Interactive Cardiovascular and Thoracic Surgery 3:243-244(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Rapidly accumulating spontaneous pulmonary hematoma complicating a small parenchymal aneurysm
Ibrahim Sameh Sersar*,
Mohammed Fouad Ismaeil,
Nabil Abdel Raouf Abdel Mageed and
Mohammed Mounir Elsaeid
Department of Cardiothoracic Surgery and Anaesthesia and Intensive Care Unit, Mansoura University, Mansoura, Egypt
* Corresponding author. Tel.: +20-50-225-5471; fax: +20-50-223-411
sameh001{at}yahoo.com
Received August 13, 2003;
received in revised form November 13, 2003;
accepted November 17, 2003
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Abstract
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A 20-year-old male is presented with hemoptysis since 3 months. Plain chest X-ray and computed tomography (CT) chest at that time showed bilateral hilar shadows. Recent X-ray showed a huge right-sided well-defined opacity. CT chest and magnetic resonance angiography were ordered for him revealing a huge intrapulmonary hematoma.
Key Words: Spontaneous pulmonary hematoma
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1. Introduction
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Pulmonary hematoma consists of hemorrhage into the alveolar and interstitial spaces. It is usually associated with surrounding intraparenchymal hemorrhage [1]. However, 24–48 h after the trauma, a hematoma typically develops into a discrete mass with distinct margins. It usually resolves in approximately 2–4 weeks. Occasionally, these hematomas may cavitate if they become secondarily infected and present as an abscess requiring drainage [2].
Post-traumatic pulmonary hematoma may result from direct blunt trauma, blast injury, or indirect forces from the ballistics of a missile. Pulmonary hematomas may also result from overdosage of anticoagulants, or rarely as a complication of subclavian vein catheterization. Although Nakayama and coworkers [4] have reported that pulmonary hematoma can occur as isolated injuries in children, in adults they are typically associated with other injuries and have an overall mortality rate of 22–30%, as recorded by Besson and Saegesser [7] and Stellin [1–3,5].
The most frequent clinical sign is hemoptysis. Chest pain and compression symptoms may be present. Pulmonary hematoma should be suspected in any patient with major chest wall injury; it can be confirmed by radiologic evaluation. Computed tomography (CT) scan can be helpful in distinguishing between contusion and hematoma. It is a more sensitive and accurate means of diagnosing pulmonary hematoma. Magnetic resonance imaging (MRI) allows documentation of pulmonary hematoma and exclusion of more ominous lesions [6].
Indications for surgery were as follows: infection, hemoptysis and suspicions of malignant lesion. The early and late results are excellent [7].
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2. Case report
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A 20-year-old male was admitted to our center with hemoptysis since 3 months. He had no history of smoking or any significant pulmonary disease. No history of trauma or anticoagulation was present.
A postero-anterior and lateral chest X-ray 3 months previously showed only bilateral hilar shadows. CT chest showed enlarged both pulmonary arteries and pneumonic patch on the right lung mid zone (Fig. 1a).
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Fig. 1 (a) The first CT chest 3 months before. (b) Recent chest X-ray. (c) Recent CT chest shows a huge intrapulmonary hematoma with an aneurysm inside. (d, e) MRA showing the hematoma and the aneurysm inside it.
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Recent chest X-ray and CT revealed the same findings with a huge well-defined rounded mass adjacent to the right pleura (Fig. 1b and c). Magnetic resonance angiography (MRA) was done revealing a laminated heterogenous signal intensity on all pulse sequences. It measures 10x6.5 cm2 (Fig. 1d and e).
Doppler ultrasound revealed a free flow within this mass. Echocardiography showed calcific pericardium and dilated pulmonaries.
His physical examination showed no abnormalities. Blood chemistry and serology were normal apart from very low prothrombin concentration (34%). Tuberculin and fibreoptic bronchoscopy (FOB) were done as our routine in cases of hemoptysis. It was negative apart from some old blood trickling through the right upper lobe bronchus and BAL (brush and lavage were done through the FOB). They were negative. CT guided biopsy suggested a fibrous tumor compatible with fibrous histiocytoma. General anesthesia and muscle paralysis were done and the patient was intubated with a Double lumen endotracheal tube. After pleural adhesions were dissected, a well-circumscribed lobulated mass of 15x10x8 cm3 in the anterior segment of the right upper lobe was found. The right upper lobe was resected. Pathological examination revealed a pulmonary hematoma (Fig. 2).
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3. Discussion
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Very little if any is written or known about the spontaneous pulmonary hematoma. It should be suspected in a patient with bleeding tendency. It should be differentiated from a lung tumor. Its diagnosis, anesthesia, operative and postoperative management are challenging.
doi:10.1016/j.icvts.2003.11.011
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References
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- Trinkle JK, Richardson JD, Franz JL. Management of flail chest without mechanical ventilation. Ann Thorac Surg. 1975;19:355[Abstract]
- Mathai M, Byrd RP Jr, Roy TM. The posttraumatic pulmonary mass. J Tenn Med Assoc. 1996;89:41[Medline]
- Colebunders R, Parizel P, De Backer W, De Schepper A, Vermeire P. Pulmonary haematoma caused by oral anticoagulant therapy. Report of a case. Acta Radiol Diagn (Stockholm). 1983;24:445
- Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surg. 1989;210:770[Medline]
- Stellin G. Survival in trauma victims with pulmonary contusion. Am Surg. 1991;57:780[Medline]
- Obretenov E, Petrov D, Alaidzhiev G, Plochev M. Surgical treatment of post-traumatic intrapulmonary haematomas (Article in Bulgarian). Khirurgiia (Sofiia). 2002;58:24
- Besson A, Saegesser F. Color atlas of chest trauma and associated injuries. Oradell, NJ: Medical Economics; 1983.
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Rapidly accumulating spontaneous pulmonary hematoma
J. Thorac. Cardiovasc. Surg.,
January 1, 2005;
129(1):
233 - 234.
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Abstract
1. Introduction