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Bilateral lower extremity swelling: black pearl
American Journal of Emergency Medicine 33 (2015) 1841.e3–1841.e4
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Bilateral lower extremity swelling: black pearl Abstract Iatrogenic pneumothorax secondary to thoracentesis is relatively uncommon but does present to the emergency department (ED). Iatrogenic pneumothoraces developing tension physiology are rare. We report a case of an elderly female patient presenting to the ED with an isolated chief complaint of bilateral leg swelling, beginning the day after a thoracentesis, which was performed 3 days prior for pleural effusions secondary to lung cancer. Given that the patient was hemodynamically stable, not hypoxic, and had a history of chronic obstructive pulmonary disease and recent history of pleural effusions with diminished lung sounds throughout, this was a radiologic diagnosis. Immediately upon diagnosis, a 10F intrapleural catheter was inserted at the second intercostal space in the midclavicular line with successful resolution of the tension phenomenon. The patient tolerated the procedure well, and the catheter was removed on hospital day 2 without recurrence of the pneumothorax. She experienced resolution of her lower extremity swelling and was discharged from the hospital 2 days later. Isolated inferior vena cava syndrome secondary to a subacute tension pneumothorax was likely the cause of the patient's symptoms. This presentation is very rare and is undocumented in the literature. A high degree of suspicion for acute chest pathology should exist in every patient presenting to the ED with history of recent pleural violation. A 68-year-old woman presented to the emergency department (ED) complaining of bilateral leg swelling for 2 days. She endorsed use of home oxygen and reported that her breathing was no different from baseline. She was without shortness of breath, chest pain, or other respiratory complaints and had never had similar symptoms in the past. Her medical history was significant for chronic obstructive pulmonary disease, congestive heart failure, and metastatic lung cancer. Three days prior, the patient had a thoracentesis for bilateral malignant pleural effusions. Review of systems was otherwise negative. Blood pressure was normal at 123/79, oxygen saturation was 100% on home oxygen settings. The patient was tachycardic to 105, and her respiratory was rate was 18. The patient was in no acute distress and speaking in full sentences. Pulmonary examination revealed diffusely diminished and distant breath sounds. She exhibited symmetric 2 + pitting edema in the bilateral lower extremities up to her knees, and her distal pulses were palpable. The patient was cachectic. The physical examination was otherwise unremarkable. Laboratory workup was normal, including an unremarkable B-type natriuretic peptide. Chest radiograph demonstrated a large pneumothorax with shift of the mediastinum (Fig. 1). The patient was reassessed after diagnosis, and her clinical status remained unchanged. The decision was made to insert a 10F catheter at the second intercostal space in the midclavicular line. Catheter 0735-6757/© 2015 Elsevier Inc. All rights reserved.
placement returned copious air and 40 mL of yellow, cloudy fluid. Repeat imaging was obtained and demonstrated resolution of the tension phenomenon (Fig. 2). On hospital day 1, the intrapleural catheter was removed. The patient was discharged on hospital day 2 after no recurrence of the pneumothorax on repeat imaging and with improvement of lower extremity swelling during her stay. Another normal chest radiograph was obtained at 4-day follow-up after discharge. The patient's leg swelling was not the result of a congestive heart failure exacerbation but a subacute tension pneumothorax presumably caused by her thoracentesis 3 days prior. Iatrogenic pneumothoraces secondary to thoracentesis are relatively uncommon and occur in 0.61% of procedures. Occurrence is significantly increased with large volume effusion and unilateral procedures; neither of these risk factors were present in the patient above [1]. Inferior vena cava syndrome is caused by decreased venous return through the inferior vena cava, as a result of external compression, stricture, or thrombosis. Symptoms can include hepatic and splenic congestion, ascites, and lower extremity edema [2]. The tension pneumothorax would decrease venous return and was the most likely cause of her bilateral lower extremity edema. Given her health status, cachexia, and patient preference, a 10F intrapleural catheter was inserted at the second intercostal space in the midclavicular line, instead of a 28F (or greater) chest tube at the fourth intercostal space in the midaxillary line. Treatment of iatrogenic pneumothorax with small-caliber catheters has been well studied and is generally well accepted [3-8]. However, no literature exists that is specific to the case described above. A low threshold for obtaining a chest radiograph should exist in every patient presenting to the ED with history of recent pleural violation, and pneumothorax should always be high on the differential. Clinton C. Smithson III, MD* Jared C. Ham, BS Andrew L. Juergens II, MD Baylor Scott & White Health, MS-11-AG062 2401 South 31st Street, Temple, TX, 76502, USA *Corresponding author
http://dx.doi.org/10.1016/j.ajem.2015.04.036
References [1] Ault MJ, Rosen BT, Scher J, Feinglass J, Barsuk JH. Thoracentesis outcomes: a 12-year experience. Thorax 2015;70:127–32. http://dx.doi.org/10.1136/thoraxjnl-2014206114.
