AN UNUSUAL COMPLICATION OF PULMONARY BIOPSY: ATRAUMATIC LUNG HERNIATION

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Lung herniation, in which lung tissue protrudes through its bounding structures, is a rare condition which may occur as a result of trauma, thoracic operations, increased thoracic pressure, or congenital abnormalities(1). CASE PRESENTATION: A 57-year-old African American man presented to the emergency department after one day of right-sided chest pain accompanied by worsening dyspnea after a coughing episode. He described a painful pressure-like sensation adjacent to the sternum that worsened with deep inspiration and was not relieved with positioning. The patient had a history of a sarcoidosis, daily marijuana use, and a prior thoracoscopic right anterior lung wedge resection for a pulmonary biopsy 2 years prior. On physical exam the patient had a heart rate of 108 beats per minute, blood pressure of 137/98 mmHg, respiratory rate of 18, and oxygen saturation of 95% on room air. He had tenderness to palpation of the right upper quadrant of his abdomen with no palpable mass in the chest or abdomen. There was no tenderness to anterior rib palpation. Chest x-ray was unremarkable except for post-surgical changes of the right hemithorax. A chest computed tomography scan revealed a partial herniation of the right middle lobe of the lung between the right fourth and fifth ribs anteriorly. After initial assessment by thoracic surgery, the patient elected for conservative management and was discharged from the hospital. Due to increasing chest pain, he underwent successful surgical repair of the hernia six months later with subsequent resolution of his chest pain. DISCUSSION: Postoperative intercostal hernias are more common after minimally-invasive surgeries, such as video-assisted thoracoscopy (VATS), compared to major thoracic interventions(2). This increased risk has been attributed to the limited access to tissue in minimally-invasive procedures and resultant inadequate closure of the chest wall. Challenges with wound closure leading to lung hernia have been reported in the literature related to VATS with an anterior approach(3). Our case presents a patient with lung herniation likely secondary to inadequate closure of his prior mediastinoscopy incision. Additionally, his underlying sarcoidosis may have predisposed him to inadequate wound healing, and his chronic coughing from marijuana use may have incited the herniation through increased intrathoracic pressure. CONCLUSIONS: In a patient with a history of minimally invasive thoracic surgery who is complaining of parasternal pleuritic chest pain, lung herniation must be on the differential diagnosis. Increasing size, worsening pain, or incarceration of the hernia are indications for urgent surgical intervention that physicians must keep in mind when treating patients with this rare cause of chest pain. Reference #1: Weissberg D. Lung hernia - a review. Adv Clin Exp Med. 2013. Reference #2: Temes RT, Talbot WA, Green DP, Wernly JA: Herniation of the lung after video-assisted thoracic surgery. Ann Thorac Surg. 2001. Reference #3: Vasileios K. Kouritas, Robert S. George, Alessandro Brunelli, Emmanouel Kefaloyannis; Lung herniation after uniportal video-assisted thoracic surgery lobectomy presenting with subcutaneous surgical emphysema, European Journal of Cardio-Thoracic Surgery. 2016. DISCLOSURES: No relevant relationships by Dave Gupta, source=Web Response No relevant relationships by Erica Sheline, source=Web Response No relevant relationships by Manasi Tannu, source=Web Response