Hernia pulmonar intercostal espontánea. Informe de caso y revisión de la literatura / Spontaneous intercostal pulmonary hernia. A case report and literature review

RESUMEN La hernia pulmonar o neumocele es la protrusión del parénquima pulmonar a través de un defecto de la pared torácica. Solo se ha reportado una veintena de casos en la última década. Se presentó el caso de un paciente masculino de 86 años, con antecedentes de enfermedad pulmonar obstructiva crónica, que acudió a consulta por la presencia de una masa en región lateral izquierda del tórax de 6 meses de evolución, con aumento de tamaño y presencia de dolor tras una crisis de su enfermedad de base. Por pruebas de imágenes se diagnosticó una hernia pulmonar intercostal espontánea, secundaria a una diastasis del espacio intercostal entre la octava y novena costilla. Los familiares se negaron a la corrección quirúrgica del defecto en la pared. La hernia pulmonar espontánea debe ser considerada en pacientes con factores de riesgo de aumento de la presión intratorácica, que acudan a consulta por dolor torácico, masa suave focalizada en la pared y tos persistente.

ABSTRACT Pulmonary hernia or pneumocele is the protrusion of the pulmonary parenchyma through a defect in the thoracic wall. Only 20 cases were reported in the last decade. It was presented the case of a male patient, aged 86 years. With a history of chronic obstructive pulmonary disease, who assisted the consultation because of presenting a mass in the left lateral region of the thorax of 6 months of evolution, with increase in size and pain after a crisis of his underlying disease. By imaging study it was diagnosed a spontaneous intercostal pulmonary hernia, secondary to a diastasis of the intercostal space between the eighth and ninth ribs. Relatives refused the surgical correction of the wall defect. Spontaneous pulmonary hernia should be considered in patients at risk of intra-thoracic pressure increase who assist to consultation due to thoracic pain, focalized soft mass in the wall and persistent cough.

Ultrasound diagnosis of reticular diaphragmatic hernia in bovines / Diagnóstico ultrassonográfico da hérnia reticular diafragmática em bovinos

A reticular diaphragmatic hernia is a congenital or acquired alteration resulting from protrusion of the reticulum into the thoracic cavity. In ruminants, lesions to the diaphragmatic muscle, due to penetration of sharp metallic objects, is the most common cause of this disease. Therefore, given the low number of reports on this disease in the bovine species, the current study aims to describe the clinical, laboratory, and anatomopathological findings, with special emphasis on the ultrasound diagnosis of five cattle with reticular diaphragmatic hernia. The laboratory data were analyzed using mean and standard deviation, and clinical, ultrasound, and pathological findings were evaluated using descriptive statistics. Clinically the animals exhibited varying degrees of dehydration, abdominal distension, tympany, and alterations in ruminal motility, in addition to cardiorespiratory alterations such as murmur, dyspnea, and muffling of lung sounds. The laboratory examination showed neutrophilic leukocytosis and hyperfibrinogenemia. The ultrasonographic images demonstrated reticulum inside the thoracic cavity adjacent to the lung and heart, although no reticular motility was observed. The pathological lesions confirmed the findings of the ultrasound exams. Thus, the current study demonstrated that ultrasonography was efficient in diagnosing reticular diaphragmatic hernia in the bovine species.(AU)

