CHRONIC COUGH CAUSING AN UNEXPECTED COMPLICATION

Abstract

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Diseases SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Cough is a physiologic defense mechanism to protect airways from foreign material and secretions. It’s one of the most common symptoms responsible of outpatient clinic evaluation and consists of approximately 30 million of visits annually in United States. Can be classified upon the duration on acute (less than 3 weeks), subacute (3 to 8 weeks) and chronic (more than 8 weeks). Sustained cough can be associated with multiple complications including cardiovascular, gastrointestinal, genitourinary, musculoskeletal, ophthalmologic, psychosocial, respiratory and skin complications. The most frequent documented is rib fractures. Other less reported complications include muscle rupture and pneumothorax CASE PRESENTATION: A 72yo woman G3P3A0 with morbid obesity, hypertension, fibromyalgia, diabetes mellitus type 2 and sleep apnea on Bipap with no toxic habits who presents with a chief complaint of dry cough and progressive shortness of breath of approximately 1 year evolution, with multiple visit to primary physician as well as emergency room without improvement of symptoms and treated with antibiotic therapy for pneumonic process. She continued with cough not responsive to medical management developing a tearing abdominal pain that radiate to the back and upper chest associated ecchymosis, worsening of dyspnea, early satiety, left breast pain and an episode of syncope. She denied fever, sputum, or recent trauma. Chest Xray performed on multiple occasions without evidence of abnormality. Chest CT with contrast showed a diaphragmatic rupture with displacement of small and large bowel into left side thoracic cavity causing left pulmonary collapse. Thoracic surgery was performed with placement of intestine on abdominal cavity, correction of diaphragmatic rupture and chest tube placement for pneumothorax. After procedure patient reported resolution of dyspnea. DISCUSSION: Diaphragm is an inspiratory muscle, which contracts during expiratory phase. Valsalva maneuver results in lack coordination of different muscles of expiration, the muscle of the abdominal wall contracts pushing the diaphragm upward whereas the ribs are pushed inward and downward causing diaphragmatic rupture. This complication is caused by thoracic injury in 7% and by thracoabdominal injury in 22% of cases. Herniation of bowel loops into the chest can be a consequence of diaphragmatic rupture, which impairs ventilation and oxygen delivery. The true incidence of abdominal organ herniation due to diaphragmatic rupture is unknown since many cases likely go undiagnosed. Diaphragmatic rupture has an overall mortality rate of 25% as reported by the National Trauma Data Bank. CONCLUSIONS: Due to an increase rate of herniation and strangulation of abdominal organs secondary to diaphragmatic rupture, which can be life threatening and surgical procedure is life saving; physician should be aware of the uncommon complication of cough. Reference #1: Hillenbrand A, Henne-Bruns, D. Cough induced rib fracture, rupture of the diaphragm and abdominal herniation. World Journal of Emergency Surgery 2006, 1:34 DISCLOSURES: No relevant relationships by Aixa Dones Rodriguez, source=Web Response No relevant relationships by Marlene Farinacci Vilaro, source=Web Response No relevant relationships by Ricardo Fernandez, source=Web Response No relevant relationships by Luis Gerena Montano, source=Web Response No relevant relationships by Hernan Gonzalez Monroig, source=Web Response No relevant relationships by Modesto Gonzalez-del Rosario, source=Web Response