Thoracic aortic dissection presenting with bilateral haemothoraces: a potentially missed diagnosis.

Thoracic aortic dissection is a life-threatening diagnosis, which should not be missed. We present a case in which a patient who presented to the emergency department with chest pain was assessed and referred for admission for treatment of pneumonia, due to misinterpretation of a chest radiograph finding. The patient was re-reviewed and subsequently underwent further investigation, which confirmed aortic dissection. She underwent emergency thoracic endovascular aortic graft repair with stent graft insertion. This case demonstrates haemothorax as an uncommon complication of aortic dissection.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis.

BACKGROUND: Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure. METHODS: We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation. RESULTS: Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21). CONCLUSION: Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

[VATS in Thorax Trauma]. / Videoassistierte Thorakoskopie (VATS) beim Thoraxtrauma.

Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group - as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) - has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today's better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).

Primary Pulmonary Synovial Sarcoma with Hemothorax: a Case Report.

Background: Synovial sarcoma is a rare and aggressive soft tissue malignancy most commonly arises from periarticular tissue of the extremities. Although several cases in the literature have reported different origins, primary pulmonary synovial sarcoma (PPSS) is an exceedingly rare and underrecognized entity, accounting for 0.5% of all lung malignancies. Clinical presentation includes chest pain, dyspnea, cough, and hemoptysis. The finding of hemothorax is a rare presentation and was barely reported in the literature. Due to its rarity and aggressive nature, the optimal treatment is unclear, while the mainstay remains surgical resection with chemo- and/or radiation therapy. Objective: To report a case of hemorrhagic effusion subsequently diagnosed with primary pulmonary synovial sarcoma with the main objective of enriching the literature regarding this rare malignancy. Case report: A 52-year-old male smoker with a background of coronary artery disease, hypertension, and diabetes mellitus was referred to our hospital. The patient presented with a history of chest pain, dyspnea, and massive right-sided pleural effusion. Laboratory investigations were unremarkable except for anemia. Chest x-ray showed a complete opacity on the right lower zone with right-sided pleural effusion. Thoracentesis was done and revealed hemorrhagic exudative effusion. Computed tomography (CT) scan showed a right heterogeneous lung mass compressing the medial segment of the middle lobe. Subsequently, the patient underwent bronchoscopy, which showed compression and edema on the right middle lobe bronchus with traces of blood coming from the right lower lobe. The patient underwent a right posterolateral thoracotomy, a fungating mass eroding the medial segment of the middle lobe was resected that was diagnosed as high-grade primary pulmonary synovial sarcoma. Radiotherapy was instituted. The patient died after two years due to recurrence. Conclusion: PPSS is an aggressive disease with poor prognostic outcomes, and Its presentation is almost similar to other lung malignancies. Meanwhile, there is no definitive management guideline, and most management depends on surgical resection if feasible with adjuvant chemo-radiation therapy.

Thoracic endometriosis presenting as hemopneumothorax.

Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and hemoptysis. Common manifestations include pneumothorax, hemothorax, and pulmonary or pleural nodules. In addition, symptoms and manifestations can be "catamenial" happening a few days after menstruation onset. This disease can be debilitating, causing a significant impact on the quality of life of young women. We present a case of a young female who was referred to our hospital with recurrent right-sided pleural effusions and pneumothoraces. Pleural fluid drainage was consistent with hemothorax. Transvaginal ultrasound showed mild intraperitoneal fluid in the Cul-de-Sac. Due to concerns for thoracic endometriosis, video-assisted thoracoscopic surgery was performed confirming the diagnosis by pathology. Therapeutic pleurectomy with diaphragmatic repair and pleurodesis was performed. The patient was started on medroxyprogesterone acetate injections two weeks after with great clinical response.

Hemothorax caused by costal exostosis injuring diaphragm: a case report and literature review.

