HERNIATION OF AN EMPHYSEMATOUS PULMONARY BULLA INTO THE INTERCOSTAL SPACE

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SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Herniation of the lung into the thoracic wall is a rare presentation. It is defined as the protrusion of the lung tissue covered with pleura into the thoracic wall. Given the rarity of the presentation, only a limited number of cases have been reported in literature. Here, we present a case of bullous lung herniation in a patient with COPD on immunosuppressant medication without the involvement of thoracic surgical intervention. CASE PRESENTATION: A 74-year-old gentleman was admitted for 2 weeks of dyspnea and intermittent productive cough. He had a past medical history of COPD, pulmonary fibrosis, and RA (treated with Rituxan, Azathioprine, and Prednisone). Prior to hospitalization, he was treated with a 5-day course of Azithromycin and 20 mg of Prednisone. His symptoms progressed despite therapy. On admission, he denied chest pain, hemoptysis,night sweats, fever, weight loss, or recent trauma. On physical examination, his blood pressure was 160/79, oxygen saturation of 93% on 3 liters nasal cannula (not on baseline oxygen). Laboratory was significant for WBC elevation of 15.6, PT of 20.1, INR of 2.0, sputum culture was positive for gram positive cocci and rods. On imaging, chest CT scan showed emphysematous and bullous changes of the lung parenchyma with a 2.9 cm thick walled bulla in the right lung that was herniating between his 6th and 7th rib. Additionally, a subtle, nondisplaced fracture of the 7th rib was also noted. He was treated with prednisone 5 mg and his RA medications were held. Pulmonology was consulted, and strict control of his cough was recommended in order to prevent a pneumothorax secondary to increased pulmonary pressure, especially given his rib fracture. Surgery was not indicated. The patient’s status improved with DuoNeb, mucolytics, spirometry, lidocaine patches, tramadol and acapella valve use. The patient was discharged home. He followed with pulmonology as an outpatient for monitoring. DISCUSSION: Lung herniation into the thoracic space can be congenital or acquired through medical or surgical therapy. Herniation of an emphysematous bullae is a rather rare presentation of this phenomenon. However, increased intrathoracic pressure secondary to a coughing fit, coupled with emphysematous lung in COPD patients can cause herniation through the intercostal space given the presence of a weak site in the muscular or sub connective tissue. Most cases present in the upper lobes of the lungs, which represents another novel presentation in our patient with his herniation being between the 6th and 7th intercostal space. CONCLUSIONS: Herniation of emphysematous bullae is a very rare condition and complication, very few cases have been reported. The clinical presentation is nonspecific, and the use of chest X-ray does not always identify the herniation. In most of the reported cases, the diagnosis can be confirmed with a chest tomography. Reference #1: Okur E, Tezel C, Baysungur V, Halezeroglu S. Extrathoracic herniation of a lung bulla through a tube thoracostomy site. Interact Cardiovasc Thorac Surg. 2008;7(6):1210–1. Reference #2: Van Berkel V, Kuo E, Meyers BF. Pneumothorax, bullous disease, and emphysema. Surg Clin North Am 2010;90:935–53. Reference #3: Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques, and outcomes. Chest Surg Clin N Am. 2003;13(4):631–49 DISCLOSURES: No relevant relationships by Armida Lefranc, source=Web Response No relevant relationships by Tony Makdisi, source=Web Response No relevant relationships by Aniket Pandya, source=Web Response