Spontaneous massive hemopneumothorax: Double trouble with a twist

Our plain-English summary of Spontaneous massive hemopneumothorax: Double trouble with a twist, by M. Kuriakose, A. Khanna, D. Talwar (Lung India, 2017).

The study

• Authors: M. Kuriakose, A. Khanna, D. Talwar
• Journal: Lung India
• Published: 2017;34(3):283-286
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Spontaneous hemopneumothorax (SHP) is observed in 3%-7% cases of spontaneous pneumothorax where the tear of an adhesion can lead to bleeding with associated hemothorax. This condition has been reported in patients with hemophilia, sarcoidosis, congenital cystic adenomatoid malformation, systemic lupus erythematosus, etc., Here, we describe an unusual case of acute massive SHP in a 62-year-old male who underwent a percutaneous transluminal coronary angioplasty (PTCA) and presented with worsening dyspnea over the next 3 days. On evaluation, he had a massive hemopneumothorax which was considered to be secondary to the use of anticoagulants during the PTCA procedure. Pleural fluid analysis revealed frank blood and was consistent with the diagnosis of hemothorax. Surprisingly, the pleural fluid cytology revealed malignant cells. As the patient had a normal chest X-ray 3 days ago, thoracoscopic pleural biopsy was taken which confirmed the diagnosis of an epithelioid mesothelioma. Although post-PTCA or mesothelioma-associated hemothorax has been rarely reported, these two conditions have not been associated with SHP. Since the patient had no prior clinicoradiological features of mesothelioma, the procedure, and the anticoagulants probably contributed to the massive and rapid accumulation of blood. The presence of small amount of air added further confusion to the dual etiology and has not been described earlier.

In plain English

This case report described one 62-year-old man in India, a chronic smoker with diabetes and high blood pressure. On the second day after an emergency coronary angioplasty for a heart attack, he developed rapidly worsening breathlessness. A chest X-ray before the angioplasty had been normal. Afterwards, imaging showed a large collection of fluid and air in the left chest, and tests confirmed it was blood (a hemopneumothorax). The fluid's hematocrit was 27%, compared with 29.7% in his blood, and around 2 liters of blood were drained. Unexpectedly, the fluid contained malignant mesothelial cells. Biopsies of normal-appearing pleura showed epithelioid mesothelioma, even though CT had shown no lung or pleural nodules. The authors reported no prior clinical or radiological clues and no history of asbestos exposure. He had talc pleurodesis, then a disabling stroke, and was offered only supportive care. The authors concluded that the procedure and anticoagulants probably contributed to the rapid bleeding, and they reported this bleeding as the primary presentation of his mesothelioma.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 62-year-old male, a chronic smoker with diabetes and hypertension, treated at Metro Multispecialty Hospital, Noida, Uttar Pradesh, India. Dates are not given.
• Exposure: The authors reported that the patient had no history of asbestos exposure. The bleeding was considered related to coronary angioplasty (PTCA) and anticoagulation.
• Main results:
  • A chest X-ray taken before the PTCA was normal. After the PTCA, it showed a large spontaneous hemopneumothorax.
  • In this patient, the pleural fluid hematocrit was 27% compared with a blood hematocrit of 29.7%, establishing hemothorax.
  • Around 2 L of blood were removed from the patient's pleural cavity.
  • The patient's pleural fluid cytospin showed malignant mesothelial cells.
  • CT of the patient's chest showed no lung or pleural nodules.
  • Multiple biopsies from the patient's normal-appearing parietal pleura were suggestive of epithelioid mesothelioma. Immunohistochemistry confirmed the diagnosis: tumor cells were positive for calretinin, WT1 and CK5 6 (as printed), and negative for TTF1, CK20 and carcinoembryonic antigen.
  • In this patient, PET-CT showed nodular left pleural thickening with increased FDG uptake (SUV 4.5), and FDG-avid small left hilar and subcarinal lymph nodes (SUV 4.3).
  • The patient underwent talc pleurodesis. He then developed left-sided hemiparesis from a stroke and was offered only supportive care.
• The authors' conclusion: The authors concluded that, since the patient had no prior features of mesothelioma, the PTCA procedure and the anticoagulants probably contributed to the massive and rapid accumulation of blood. They reported spontaneous hemopneumothorax as the primary presentation of the mesothelioma.

Topics

Medical terms in this study, explained in our Lexicon: Pneumothorax, Hemothorax, Adenomatoid Tumor, Dyspnea, Fluid Cytology, Chest X-Ray, Pleural Biopsy, Epithelioid.

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