BACKGROUND: Osteochondromas, also known as exostoses, are the most common benign tumors of bone and can be classified into isolated and multiple osteochondromas. A great majority of osteochondromas is asymptomatic, painless, slow-growing mass, and incidentally found. However, osteochondromas occurring in adolescence or in adult patients can grow in size and become symptomatic as a result of mechanical irritation of the surrounding soft tissues or peripheral nerves, spinal cord compression, or vascular injury. CASE PRESENTATION: We present a case of a 13-year-old girl with spontaneous hemothorax, the cause of which was identified by limited thoracotomy with the aid of video-assisted thoracic surgery to be bleeding from a diaphragmatic laceration incurred by a costal exostosis on the left sixth rib. Preoperative chest computed tomography (CT) depicted a bony projection arising from the rib and bloody effusion in the intrathoracic cavity, but was unable to discern the bleeding cause from the lung or the diaphragm. This case will highlight our awareness that costal exostosis possibly results in bloody pleural effusion. Meanwhile, English literatures about solitary costal exostosis associated with hemothorax were searched in PubMed and nineteen case reports were obtained. Combined our present case with available literature, a comprehensive understanding of this rare disease entity will further be strengthened. CONCLUSIONS: Injury to the diaphragm is the primary cause of hemothorax caused by costal osteochondroma, including the present case. Thoracic CT scan can help establish a diagnosis of preoperative diagnosis of costal osteochondroma. Surgical intervention should be considered for those patients with symptomatic osteochondroma of the rib. Combined with our case and literature, prophylactic surgical removal of intrathoracic exostosis should be advocated even in asymptomatic patients with the presentation of an inward bony spiculation.

Hemotórax mortal secundario a lesiones de arterias intercostales posteriores: Reporte de caso / Fatal hemothorax secondary to posterior intercostal artery injuries: case report

Resumen La lesión de la arteria intercostal es un diagnóstico diferencial poco sospechado. Puede complicarse con una inestabilidad hemodinámica por un hemotórax o un hematoma intratorácico, lo que contribuye a su morbilidad y mortalidad. Se reporta el caso de un paciente de 61 años sin antecedentes patológicos conocidos que acudió al servicio de urgencias por dolor asociado a dificultad respiratoria posterior a un trauma torácico cerrado por caída de 8 días de evolución. Los estudios de imagen revelaron un hemotórax derecho, que ameritó la colocación de un tubo pleural. Se realizó una laparotomía exploratoria sin evidencia de hemorragias ni colecciones intrabdominales, y que posteriormente falleció. En el examen de necropsia se evidenciaron fracturas del noveno y décimo arco costal posterior derecho, asociado a un hematoma. El hemotórax secundario a la lesión de la arteria intercostal es poco frecuente, pero es una emergencia que requiere un diagnóstico asertivo y una intervención oportuna.

Abstract Intercostal artery injury is a poorly suspected differential diagnosis. It can be complicated by hemodynamic instability due to hemothorax or intrathoracic hematoma, which contributes to morbidity and mortality. We report the case of a 61-year-old patient with no pathological history known, who was presented to the emergency department for pain associated with respiratory distress following a blunt chest trauma due to a fall 8 days earlier. The Imaging studies revealed a right hemothorax, which required the placement of a pleural tube. An exploratory laparotomy was performed without evidence of bleeding or intra-abdominal collections, and he subsequently died. The necropsy examination revealed fractures of the ninth and tenth right posterior costal arch, associated with a posterior costal hematoma. The hemothorax that is secondary to an intercostal artery injury is rare, but it is an emergency that requires assertive diagnosis and timely intervention.

Porous diaphragm syndrome presenting as hemothorax secondary to hemoperitoneum after laparoscopic myomectomy: A case report and literature review.

