Spontaneous lung herniation after forceful coughing
a b s t r a c t
Spontaneous lung herniation is a rare finding, most often the result of forceful coughing. Risk factors include obe- sity, male gender, Tobacco use, and steroid use. Surgical repair is recommended due to increasing size of hernia- tion and pain control. Life style modification, such as Smoking cessation, is recommended in this patient population.
(C) 2019
- Case report
A 46 year old obese Hispanic male (BMI 37.6) presented to the Emer- gency Department with continued left sided rib pain and swelling to the left lateral chest wall for the last 2 weeks. Two weeks earlier, the same patient was treated in the Emergency Department for Acute bronchitis and was noted to have cough, dyspnea and left lateral chest and left an- terior abdominal wall ecchymosis from coughing. CT angiogram per- formed at that time revealed no pneumonia, no pulmonary embolus, and no abdominal hematoma. CT scan did reveal chronic changes of COPD with chronic small airway disease and air trapping. At this current Emergency Department presentation, patient reports that the cough, dyspnea, and ecchymosis have resolved, but that left sided rib pain per- sists and he is experiencing a “bulge” on the lateral chest wall with movement, deep inspiration, or coughing.
Initial chest x-ray during the second presentation revealed no rib fracture or acute findings. On physical exam, a 3 cm palpable, tender mass with crepitus is noted on the left lateral chest wall, at the level of the 8th and 9th ribs. CT scan of chest without contrast was obtained to further evaluate patient’s pain and Physical exam findings. CT scan re- vealed spontaneous intercostal lung herniation at the left posterolateral 8th and 9th rib interspace (Fig. 1).
Thoracic surgery was consulted and patient was evaluated in outpa- tient follow up. Because of the patient’s persistent pain at the area of the lung herniation, the pt underwent surgical repair 1 month after
* Corresponding author at: Emergency Department, Saint Vincent Hospital, 232 West 25th Street, Erie, Pa 16544 USA.
E-mail addresses: [email protected] (C.L. Dahlkemper), [email protected] (W.P. Greissinger).
diagnosis. surgical findings included a large defect that appeared chronic between the 7th and 8th intercostal space in the chest cavity. The ribs were reapproximated with 2-0 Vicryl suture and defect closed. The patient was discharged home on post-operative day 3. At the pa- tient’s 2 week post-operative appointment, repeat chest x-ray revealed no effusion or lung outside of the chest cavity. The patient continued to have significant pain, that was felt will resolve over time. The patient had been discharged to resume normal activities. General Surgery was also consulted to evaluate an incidental ventral hernia and did not feel that this required surgical intervention at the current time. The patient remains tobacco free (see Fig. 2).
- Discussion
Intercostal lung herniation is defined as protrusion of pleura- covered pulmonary parenchyma through an abnormal weakness or de- fect of the thoracic wall [1]. The causes of this rare finding are usually trauma, congenital, or surgical related [1]. Spontaneous lung herniations are very rare and is caused by coughing, sneezing, or other causes of in- creased intrathoracic pressure [1]. The literature reports that the major- ity of spontaneous lung herniations occur in obese male tobacco abusers with COPD [2]. Other risk factors include previous thoracic surgery, tho- racic trauma, or congenital factors [3]. The majority of these cases are treated with surgical repair due to pain from the defect [3]. Smoking cessation is paramount to decrease the risk of reoccurrence [4].
Declaration of Competing Interest
The authors declared that there is no conflict of interest.
https://doi.org/10.1016/j.ajem.2019.11.025
0735-6757/(C) 2019
851.e6 C.L. Dahlkemper, W.P. Greissinger / American Journal of Emergency Medicine 38 (2020) 851.e5–851.e6
References
- Kara HV, Javidfar J, D’Amico TA. Spontaneous herniation of the lung and diaphragm treated with surgical repair. Ann Thorac Surg 2015;99(5):1821-3. https://doi.org/ 10.1016/j.athoracsur.2014.06.105.
- Jastrow KM, Chu D, Jaroszewski D, Huh J, Bakaeen F. Posterior lung herniation after a coughing spell: a case report. Cases J 2009;2:86-91. https://doi.org/10.1186/1757- 1626-2-86.
- Weissberg D, Refaely Y. Hernia of the lung. Ann Thorac Surg 2002;74(6):1963-6. https://doi.org/10.1016/s0003-4975(02)04077-8.
- Brock MV, Heitmiller RF. Spontaneous anterior thoracic lung hernias. J Thorac Cardiovasc Surg 2000;119:1046-7.
Fig. 1. Profound left chest and abdominal wall ecchymosis noted on patient’s Initial presentation.
Fig. 2. CT imaging reveals spontanous lung herniation as indicated.