prior imaging, surgical records, and the history of tuberculosis treatment.

Historical procedures may not be immediately recognizable from modern electronic medical records.

Stage 4: Evaluate Acute Abnormalities Independently

Identify consolidation, cavitation, pleural collections, or other findings relevant to the current presentation.

Do not assume that chronic surgical material explains all abnormalities.

Stage 5: Communicate Findings According to Clinical Urgency

Prioritize actionable acute findings while accurately documenting the historical implants.

When clinically appropriate, recommend additional evaluation for suspected implant-related complications.

The objective is not merely to produce a correct descriptive report.

It is to provide information that improves clinical decision-making.

12. Sepsis and Antimicrobial Management: Why Imaging Alone Is Insufficient

Severe Pseudomonas aeruginosa pneumonia complicated by sepsis requires coordinated management.

Imaging contributes by identifying the pulmonary distribution of infection and evaluating complications.

It does not replace microbiologic diagnosis or critical care management.

Microbiologic Evaluation

Blood cultures and appropriate respiratory specimens should be obtained when feasible.

In septic shock, obtaining specimens should not cause a clinically significant delay in antimicrobial treatment.

Empiric Antimicrobial Therapy

When clinical risk factors support concern for Pseudomonas, empiric therapy may require an agent with antipseudomonal activity.

Potential options, depending on the clinical context and local susceptibility patterns, include:

Piperacillin-tazobactam
Cefepime
Ceftazidime
Meropenem
Imipenem-cilastatin
Aztreonam in selected circumstances

The appropriate regimen depends on illness severity, prior microbiology, resistance risk, allergies, renal function, and local antimicrobial susceptibility data.

The ATS/IDSA hospital-acquired and ventilator-associated pneumonia guidelines provide a framework for selecting empiric and definitive therapy [8].

Susceptibility-Guided Treatment

Once microbiologic results become available, antimicrobial treatment should be reassessed.

Selection of definitive therapy should reflect organism identification, susceptibility testing, infection severity, and the patient's clinical response.

De-escalation is appropriate when supported by the available evidence.

Source Control and Supportive Care

Patients with septic shock may require hemodynamic resuscitation, vasopressors, respiratory support, and evaluation for a source requiring intervention.

The Surviving Sepsis Campaign emphasizes timely recognition, appropriate antimicrobial therapy, hemodynamic management, and source control when indicated [9].

In patients with historical plombage, suspected implant infection would require additional evaluation.

However, implant removal should not be assumed necessary without evidence of an implant-related complication.

13. Radiology AI Perspective: Can Artificial Intelligence Recognize Plombage?

Modern chest imaging AI systems can support selected tasks involving pulmonary nodules, consolidation, pleural effusion, pneumothorax, and other thoracic abnormalities.

However, identifying historical Lucite ball plombage presents a different problem.

The difficulty is not necessarily detecting rounded structures.

The challenge is recognizing their origin, anatomical location, historical significance, and relationship to the patient's current condition.

The Rare-Finding Problem

Most clinical AI systems are developed using datasets selected for particular diagnostic tasks.

Rare historical procedures may be poorly represented or absent from training data.

A model optimized for pulmonary nodule detection may encounter a cluster of spherical extrapleural implants that differs substantially from the images on which it was trained.

Possible responses include incorrect classification, failure to recognize the finding, or inappropriate generation of alerts.

These are plausible failure modes, not measured performance results for any specific commercial product.

Why Image Recognition Is Not Clinical Understanding

A model may identify several rounded structures.

That observation alone does not establish whether they represent metastatic disease, granulomas, surgical implants, or another process.

Clinical interpretation requires additional information.

In this case, the relevant information includes:

Image morphology + extrapleural location + patient age + remote tuberculosis history + historical surgery + CT anatomy.

The combination produces a much more specific diagnosis than morphology alone.

The Importance of Multimodal Context

A future clinical decision-support system might combine imaging features with structured and unstructured clinical information.

For example, historical operative reports, prior radiology reports, and problem-list entries could help establish the presence of previous collapse therapy.

However, such integration introduces challenges involving data completeness, terminology, interoperability, privacy, and validation.

Historical surgical procedures may also be documented inconsistently.

An AI system cannot reliably reconstruct missing clinical information simply because a visually unusual finding is present.