Porous diaphragm syndrome includes all pleural cavity conditions, including pleural effusion, hemothorax, or pneumothorax, that occur secondary to peritoneal cavity disorders through defects in the diaphragm. In this report, we describe the first known case of porous diaphragm syndrome presenting as hemothorax after laparoscopic myomectomy. A 46-year-old nulliparous woman underwent laparoscopic myomectomy for multiple fibroids. Eight hours after surgery, the patient developed exertional dyspnea followed by hemoptysis. Radiological diagnosis revealed massive hemothorax in the right thoracic cavity. Thoracoscopic findings showed the presence of small fenestrae at the center of the right diaphragm, which were repaired thoracoscopically. Hence, quick postoperative diagnosis resulted in successful treatment. In this case, porous diaphragm syndrome is believed to be caused by retention of intraoperative bleed and saline from intra-abdominal lavage, in the abdominal cavity. Porous diaphragm syndrome is a potential life-threatening condition that gynecological surgeons should consider in this era of laparoscopic surgery.

[Treatment of a patient with acute thoracoabdominal aortic dissection complicated by haemothorax]. / Lechenie patsienta s ostroi dissektsiei torakoabdominal'nogo otdela aorty, oslozhnennoi gemotoraksom.

Total left-sided haemothorax is a rare and severe complication of acute DeBakey type III aortic dissection. The primary aim of treatment is immediate arrest of haemorrhage and stabilization of the haemodynamic status of the patient. Endovascular isolation of the ruptured thoracic portion of the aorta using a stent graft (TEVAR) has recently become the 'gold standard' in treatment of acute, rupture-complicated aortic dissections of this localization. Described in the article is a clinical case report concerning successful endovascular treatment of a seriously ill patient with dissection of the thoracoabdominal portion of the aorta, rupture and massive haemorrhage into the left pleural cavity. The patient underwent endoprosthetic repair of the descending aorta in the setting of a hybrid operating room under local anaesthesia, followed by drainage of the left pleural cavity. The postoperative period was uneventful with no complications. The patient was discharged in a satisfactory condition on day 10 after the emergency surgical intervention. An important advantage of TEVAR for aortic ruptures is a minimally invasive nature of the procedure, consisting in no need to perform either sternothoracotomy or to connect a heart-lung machine, thus decreasing surgical wound, reducing the risk of perioperative life-threatening haemorrhage, and contributing to early activation of the patient.

Hemothorax after oocyte retrieval in a patient with a history of COVID-19: a case report.

Spontaneous hemothorax is a rare disorder characterized by pleural fluid hematocrit greater than 50% of the peripheral blood hematocrit without natural or iatrogenic trauma to the lungs or pleural space. Since the first case of COVID-19, more than 85 million cases have been confirmed and most patients have sustained symptoms after more than six months of acute infection. This paper reports the case of a 38-year-old woman without signs of endometriosis and a history of COVID-19 infection who developed spontaneous hemothorax after oocyte retrieval. Three months before undergoing assisted reproductive technology (ART) treatment, the patient had a symptomatic COVID-19 infection with a negative PCR test and a positive IgG test four weeks after the onset of symptoms. Controlled ovarian stimulation and oocyte retrieval were conducted uneventfully. Two hours after oocyte retrieval, the patient developed nausea and mild hypogastric pain. Ten hours after the procedure, the patient went to the emergency department with abdominal pain. Chest computed tomography scans revealed moderate right pleural effusion and laminar left pleural effusion. Since the patient had respiratory symptoms, the choice was made to drain the pleural fluid. Fluid analysis confirmed the patient had right hemothorax (400 mL). After drainage, the patient's clinical and imaging signs improved gradually without complications. The patient was asymptomatic one week after the procedure.

Pulmonary sequestration with Aspergillus infection presenting as massive hemoptysis and hemothorax with highly elevated carcinoembryonic antigen in pleural effusion that mimics advanced lung malignancy.

