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Ann Thorac Surg 2007;83:1521-1523
© 2007 The Society of Thoracic Surgeons
Department of Thoracic Surgery, Ondokuz May
s University, Medical School, Samsun, Turkey
Accepted for publication September 14, 2006.
* Address correspondence to Dr Celik, Ondokuz Mays University, Medical School, Department of Thoracic Surgery, Samsun 55139, Turkey (Email: cburcin{at}hotmail.com).
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Abstract |
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Introduction |
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The collagen vascular disorders are a group of systemic disorders characterized by inflammation of vessels, connective tissues, and serosal surfaces. Each of these disorders may be associated with lung disease [3]. Rheumatoid disease is a systemic disease of unknown origin that is characterized principally by chronic inflammation and destruction of joints. Pleural abnormalities are probably the must frequent manifestation of rheumatoid disease in the thorax [3, 4]. We present a case of massive spontaneous hemopneumothorax in a young patient with rheumatoid lung disease as an unusual complication.
A 35-year-old woman was admitted to the hospital with a history of progressive dyspnea. She had a 3-year history of rheumatoid arthritis with positive rheumatoid factor. She had been treated with prednisone in a dosage of 16 mg/day. She was a nonsmoker.
On physical examination, she was pale and short of breath. Reduced breathing sounds and hyperresonant percussion on the left hemithorax suggested pneumothorax. Her initial heart rate was 114 beats/min, blood pressure was 100/60 mm Hg, respiratory rate was 34 breaths/min, and arterial oxygen saturation was 95% in room air. A chest roentgenogram taken at admission revealed a hydropneumothorax on the left hemithorax with mediastinal shift (Fig 1). A chest computed tomography scan revealed infiltration in the upper lobe parenchyma on the left hemithorax (Fig 2). Thoracentesis revealed bloody fluid.
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A thoracostomy tube was inserted, with an initial drainage of 1200 mL of fresh blood and air. The patient was closely monitored. During the next 2 hours, 600 mL of blood was drained. Episodes of hypotension developed despite aggressive fluid replacement and the patient underwent an emergent thoracotomy in the operating room.
During the operation, 1000 mL of clotted blood was found inside the left pleural cavity. Active bleeding was identified from the lingular branch of the pulmonary artery, and there was a partial necrosis in the upper and lower lobe parenchyma. The lingular branch of the pulmonary artery was ligated, and the necrotizing lingular segment of the upper lobe was resected (wedge resection). Pathologic examination showed necrosis and acute inflammation in the lung parenchyma.
Postoperatively, despite antibiotic therapy, empyema and sepsis developed. The patient’s condition deteriorated, and mechanical ventilation treatment was given for 15 days. During this time, we administered a steroid in high dosage (250 mg/day), and the patient recovered slowly. The chest tube was removed on postoperative day 30, and the patient discharged on postoperative day 45 in good condition. She is well 3 years postoperatively.
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Pleuropulmonary manifestations and complications of rheumatoid disease include pleural effusion, pneumothorax, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, pulmonary necrobiotic nodule, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis [3, 4]. Pleural involvement is probably the most common intrathoracic manifestation of rheumatoid disease, occurring in about 5% of patients. Patients with rheumatoid disease have an increased incidence of pleural effusion. Pleural effusions were more common in men than in women [3, 7]. Pleural effusions are usually small and unilateral, but may be bilateral and large. The fluid is an exudate with high concentrations of protein and lactate dehydrogenase. The glucose concentration is usually low. Although the pleural effusions may resolve spontaneously, they may persist for long periods of time [3, 4].
Pulmonary necrobiotic nodules are a relatively rare manifestation of rheumatoid disease, occurring in less than 0.5% of patients. The nodules can cavitate and cause hemoptysis if they are close to a main bronchus, or they may cause pneumothorax if they are situated peripherally adjacent to the pleura [6]. We did not observe any pulmonary necrobiotic nodules perioperatively nor in the pathologic examination.
Common presentations in cases of spontaneous hemopneumothorax are the sudden onset of chest pain or dyspnea, as the case of our patient illustrates [2, 8]. Initial management consists of resuscitation with adequate fluid replacement and drainage of the pleural space. In patients with massive hemopneumothorax, urgent surgical therapy is better than tube drainage alone. A thoracotomy provides the opportunity to stop the bleeding, evacuate coagulated blood from the pleural cavity, and secure effective drainage by drain placement under direct vision [2].
The various aspects of rheumatoid lung disease and its clinical significance have been reported, and we report here a rare case of massive spontaneous hemopneumothorax associated with rheumatoid lung disease. As in this patient, consideration should be given to rheumatoid disease being associated with unusual, life-threatening pulmonary complications. In these patients, urgent surgical therapy should be performed, and an operation in the early stage is likely to provide a good outcome.
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This article has been cited by other articles:
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  H. A. Ali, M. Lippmann, U. Mundathaje, and G. Khaleeq Spontaneous Hemothorax: A Comprehensive Review Chest, November 1, 2008; 134(5): 1056 - 1065. [Full Text] [PDF]
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