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Ann Thorac Surg 2001;71:2011-2013
© 2001 The Society of Thoracic Surgeons

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Case report

Delayed pulmonary hemorrhage 17 years after gunshot wound to the chest

^a Department of Surgery, University of California, San Francisco/Fresno Campus, University Medical Center, Fresno, California, USA

Accepted for publication April 17, 2000.

Address reprint requests to Dr Bilello, Department of Surgery-UCSF/Fresno, University Medical Center, 445 S Cedar Ave, Fresno, CA 92702
e-mail: jbilellomd{at}communitymedical.org

	Abstract

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A 45-year-old male returned 17 years after a gunshot wound to the chest with intermittent hemoptysis that progressed to frank pulmonary hemorrhage. The complications of retained intrathoracic foreign bodies are briefly reviewed.

	Introduction

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Complications secondary to retained intrathoracic missiles are uncommon but have been previously reported [1–3]. Retained missiles have been expectorated and have caused late bronchial obstruction [2, 3]. We report a case of intermittent hemoptysis, which progressed to life-threatening hemoptysis 17 years after gunshot wound to the chest.

A 45-year-old man presented to the emergency department complaining of hemoptysis, expectorating a half-cup of blood with clot. He had sustained a single gunshot wound to the right chest and arm in 1982 and was treated with a tube thoracostomy. The patient related previous episodes of intermittent hemoptysis in 1986 and 1994. He denied fevers, weight loss, chest pain, or chronic cough and was able to perform his tasks as a gardener. He denied exposure to or treatment for tuberculosis. On exam, the patient was afebrile, normotensive, nontachycardiac, and in no distress. He had no significant findings on physical exam except for well-healed scars on his right arm and chest from his previous injury.

Chest roentgenogram showed bullet fragments in the soft tissues of the right chest wall as well as a large portion of a bullet in the right lower lobe of the lung (Fig 1A, B). Computerized axial tomography of the chest showed a 2 x 2-cm mass associated with a metallic object, surrounding inflammation, atelectasis, and suspected blood in the right lower lobe (Fig 2). Bronchoscopy was negative except for a small clot in the right lower lobe bronchus. Smear for acid-fast bacilli was negative.

View larger version (240K): [in this window] [in a new window]   Fig 1. Posteroanterior (A) and lateral (B) chest roentgenograms showing metallic bullet fragment in posterior aspect of the right lower lobe.

View larger version (119K): [in this window] [in a new window]   Fig 2. Computerized tomography of the chest illustrating inflammation and cavitation in the posterior segment of the right lower lobe associated with the bullet.

He was taken urgently to the operating room, a double lumen endotracheal tube was placed, and a right posterolateral thoracotomy was performed. On exploration, the basal posterior portion of the right lower lobe contained a firm 3 x 3-cm mass with a thick, fibrous adhesion that extended to the right hemidiaphragm. A portion of the diaphragm was resected with the abnormal lung and the diaphragm repaired. The specimen was opened and a 2 x 2-cm fibrous capsule containing a bullet and clot was noted. The surrounding lung tissue was grossly hemorrhagic. Microscopic evaluation revealed that the bullet-containing cavity had respiratory epithelium with some squamous metaplasia. There was evidence of pneumonitis, chronic scarring, and intraalveolar blood, and there was acute vascular congestion in the vessels adjacent to the cavity.

The patient did well, was discharged on postoperative day 6, and has had no further episodes of hemoptysis.

	Comment

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Retained intrapulmonary foreign bodies presenting with hemoptysis have been previously reported in the literature [1]. Delayed sequelae from lung injury are rare. Bullets and other fragments have the potential to embolize once gaining access to systemic vessels or the heart [4]. Remote complications from retained pulmonary penetrating missiles also include pneumatocele, pulmonary arteriovenous fistula (with right-to-left shunt), and risk of cerebral abscess and pulmonary artery aneurysm [5]. Bullets can embolize from the systemic veins to the pulmonary arteries and cause signs and symptoms of pulmonary embolus. However, it is more common for them to remain in the right heart, as the missile tends to become trapped beneath the tricuspid valve and its associated chordae tendineae [6].

Most bullets and foreign bodies in the lung remain inert and become surrounded by fibrous tissue, especially if there is migration into the pleural space [4]. In the absence of symptoms and complications, bullet removal from the pleura and parenchyma is contraindicated, as such procedures may end up doing more harm than good [7]. However, our patient presented with intermittent hemoptysis that progressed to pulmonary hemorrhage. Both histologically and clinically, it appears that there was chronic inflammation that caused erosion between a respiratory epithelium-lined cavity and pulmonary vessels.

Although erosion is usually heralded by the onset of hemoptysis, pneumonitis, and/or abscess, Symbas and Gott still recommend elective removal of asymptomatic large or sharp foreign bodies in proximity to major pulmonary vessels and airways, where erosion would be catastrophic [5]. The inciting bullet in this case was peripheral in the basilar posterior segment of the right lung. The self-limited, intermittent nature of the previous two episodes of hemoptysis 13 and 5 years ago cannot be explained. The patient reported by Kovnat and associates had a 3-year symptomatic interval with five bouts of intermittent nocturnal hemoptysis 25 years after the original shrapnel injury, but there was no precipitous onset of pulmonary hemorrhage [1].

This case supports the principle that elective removal of a symptomatic, intrapulmonary-retained foreign body may prevent subsequent life-threatening sequelae. In this case, the delayed pulmonary hemorrhage nearly brought about the original intentions of the patient’s assailant 17 years later.

	References

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1. Kovnat D.M., Anderson W.M., Rath G.S., et al. Hemoptysis secondary to retained transpulmonary foreign body: diagnosis by fiberoptic bronchoscopy 28 years after injury. Am Rev Respir Dis 1974;109:279-282.[Medline]
2. Saunders M.S., Cropp A.J., Mounir M.D. Spontaneous erosion and expectoration of a retained intrathoracic bullet: case report. J Trauma 1992;33:909-911.[Medline]
3. Kelley W.A., James E.C. Retained intrapulmonary bullet presenting with bronchial obstruction. J Trauma 1976;16:153-154.[Medline]
4. Van Way C.W. Intrathoracic and intravascular migratory foreign bodies. Surg Clin North Am 1989;69:125-133.[Medline]
5. Symbas P.N., Gott J.P. Delayed sequelae of thoracic trauma. Surg Clin North Am 1989;69:135-142.[Medline]
6. Ledgerwood A.M. The wandering bullet. Surg Clin North Am 1977;57:97-109.[Medline]
7. Mattox K.L. Indications for thoracotomy: deciding to operate. Surg Clin North Am 1989;69:47-58.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James W. Davis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bilello, J. F. Articles by Davis, J. W. Search for Related Content PubMed PubMed Citation Articles by Bilello, J. F. Articles by Davis, J. W. Related Collections Lung - other