Spontaneous Hemothorax: What is in a Name?

Abstract

Dear Editor, We read with interest the article by Singh et al. [1] on their experience of managing patients with idiopathic massive spontaneous hemothorax. As the authors clearly stated, it is rare to find rupture of pleural adhesions spontaneously causing massive hemothorax alone (apparently without pneumothorax). In our experience of treating patients with spontaneous hemothorax, by far the most likely pathophysiological explanation remains the occurrence of spontaneous pneumothorax followed by the development of hemothorax. It should be noted that the pneumothorax by the time the patient presents to the hospital may have resolved, be undetectable by a plain chest radiograph, be obscured by the massive pleural effusion/ hemothorax, particularly when the radiograph is taken supine [2]. Performing a computed tomography scan would reveal the presence of any pneumothorax, and may also aid the diagnosis of the underlying pathology for the hemothorax. Clearly, in most cases of spontaneous hemoor hemopneumothorax, patients are too unstable to undergo such investigation or have their surgery delayed. Additional information we would have liked from the article in order to gain a better understanding of the disease etiology are: (1) spontaneous hemothorax as a percentage of spontaneous hemopneumothorax and primary spontaneous pneumothorax presenting to their institution, (2) whether there was airleak following the initial chest tube insertion, (3) whether any blebs or bullae were found intraoperatively and resected, and (4) the postoperative chest drainage duration, hospital stay and whether there were any complications or recurrences upon follow-up. To our surprise, we have also found that what appears to be spontaneous is not necessarily so. Recently, we encountered a young man with good past health who presented with 3 days history of increasing dyspnoea. He denied any history of trauma. Chest radiograph supported the diagnosis of ‘‘spontaneous’’ hemopneumothorax and chest tube was inserted. Just as we were pondering on proceeding with surgical management, the patient revealed that he has been seeing a traditional Chinese doctor for allergic rhinitis. Furthermore, the therapist had performed acupuncture for him 4 days ago to his cervical and shoulder regions. Computed tomography showed no retained foreign body, satisfactory drainage of hemothorax, and no other significant pathology. He was managed conservatively and discharged without complications. The association of acupuncture and pneumothorax was noted in the English literature as far back as the 1970s [3]. Since then, acupuncture associated hemothorax, and even cardiac tamponade, have also been reported [4]. Many in Asia consider acupuncture as completely harmless and would undergo sessions as routinely as going to the gym in Western cultures. In addition, the popularity of acupuncture may rise as its analgesic properties are increasingly recognized [5]. This serves as a poignant reminder to health professionals to consider this unusual cause of pneumoand hemothorax. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.