BACKGROUND: Pulmonary sequestration (PS) associated with massive hemoptysis, hemothorax, and elevated tumor markers or even lung malignancy has been reported in several studies. These clinical features combined with lung lesions on chest imaging are sometimes hard to differentiate from lung malignancies and often complicate the diagnostic procedure. CASE PRESENTATION: A 45-year-old man with PS presented with massive hemoptysis, hemothorax, and extremely elevated carcinoembryonic antigen (CEA) in pleural effusion was initially misdiagnosed with advanced lung carcinoma, but was ultimately diagnosed with PS with Aspergillus infection. CONCLUSIONS: PS is rarely concurrent with lung cancer; most of the time, it is misdiagnosed as a malignancy, especially when presenting with a fungal infection, which could remarkably elevate CEA in pleural effusion.

A 43-Year-Old Man With Rapidly Respiratory Failure and Spontaneous Massive Hemothorax.

CASE PRESENTATION: A 43-year-old man urgently was referred to the hospital complaining of rapidly worsening dyspnea and right-side chest wall discomfort for 1 hour. Two hours later, he experienced acute respiratory failure that subsequently required intubation and invasive mechanical ventilation, thus he was transferred to ICU. He had no fever, weight loss, or bleeding tendency. He was previously healthy with no history of trauma and was not currently on any medication.

Multifocal pleural capillary hemangioma: a rare cause of hemorrhagic pleural effusion-case report.

BACKGROUND: Capillary hemangioma can be found in many organs, but rarely in pleura. Previously, only localized pleural capillary hemangioma cases have been reported. Corticosteroids are the most commonly recommended drugs in capillary hemangioma. CASE PRESENTATION: Here, we present a case of a young woman with recurrent hemorrhagic pleural effusion. Despite repeatedly thoracentesis, the routine examinations, including chest computed tomography (CT) scan, pleural effusion biochemical test, and cytology all failed to make a definite diagnosis. Thus, single port video-assisted thoracoscopy (VATS) was then performed. Numerous nodules arising from the parietal pleura were found, and biopsies showed multifocal pleural capillary. However, recurrent pleural effusion was successfully managed by oral azathioprine, after failure of dexamethasone treatment. CONCLUSIONS: To our knowledge, this is the first case of a patient with recurrent hemorrhagic pleural effusion masquerading as malignant pleurisy, but in fact caused by multifocal pleural capillary hemangioma.

Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal.

BACKGROUND: Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature. METHODS: We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms. RESULTS: We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research. CONCLUSION: Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.

Primary pulmonary Ewing's sarcoma: rare cause of massive hemothorax in a young girl-case report.

BACKGROUND: Ewing's sarcoma is a common malignant bone tumor in children and young adults. Rarely, extra-skeletal soft tissues and visceral organs can also be the site of origin of Ewing's sarcoma. Primary pulmonary Ewing's sarcoma is an extremely rare malignancy. CASE PRESENTATION: We report an unusual case of primary pulmonary Ewing's sarcoma in a 15-year-old girl who initially presented with massive hemothorax. By histopathology evaluation of surgical biopsy specimens, the diagnosis of extraosseous Ewing's sarcoma was confirmed by both light microscopy and immunohistochemistry. Emergency, open surgery was performed by thoracic surgery at an early stage. After 3 cycles of chemotherapy, the patient was found to be stable at follow-up examination. No more hydrothorax or other symptoms. CONCLUSIONS: We have described an extremely rare case of primary pulmonary Ewing's sarcoma with massive hemothorax. The patient underwent surgical resection and postoperative chemotherapy, no sign of recurrence to date as an outcome.

Thoracic surgery outcomes for patients with Coronavirus Disease 2019.