A hérnia reticular diafragmática é uma alteração congênita ou adquirida resultante da protrusão do retículo para o interior da cavidade torácica. Em ruminantes, lesões no músculo diafragmático devido a penetração de objetos metálico pontiagudos constitui a causa mais comum dessa enfermidade. Portanto, diante dos poucos relatos a cerca dessa enfermidade nos animais da espécie bovina, este estudo tem como objetivo descrever os achados clínicos, laboratoriais, anatomopatológicos e dar ênfase especial no diagnóstico ultrassonográfico de cinco bovinos acometidos com hérnia reticular diafragmática. Os dados laboratoriais foram analisados utilizando-se media e desvio padrão e os achados dos exames clínico, ultrassonográfico e anatomopatológicos foram avaliados através de estatística descritiva. Clinicamente os animais exibiam desidratação em variados graus, distensão abdominal, timpania e alterações na motilidade ruminal. Além de alterações cardiorrespiratórias como sopro, dispneia e abafamento dos sons pulmonares. O exame laboratorial revelou leucocitose por neutrofilia e hiperfibrinogenemia. As imagens ultrassonográficas revelaram retículo no interior da cavidade torácica adjacente ao pulmão e coração, porém nenhuma motilidade reticular foi observada. As lesões anatomopatológicas confirmaram os achados dos exames ultrassonográficos. Dessa maneira, este trabalho demonstrou que a ultrassonografia foi eficiente no diagnóstico da hérnia reticular diafragmática nos animais da espécie bovina.(AU)

Hernia diafragmática congénita: predictores posnatales de mortalidad / Congenital diaphragmatic hernia: postnatal predictors of mortality

La hernia diafragmática congénita (HDC) es una enfermedad de baja prevalencia, con elevada morbimortalidad. Los factores pronósticos posnatales, durante el primer día de vida, son útiles para la toma de decisiones.Objetivos. Determinar la capacidad predictiva de los factores posnatales ecocardiográficos, clínicos y bioquímicos de mortalidad en los recién nacidos con HDC durante el primer día de vida.Método. Estudio observacional analítico de cohorte retrospectiva. Se incluyeron los pacientes con HDC, en forma consecutiva, desde marzo de 2012 a noviembre de 2018. Se analizaron como predictores el índice de oxigenación (IO), valor más alto de presión parcial de dióxido de carbono en sangre (pCO2), puntaje de gravedad SNAPPE II, ecocardiograma, dosaje de NT-pro péptido natriurético B (NT-proPNB), todos medidos en el primer día de vida.Resultados. La población fue de 178 pacientes con HDC. La sobrevida, del 75 %. El 24 % recibió oxigenación por membrana extracorpórea. La presencia precoz de hipertensión pulmonar sistémica o suprasistémica no mostró capacidad predictiva (OR 2,2; IC 95 %: 0,8-8), p = 0,1. NT-proPNB tampoco mostró buena discriminación (área bajo la curva (ABC) 0,46, p = 0,67). El IO, SNAPPE II y el valor más alto de pCO2 mostraron buena discriminación, ABC IO 0,82, ABC SNAPPE II 0,86 y ABC pCO2 0,75, p < 0,001.Conclusión.SNAPPE II, IO y valor más alto de pCO2, medidos el primer día de vida, mostraron buena capacidad predictiva con respecto a la evolución; SNAPPE II fue superior al IO y al valor más alto de CO2.

Introduction: Congenital diaphragmatic hernia (CDH) prevalence is low while its associated morbidity and mortality rates are high. Postnatal prognostic factors on the first day of life are useful for predicting the outcome. Objectives: To determine the mortality predictive ability of postnatal echocardiographic, clinical, and biochemical factors among newborn infants with CDH in their first day of life. Method: Observational analytical study of a retrospective cohort. Patients with CDH were consecutively included between March 2012 and November 2018. On the first day of life, analyzed predictors were the oxygenation index (OI), the highest partial pressure of carbon dioxide (pCO2) level in blood, the SNAPPE II severity score, the echocardiography, and the N-terminal pro-B-type natriuretic peptide (NTproBNP) value. Results: The population consisted of 178 patients with CDH. Survival was 75 %. Extracorporeal membrane oxygenation was used in 24 %. The early onset of systemic or suprasystemic pulmonary hypertension showed no predictive ability (OR: 2.2, 95 % CI: 0.8-8), p = 0.1. NT-proBNP did not show good discrimination either (area under the curve [AUC]: 0.46, p = 0.67). The OI, SNAPPE II score, and the highest pCO2 level showed adequate discrimination power, AUC for OI: 0.82, AUC for SNAPPE II: 0.86, and AUC for pCO2: 0.75, p < 0.001. Conclusion: The SNAPPE II score, the OI, and the highest pCO2 level measured on the first day of life, showed a good predictive ability in terms of the course of the disease; the SNAPPE II score was better than the OI and the highest pCO2 level.