14. How AI Could Support the Radiology Workflow

The potential role of AI in this case is best understood through a workflow-oriented framework.

Detection Support

An imaging algorithm might identify unusual spherical structures and prompt further review.

The potential value would be to draw attention to an unexpected finding.

The limitation is that detection does not establish the diagnosis.

Anatomical Localization

CT segmentation or image-analysis methods could potentially help distinguish extrapleural structures from pulmonary parenchymal lesions.

However, their reliability for historical plombage would require specific validation.

Prior-Imaging Comparison

A system integrated with the picture archiving and communication system (PACS) could assist with retrieving earlier studies.

Longitudinal comparison may help establish whether the spherical structures have remained stable.

Stability can support recognition of chronic postoperative material, although it does not exclude every possible delayed complication.

Clinical Context Retrieval

Integration with the electronic health record (EHR) could potentially identify documentation of previous tuberculosis surgery.

This may reduce the time required to reconstruct a remote clinical history.

Reporting Assistance

A validated reporting assistant could help organize chronic and acute findings into separate report sections.

The radiologist would remain responsible for determining the clinical significance and accuracy of the final report.

AI Workflow Evaluation Table

AI Function	Potential Clinical Value	Important Limitation
Abnormality detection	Highlights unusual thoracic structures	May misclassify rare implants
CT localization	Supports anatomical assessment	Requires validated segmentation
Prior-study comparison	Helps establish chronic stability	Depends on available prior imaging
EHR information retrieval	May identify historical surgery	Historical records may be incomplete
Reporting assistance	Supports structured communication	Requires radiologist verification
Pneumonia detection	May highlight acute pulmonary abnormalities	Cannot identify the pathogen reliably

Clinical Insight: AI may help redistribute attention and retrieve information, but it does not eliminate the need for anatomical reasoning or professional oversight.

15. Why Conventional AI Validation May Miss Rare Historical Procedures

The performance of a radiology AI system depends partly on how closely the deployment population resembles its development and validation populations.

This creates a challenge for rare findings.

Historical plombage is uncommon in contemporary clinical imaging.

A dataset dominated by modern thoracic examinations may contain few or no examples of Lucite ball implantation.

Consequently, a model could perform well on its intended common findings while remaining unreliable when confronted with an unusual postoperative configuration.

Domain Shift

Domain shift occurs when the characteristics of real-world data differ from those represented during model development.

For example, a system trained primarily on contemporary chest radiographs may encounter historical implants, unusual chest wall anatomy, or severe postoperative distortion.

The model's response to these findings may be unpredictable.

Out-of-Distribution Findings

A rare surgical implant may fall outside the model's familiar distribution of imaging patterns.

An important safety question is whether the system can recognize uncertainty.

A clinically responsible system should not present an unsupported diagnosis with excessive confidence.

False-Positive Alerts

If a model mistakes Lucite spheres for pulmonary nodules, it may generate unnecessary alerts.

Repeated irrelevant alerts can increase workload and reduce clinician confidence.

False-Negative Findings

Alternatively, a system may fail to identify clinically important abnormalities when the anatomy differs substantially from its training examples.

The potential for missed findings reinforces the importance of radiologist review.

What Would Meaningful Validation Require?

A research program investigating AI recognition of historical plombage would need a carefully curated imaging dataset.

The dataset should include confirmed examples of plombage and relevant mimics.

Evaluation would need to address diagnostic classification, anatomical localization, false-positive behavior, and generalization across imaging systems.

External validation would be especially important.

Without such research, claims regarding the sensitivity or specificity of AI for plombage recognition would be speculative.

16. PACS, EHR Integration, and the Value of Historical Clinical Information

This case highlights a broader issue in enterprise radiology.

The interpretation of a medical image may depend on information generated decades before the current examination.

Historical surgery may be documented in archived records, previous radiology reports, or scanned medical documents.

Those records may not be easily accessible during routine interpretation.

The Information Fragmentation Problem

A radiologist may have access to the current CT examination but limited knowledge of the patient's surgical history.

The treating physician may know that the patient previously underwent tuberculosis treatment without knowing the exact procedure.

The EHR may contain only a nonspecific entry such as “history of thoracic surgery.”

This creates an information gap.

