Spontaneous haemopneumothorax

Case contributed by Dr Henry Knipe

Presentation

Sudden onset left sided chest pain. No history of trauma. No past medical history.

Patient Data

Age: 30 years
Gender: Male
X-ray
There is a large right hydropneumothorax with collapse of the underlying lung and displacement of the mediastinum towards the left.
CT
Large right haemopneumothorax. Contrast extravasation in the right apex, appearing to originate from the posterior second intercostal space. No underlying mass or vascular malformation identified. Right lung atelectasis. No midline shift. Right ICC with the tip posterior to the left atrium. Associated subcutaneous emphysema.
DSA (angiography)

Right subclavian angiogram demonstrates bleeding from the superior (highest) intercostal arising from the costo-cervical trunk. A series of a small pseudo-aneurysms were present and active bleeding at the time of angiography. The common trunk leading to the site of the bleeding, the highest intercostal was embolised with a series of 2 mm coils without compromise of the costocervical trunk. Post embolisation there was cessation of bleeding.

Images courtesy Dr Alex Rhodes, The Royal Melbourne Hospital.

Case Discussion

This patient present with sudden onset of chest pain, with the initial chest x-ray demonstrating a right hydropneumothorax. A right intercostal catheter was inserted with approximately 1 L of fresh blood draining initially with another litre draining over the next 2 hours. 

CTA demonstrated active bleeding in the upper intercostal region with this confirmed on DSA with subsequent successful embolisation. 

No cause was identified with no proceeding trauma or infection, and no past medical history. No mass or vascular malformation identified on imaging.

Spontaneous haemopneumothorax is rare, with a few mechanisms proposed 1,2:

  • torn adhesion between the parietal and visceral pleura after a spontaneous pneumothorax
  • rupture of a bulla resulting in damage to underlying vascularised lung parenchyma​
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Case information

rID: 50169
Case created: 21st Dec 2016
Last edited: 9th May 2017
Inclusion in quiz mode: Included

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