Hernia diafragmática aguda en un adolescente / Acute diaphragmatic hernia in an adolescent

Se presenta el caso clínico de un paciente de 13 años de edad, quien ingresó en el Servicio de Cirugía del Hospital Básico de Latacunga, Ecuador, tras haber sido atropellado por un automóvil que le produjo traumatismos torácico y abdominal cerrados. Los estudios radiológicos confirmaron el diagnóstico de hernia diafragmática traumática izquierda. Durante la cirugía se encontró un defecto de 10 cm en el diafragma izquierdo, con el estómago, bazo y colon herniados en el tórax, para lo cual se efectuó reducción y frenorrafia. Dicho paciente evolucionó satisfactoriamente y egresó al quinto día. Se realizó seguimiento durante 6 meses y no presentó complicaciones.

The case report of a 13 year-old patient is presented who was admitted in the Surgery Service of the Basic Hospital from Latacunga, Ecuador, after being runned over by an automobile that produced him closed thoracic and abdominal traumatisms. The radiological studies confirmed the diagnosis of left traumatic diaphragmatic hernia. During surgery a defect of 10 cm was found in the left diaphragm, with stomach, spleen and colon herniated in the thorax, for which reduction and frenorrafia were carried out. This patient had a satisfactory clinical course and was discharged on the fifth day. Follow-up was carried out during 6 months and there were no complications.

Intrathoracic stomach mimicking bone metastasis from thyroid cancer in whole-body iodine-131 scan diagnosed by SPECT/CT

SUMMARY The whole-body iodine-131 scintigraphy is an imaging technique in monitoring patients with a history of thyroid cancer. Although the rate of false positives is negligible, it is not nonexistent. We report the case of an intervened and treated patient for thyroid cancer with good clinical and biochemical response. Scintigraphic findings were consistent with unsuspected bone metastasis. Fused SPECT/CT data allowed accurate diagnosis of giant diaphragmatic hernia associated with intrathoracic stomach, a very rare pathology that can lead to false positive results.

Congenital hemangioma in spondylocostal dysostosis: a novel association

Abstract Congenital hemangioma is a benign tumor caused by dysfunction in embryogenesis and vasculogenesis, which progresses during fetal life to manifest as fully developed at birth. Although hemangiomas are the most common tumor of infancy, rapidly involuting congenital hemangioma has not been described in spondylocostal dysostosis. I report the novel association of congenital hemangioma and spondylocostal dysostosis in a Mexican newborn female patient with neural tube defects. Given the embryological relationship between skin and nervous system, I surmise that this association is not coincidental. I also propose that these morphologic alterations be incorporated to the spondylocostal dysostosis phenotype and specifically looked for in other affected children, in order to provide appropriate medical management and genetic counseling.

Diagnóstico prenatal y manejo perinatal en enfermedades raras / Prenatal diagnosis and management of rare diseases

El diagnóstico y manejo prenatal de enfermedades raras involucra un estudio multidisciplinario. Desde una visión obstétrica, herramientas de imagenología como la ultrasonografía y en menor medida la resonancia magnética fetal (RMF) son esenciales para el diagnóstico de anomalías morfológicas y sospecha de defectos cromosómicos. Para el diagnóstico de enfermedades cromosómicas el estudio de cariograma obtenido de vellosidades coriales, líquido amniótico o sangre fetal mediante técnicas invasivas tal como biopsia corial, amniocentesis o cordocentesis ha sido hasta hace poco el gold standard del diagnóstico. Nuevas técnicas moleculares capaces de detectar microdeleciones como es el microarray nos ha permitido aproximarnos al origen de las enfermedades raras. Se revisarán además algunos de los defectos anatómicos raros y su enfoque neonatal.