A More Integrated Workflow

A clinically useful enterprise imaging environment would support:

Efficient access to relevant prior imaging.
Retrieval of historical surgical information.
Consistent terminology across radiology reports.
Identification of clinically important longitudinal changes.
Communication of acute findings without losing historical context.

AI-assisted information retrieval could eventually support some of these functions.

However, the clinical value would depend on accurate data linkage, appropriate access controls, reliable information extraction, and human verification.

Why Interoperability Alone Is Not Enough

Standards such as DICOM, HL7, and FHIR support the exchange of imaging and healthcare information.

They do not guarantee that historical surgical terminology is complete, clinically accurate, or readily interpretable.

A system may successfully transfer the phrase “old chest surgery” without providing enough information to distinguish thoracoplasty from plombage.

The challenge is therefore both technical and semantic.

Successful integration requires the preservation of clinical meaning.

17. Healthcare System Implications: Avoiding Unnecessary Diagnostic Escalation

Misinterpretation of unusual postoperative findings can affect healthcare resource utilization.

If historical plombage material is incorrectly classified as multiple pulmonary nodules, the patient may be considered for unnecessary surveillance or further diagnostic evaluation.

Potential consequences include additional imaging, specialist consultations, increased patient anxiety, and avoidable expenditure.

These consequences are plausible workflow risks rather than outcomes documented in this individual case.

The Value of Accurate Historical Recognition

Correct identification of plombage can help clinicians distinguish a chronic postoperative condition from a newly suspected pulmonary disease.

This may reduce inappropriate diagnostic escalation.

The Value of Recognizing Acute Complications

The opposite error is also important.

Assuming that all abnormalities near old implants are harmless may delay recognition of a true complication.

CT can be valuable when symptoms or imaging findings raise concern for infection, erosion, or fistula formation.

Evaluating AI Investment

For hospitals considering AI-assisted radiology software, this case illustrates why diagnostic value should not be measured solely by the number of abnormalities detected.

Relevant evaluation questions include:

Does the software reduce clinically important missed findings?
Does it increase false-positive alerts?
Can it distinguish chronic postoperative findings from acute abnormalities?
Does it improve access to relevant prior studies?
Does it reduce unnecessary follow-up recommendations?
Can clinicians understand and verify its outputs?
Does it integrate effectively into existing PACS and EHR workflows?

No quantitative financial benefit or return on investment can be established from this case alone.

A meaningful economic evaluation would require real-world workflow data, implementation costs, clinical outcomes, and an appropriate comparison group.

18. A Practical Radiology Reporting Framework

A useful reporting strategy separates anatomical description, historical interpretation, and acute clinical findings.

Step 1: Describe the Chronic Surgical Material

Identify the location and configuration of the implants.

Step 2: State the Most Likely Historical Explanation

When supported by the imaging pattern and clinical history, identify remote extrapleural plombage.

Step 3: Evaluate Potential Implant-Related Complications

Describe any suspicious surrounding fluid, inflammatory change, migration, erosion, or fistula.

Step 4: Report Acute Pulmonary Findings Separately

Characterize consolidation, cavitation, effusion, or other abnormalities relevant to the current clinical presentation.

Step 5: Avoid Unsupported Microbiologic Conclusions

Do not identify Pseudomonas aeruginosa as the cause of pneumonia based on imaging morphology alone.

Suggested Integrated Impression

1. Multiple spherical right upper extrapleural implants compatible with remote Lucite ball plombage for pulmonary tuberculosis.

2. Associated chronic pleural and fibrotic changes.

3. Evaluate and report any acute pulmonary or pleural abnormalities independently.

4. Clinical and microbiologic correlation is necessary to establish the infectious etiology.

This framework preserves the historical diagnosis while maintaining appropriate attention to the patient's immediate clinical condition.

19. Clinical Risk and Diagnostic Insight

The Most Important Diagnostic Lesson

The central risk is not simply failure to recognize an obsolete surgical procedure.

It is failure to separate three different categories of information:

Historical treatment

The patient underwent extrapleural Lucite ball plombage for pulmonary tuberculosis.

Chronic anatomical consequences

The retained implants were associated with fibrous encapsulation, pleural calcification, and chronic tissue changes.

Acute life-threatening disease

The patient developed severe pneumonia and recurrent septic shock, with fatal Pseudomonas aeruginosa infection.

These categories are related through the patient's clinical history, but they are not interchangeable.