OBJECTIVE: As the Coronavirus Disease 2019 pandemic continues, appropriate management of thoracic complications from Coronavirus Disease 2019 needs to be determined. Our objective is to evaluate which complications occurring in patients with Coronavirus Disease 2019 require thoracic surgery and to report the early outcomes. METHODS: This study is a single-institution retrospective case series at New York University Langone Health Manhattan campus evaluating patients with confirmed Coronavirus Disease 2019 infection who were hospitalized and required thoracic surgery from March 13 to July 18, 2020. RESULTS: From March 13 to August 8, 2020, 1954 patients were admitted to New York University Langone Health for Coronavirus Disease 2019. Of these patients, 13 (0.7%) required thoracic surgery. Two patients (15%) required surgery for complicated pneumothoraces, 5 patients (38%) underwent pneumatocele resection, 1 patient (8%) had an empyema requiring decortication, and 5 patients (38%) developed a hemothorax that required surgery. Three patients (23%) died after surgery, 9 patients (69%) were discharged, and 1 patient (8%) remains in the hospital. No healthcare providers were positive for Coronavirus Disease 2019 after the surgeries. CONCLUSIONS: Given the 77% survival, with a majority of patients already discharged from the hospital, thoracic surgery is feasible for the small percent of patients hospitalized with Coronavirus Disease 2019 who underwent surgery for complex pneumothorax, pneumatocele, empyema, or hemothorax. Our experience also supports the safety of surgical intervention for healthcare providers who operate on patients with Coronavirus Disease 2019.

Angiectasia of the parietal pleura in a hemodialysis patient with central venous stenosis and bloody pleural effusion: a case report.

Pleural effusion in hospitalized patients with long-term hemodialysis (HD) has been frequently reported. The most common causes of unilateral pleural effusions include hypervolemia, parapneumonic, uremic effusion, and malignancy. In contrast, central venous stenosis (CVS) has rarely been shown to result in pleural effusion. CVS is often diagnosed by percutaneous angiography, yet there are no reports of cases where percutaneous angiography missed CVS and instead intrathoracic endoscopy was performed. Herein, we report a case of CVS with angiectasia of the parietal pleura detected on intrathoracic endoscopy. A 62-year-old man with HD presented with massive unilateral pleural effusion. Although the cause of pleural effusion was suspected to be CVS, percutaneous angiography did not show apparent stenosis, and as a result, other potential causes of bloody effusion were investigated. The intrapleural cavity was assessed using intrathoracic endoscopy, which revealed angiectasia and no malignancy. As these findings might be suggestive of congestive and dilated vessels with venous stenosis or occlusion, 3D-computed tomography (CT) scans were performed instead of percutaneous angiography to determine whether a stenosis or occlusion was present. Brachiocephalic vein stenosis was found near the aortic arch. CVS was treated through ligation of the arteriovenous fistula (AVF), resulting in a dramatic decrease in the left pleural effusion. This case would suggest that CVS should be suspected when angiectasia of the parietal pleura is observed in HD patients. In addition, the benefit of utilizing 3D-CT should be considered when HD patients present with a unilateral hemothorax on the same side as that of the AVF, particularly when on the left side.

Outcomes in Delayed Drainage of Hemothorax.

BACKGROUND: Prompt drainage of traumatic hemothorax is recommended to prevent empyema and trapped lung. Some patients do not present the day of their trauma, leading to their delayed treatment. Delayed drainage could be challenging as clotted blood may not evacuate through a standard chest tube. We hypothesized that such delays would increase the need for surgery or secondary interventions. METHODS: Our trauma registry was reviewed for patients with a hemothorax admitted to our level 1 trauma center from 1/1/00 to 4/30/19. Patients were included in the delayed group if they received a drainage procedure >24 hours after injury. These patients were matched 1:1 by chest abbreviated injury score to patients who received drainage <24 hours from injury. RESULTS: A total of 19 patients with 22 hemothoraces received delayed drainage. All but 3 patients had a chest tube placed as initial treatment. Four patients received surgery, including 3 who initially had chest tubes placed. Longer time to drainage increased the odds of requiring intrathoracic thrombolytics or surgery. In comparison, 2 patients who received prompt drainage received thrombolytics (P = .11) and none required surgery (P = .02). Patients needed surgery when initial drainage was on or after post-injury day 5, but pigtail catheter drainage was effective 26 days after injury. DISCUSSION: Longer times from injury to intervention are associated with increased likelihood of needing surgery for hemothorax evacuation, but outcomes were not uniform. A larger, multicenter study will be necessary to provide better characterization of treatment outcomes for these patients.