Prenatal diagnosis and management of rare diseases is a multidisciplinary task. From the obstetric vision, prenatal diagnosis is based on fetal images obtained by ultrasound or magnetic resonance and fetal chromosomes study. The study of fetal morphology allows us the diagnosis of fetal abnormalities and the suspicion of chromosomal defects. Fetal chromosomal study is obtained either by chorionic villus sampling, amniocentesis and cordocentesis, all associated to fetal risk. New screening techniques such as fetal DNA on maternal blood or the study of fetal micro deletions using micro Array on amniotic fluid has extended diagnostic opportunity of rare fetal diseases. We will review some of the most common rare diseases and the neonatal approach.

Hernia diafragmática no traumática complicada en un anciano / Non traumatic complicated diaphragmatic hernia in an old man

La hernia de Morgagni es una variedad poco frecuente de hernia diafragmática no traumática. En un paciente anciano del sexo masculino se encontró un gran saco herniario que contenía estómago, epiplón mayor y colon transverso, encarcelados a través de un defecto diafragmático retroesternal, lo cual es muy raro en la vejez. El paciente tenía antecedentes de litiasis vesicular, úlcera duodenal y diastasis de los músculos rectos abdominales, e ingresó con dolor torácico, epigastralgia, aerogastria, distensión en la porción superior del abdomen y vómitos. El diagnóstico se obtuvo mediante radiografías posteroanterior y lateral del tórax y del abdomen. Se realizó una laparotomía de urgencia y se encontró una hernia de Morgagni encarcelada sin afectación vascular. Se redujo el contenido, se resecó el saco herniario, se reparó el defecto herniario y se efectuó la colecistectomía. La recuperación posoperatoria fue inmediata y completa. El seguimiento posoperatorio de 6 meses no mostró recidiva herniaria(AU)

Morgagni hernia is an uncommon variety of non-traumatic diaphragmatic hernia, usually located in the right-side anterior diaphragm. A big herniary sac, which contained the greater omentum, the stomach, and the transverse colon incarcerated due to a retrosternal diaphragmatic defect, was found in an old male patient. This is very unusual finding in the elderly. This patient had a history of cholelithiasis, duodenal ulcer and diastasis recti. He was admitted at the hospital with chest pain, epigastralgia, aerogastria, upper abdominal distension, and vomits. He underwent emergency radiological studies. The diagnosis was based on chest posterior-anterior and lateral X-rays of the chest and the abdomen. Emergency laparotomy was performed to find Morgagni hernia without any vascular effect. The content was removed, the hernia sac was excised, the Morgagni foramen was repaired and cholecistectomy was performed. The recovery of the patient was complete and immediate postoperatively. The six-month follow-up showed no hernia recurrence(AU)

Agenesis of right diaphragm in the adults a diagnostic dilemma.

Diaphragmatic agenesis is the most extreme form of congenital diaphragmatic defect, and it may be unilateral or bilateral. Diaphragmatic agenesis is a rare diagnosis, typically made early in infancy and is generally associated with other genetic anomalies, especially anueploidy syndromes. It is associated with a high mortality, if not treated in infancy. However, a few patients have survived till adulthood. In this report, we describe the case of an adult female who presented with progressive shortness of breath during third trimester of pregnancy with complete agenesis of the right side of the diaphragm. A new diaphragm was created using polypropylene mesh after which she improved symptomatically and the lung showed good expansion.

Right diaphragmatic hernia in an elderly man.

A 71-year-old male presented with progressive exertional breathlessness and cough for the last four years. His breathlessness aggravated after a heavy meal and on lying down. He was a smoker, but had no co-morbidities. He did not remember any major trauma or surgery. Examination of the respiratory system revealed mediastinal shift to the left, diminished breath sounds over the whole of the right hemithorax and gurgling sounds all over, mainly the infrascapular area. Examination of other organ systems revealed no abnormality.