A radiologist who identifies the historical implants has solved one diagnostic problem.

The clinician must still evaluate the acute infection independently.

Why This Matters for AI-Assisted Radiology

An AI model might recognize the spherical pattern.

It might even associate that pattern with an uncommon historical procedure.

However, a clinically useful interpretation must also establish whether the finding is chronic, whether complications are present, and how the finding relates to the patient's current illness.

That requires context-sensitive reasoning rather than image classification alone.

The distinction is central to safe clinical AI deployment.

20. Practical Radiology Pearls

Pearl 1 — Recognize the pattern.

Multiple similarly sized spherical structures clustered in the upper extrapleural space should raise the possibility of historical plombage.

Pearl 2 — Localize before labeling.

A spherical structure outside the lung parenchyma should not automatically be classified as a pulmonary nodule.

Pearl 3 — Understand the material.

Lucite is an acrylic polymer. Its imaging appearance should not be equated with metallic implants or dense calcification.

Pearl 4 — Separate chronic findings from acute disease.

Historical surgical material and acute pneumonia can coexist without a proven causal relationship.

Pearl 5 — Evaluate delayed complications.

Old implants may remain stable for decades, but infection, migration, erosion, and fistula formation are recognized potential complications.

Pearl 6 — Do not diagnose the organism from CT.

Imaging can characterize pneumonia and its complications but cannot reliably identify Pseudomonas aeruginosa.

Pearl 7 — Preserve diagnostic uncertainty.

Fibrous encapsulation or chronic inflammatory changes do not independently establish the source of sepsis.

Pearl 8 — Use prior imaging whenever available.

Longitudinal comparison can help distinguish stable postoperative anatomy from new abnormalities.

Pearl 9 — Treat AI output as decision support.

Rare historical findings may not be adequately represented in training datasets.

Pearl 10 — Communicate clinically actionable findings.

A high-quality radiology report should explain the historical implants without obscuring the acute clinical problem.

21. Frequently Asked Clinical Questions

What is Lucite ball plombage?

Lucite ball plombage is a historical surgical treatment for pulmonary tuberculosis in which acrylic spheres were placed into the extrapleural space to compress affected lung tissue. The procedure was used before effective antituberculosis chemotherapy became widely available.

What does plombage look like on a chest X-ray?

Plombage typically appears as multiple rounded structures clustered within the upper hemithorax. Their similar size and organized distribution, together with the patient's surgical history, help distinguish them from pulmonary nodules and other thoracic abnormalities.

What are the characteristic CT findings of plombage?

CT may demonstrate multiple spherical structures within the extrapleural space, often accompanied by chronic pleural thickening, fibrosis, calcification, or postoperative anatomical distortion. CT is also useful for evaluating suspected delayed complications.

Can Lucite balls remain in the chest for decades?

Yes. Historical reports describe retained plombage material many decades after implantation. Some patients remain asymptomatic, while others develop delayed complications such as infection, migration, erosion, or fistula formation.

Can plombage cause pneumonia?

Plombage may be associated with delayed infectious complications, but the presence of retained spheres does not prove that they caused a patient's pneumonia. Clinical, microbiologic, and imaging evidence is required to establish an implant-related infection.

Can chest CT identify Pseudomonas pneumonia?

CT can demonstrate pulmonary consolidation, bronchopneumonia, cavitation, necrotizing changes, and other findings associated with bacterial infection. However, these findings overlap with those of other pathogens. Microbiologic testing is necessary to establish the organism.

Should historical plombage material always be removed?

No. Management depends on symptoms, evidence of complications, surgical risk, and the patient's overall condition. Asymptomatic retained material does not automatically require removal.

Can AI detect historical plombage?

AI may be capable of identifying unusual spherical structures, but reliable recognition of plombage has not been established by the evidence presented in this case. Rare historical procedures require dedicated validation before diagnostic performance can be assumed.

Why is this case important for modern radiology?

It demonstrates the importance of combining anatomical imaging interpretation with historical clinical information. It also illustrates why AI-assisted detection must be distinguished from clinically meaningful diagnosis.

22. Key Takeaways

The radiographic appearance of Lucite ball plombage is a reminder that medical images preserve the physical consequences of historical treatment.

In this patient, multiple spherical structures in the right upper hemithorax reflected a tuberculosis intervention performed approximately five decades earlier.

The retained implants were associated with chronic fibrous and pleural changes.

The patient's final illness, however, involved severe pneumonia and recurrent septic shock, culminating in fatal Pseudomonas aeruginosa infection.

The available information does not establish that the implants were responsible for the acute infection.

For radiologists, the most important lesson is to recognize the characteristic extrapleural distribution of the spheres and distinguish historical postoperative anatomy from acute pulmonary disease.

For healthcare AI developers, the case illustrates the limitations of image recognition when rare findings require historical and clinical context.

For healthcare systems, it demonstrates the importance of longitudinal records, accurate terminology, effective imaging workflows, and responsible clinical decision support.

Conclusion: A Chest Image Can Preserve Fifty Years of Medical History

The most revealing aspect of this case is not the unusual appearance of multiple spherical structures.

It is the coexistence of two different periods of medical history within one examination.

The Lucite spheres reflect an era when pulmonary tuberculosis was treated through mechanical collapse of diseased lung tissue.

Their persistence demonstrates how surgical interventions can influence thoracic anatomy for decades.

The patient's subsequent fatal pneumonia and sepsis represent a separate and urgent clinical problem.

Accurate interpretation requires both findings to be understood without confusing their significance.

The same principle applies to contemporary AI-assisted radiology.

An algorithm may detect an abnormality, but the value of that detection depends on anatomical localization, clinical history, differential diagnosis, and appropriate communication.

The central lesson is that recognizing an imaging pattern is only the beginning of diagnosis. Understanding why the pattern exists—and what it means for the patient—is the essential clinical task.

References

[1] M. D. Horowitz, M. Otero, R. J. Thurer, and H. Bolooki, “Late complications of plombage,” The Annals of Thoracic Surgery, vol. 53, no. 5, pp. 803–806, 1992. DOI: 10.1016/0003-4975(92)91440-K.

[2] G. E. Thomas, B. Chandrasekhar, and F. W. Grannis Jr., “Surgical treatment of complications 45 years after extraperiosteal pneumonolysis and plombage using acrylic resin balls for cavitary pulmonary tuberculosis,” Chest, vol. 108, no. 4, pp. 1163–1164, 1995. DOI: 10.1378/chest.108.4.1163.

[3] M. Feuchtwanger, J. B. Borman, and I. Bruderman, “Late complications of extraperiosteal lucite ball plombage,” Thorax, vol. 16, pp. 153–155, 1961. DOI: 10.1136/thx.16.2.153.

[4] F. M. Woods and L. Buente, “Extraperiosteal Lucite ball plombage,” American Review of Tuberculosis, vol. 68, no. 6, pp. 902–911, 1953. DOI: 10.1164/art.1953.68.6.902.

[5] S. Fujitani, H.-Y. Sun, V. L. Yu, and J. A. Weingarten, “Pneumonia due to Pseudomonas aeruginosa: Part I: Epidemiology, clinical diagnosis, and source,” Chest, vol. 139, no. 4, pp. 909–919, 2011. DOI: 10.1378/chest.10-0166.

[6] M. Kollef and D. Reynolds, “The epidemiology and pathogenesis and treatment of Pseudomonas aeruginosa infections: An update,” Drugs, vol. 81, pp. 2117–2131, 2021. DOI: 10.1007/s40265-021-01635-6.

[7] J. P. Lynch III and G. G. Zhanel, “Pseudomonas aeruginosa pneumonia: Evolution of antimicrobial resistance and implications for therapy,” Seminars in Respiratory and Critical Care Medicine, vol. 43, no. 2, pp. 191–218, 2022. DOI: 10.1055/s-0041-1740109.

[8] A. C. Kalil and colleagues, “Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the IDSA and ATS,” Clinical Infectious Diseases, vol. 63, pp. e61–e111, 2016. DOI: 10.1093/cid/ciw353.

[9] L. Evans and colleagues, “Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021,” Intensive Care Medicine, vol. 47, no. 11, pp. 1181–1247, 2021. DOI: 10.1007/s00134-021-06506-y.

[10] F. F. Tuon, L. R. Dantas, P. H. Suss, and V. S. T. Ribeiro, “Pathogenesis of the Pseudomonas aeruginosa biofilm: A review,” Pathogens, vol. 11, no. 3, p. 300, 2022. DOI: 10.3390/pathogens11030300.

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