Rare presentation of spontaneous acquired diaphragmatic hernia.

Spontaneous acquired diaphragmatic hernia without any apparent history of trauma is a very rare condition and is very difficult to diagnose. We present a case of a 21-year-old male who presented with abdominal pain for one month and four episodes of vomiting for one day. Clinical suspicion, chest radiography with nasogastric tube in situ and computed tomography (CT) confirmed the diagnosis. The diaphragmatic defect was repaired surgically. The patient had an uneventful post-operative recovery.

Neonatal gastric volvulus: another cause of “Mucousy Baby” with gasless abdomen.

Neonatal acute gastric volvulus is rare and often associated with diaphragmatic anomalies. Patients usually present with vomiting and respiratory distress, but excessive salivation, failure to pass a nasogastric tube beyond 20 cms and the presence of a space occupying thoracic lesion should also prompt a search for the entity. The authors describe a case presenting with these atypical findings and stress the importance of the plain radiograph chest to make a diagnosis.

Congenital diaphragmatic hernia; delayed presentation

We report a case of late-presenting congenital diaphragmatic hernia [CDH] in a three-month-old male infant presenting to the pediatric hospital with attacks of cough and cyanosis. Although CDH is usually manifested on the first day of life, there are a number of case reports of late-presenting CDH usually presenting with respiratory or gastrointestinal symptoms. In this case report, we have focused on the anesthetic management of late-presenting CDH. Congenital diaphragmatic hernia is usually manifested on the first days of life as respiratory distress and a scaphoid abdomen. The abnormality is herniation of the abdominal viscera through a defect in the diaphragm, most commonly the foramen of Bochdalek on the left side. These infants often have a dramatic presentation, in contrast, late onset or late- presenting CDHs present outside the neonatal period with variable signs and symptoms. We describe a case of late-presenting CDH that referred to the pediatric hospital with attacks of cough and cyanosis

rear case of congenital anterior diaphragmatic hernia

We report a case of a newborn with the rare anterior diaphragmatic hernia with herniation of the liver into the pericardial sac that posed a diagnostic dilemma in our Neonatal Intensive Care Unit [NICU]. An anterior diaphragmatic hernia should be suspected in any newborn with an anterior mediastinal mass or a pericardial effusion. A MRI of the chest helped to confirm the diagnosis. The relevant literature is reviewed

Radiographic diagnosis of diaphragmatic hernia: review of 60 cases in dogs and cats

Sixty cases of diaphragmatic hernia in dogs and cats were radiologically reviewed and categorized by their characteristic radiographic signs. Any particular predilection for age, sex, or breed was not observed. Liver, stomach and small intestine were more commonly herniated. At least two radiographs, at different angles, were required for a valid diagnosis, because some radiographic signs were not visible in a single radiographic view and more clearly detectable in two radiographic views. In addition to previously reported radiographic signs for diaphragmatic hernia, we found that the location of the stomach axis and the displacement of tracheal and bronchial segments were also useful radiographic signs.

Bilateral morgagni hernia masquerading as mediastinal mass.

Bilateral Morgagni hernia is a rare entity. A patient of bilateral Morgagni hernia presenting as mediastinal mass is being reported. The hernial contents included transverse colon so the diagnosis could be confirmed preoperatively by barium enema. Surgery was curative.

Morgagni hernia in infants and children

The cumulative data regarding five cases of Morgagni hernias in infants and children over the last six years have been reviewed. All five patients were clinically normal upon presentation; however, the most common symptoms and signs were respiratory. Chest x-ray was the most common diagnostic test. The diagnoses were also later confirmed with preoperative barium meal studies. All of the patients had additional congenital anomalies, of which malrotation of the gut was the most commonly encountered. Upon operation, all of the cases contained a hollow viscus, and had a sac. The defects were repaired through abdominal approaches. There was no mortality and postoperative complication in these series.