1841.e4
C.C. Smithson III et al. / American Journal of Emergency Medicine 33 (2015) 1841.e3–1841.e4 [2] Hartley JW, Awrich AE, Wong J, Stevens K, Fletcher WS. Diagnosis and treatment of the inferior vena cava syndrome in advanced malignant disease. Am J Surg 1986; 152(1):70–4. http://dx.doi.org/10.1016/0002-9610(86)90145-5. [3] Contou D, Razazi K, Katsahian S, Maitre B, Mekontso-Dessap A, Brun-Buisson C, et al. Small-bore catheter versus chest tube drainage for pneumothorax. Am J Emerg Med 2012;30:1407–13. http://dx.doi.org/10.1016/j.ajem.2011.10.014. [4] Galbois A, Zorzi L, Meurisse S, Kerneis S, Margetis D, Alves M, et al. Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes. Acta Anaesthesiol Scand 2012;56:507–12. http://dx.doi.org/10.1111/j.1399-6576.2011. 02602.x. [5] Iepsen UW, Ringbaek T. Small-bore chest tubes seem to perform better than larger tubes in treatment of spontaneous pneumothorax. Dan Med J 2013;60:A4644. [6] Laub M, Milman N, Müller D, Struve-Christensen E. Role of small calibre chest tube drainage for iatrogenic pneumothorax. Thorax 1990;45:748–9. http://dx.doi.org/10. 1136/thx.45.10.748. [7] Liman ST, Elicora A, Akgul AG, Topcu S, Ozbay S, Mehmetoğlu SS, et al. Is a small-bore catheter efficient for most pleural pathologies? Surg Today 2014;44:834–8. http://dx. doi.org/10.1007/s00595-013-0759-2. [8] Milman N, Laub MS, Müller DM, Struve-Christensen E. Iatrogenic pneumothorax treated with a small calibre pleural tube (in Danish). Ugeskr Laeger 1991;153: 978–80.
Fig. 1. Initial chest radiograph.
Fig. 2. Chest radiograph after pneumo-cath placement.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Bilateral lower extremity swelling: black pearl Abstract Iatrogenic pneumothorax secondary to thoracentesis is relatively uncommon but does present to the emergency department (ED). Iatrogenic pneumothoraces developing tension physiology are rare. We report a case of an elderly female patient presenting to the ED with an isolated chief complaint of bilateral leg swelling, beginning the day after a thoracentesis, which was performed 3 days prior for pleural effusions secondary to lung cancer. Given that the patient was hemodynamically stable, not hypoxic, and had a history of chronic obstructive pulmonary disease and recent history of pleural effusions with diminished lung sounds throughout, this was a radiologic diagnosis. Immediately upon diagnosis, a 10F intrapleural catheter was inserted at the second intercostal space in the midclavicular line with successful resolution of the tension phenomenon. The patient tolerated the procedure well, and the catheter was removed on hospital day 2 without recurrence of the pneumothorax. She experienced resolution of her lower extremity swelling and was discharged from the hospital 2 days later. Isolated inferior vena cava syndrome secondary to a subacute tension pneumothorax was likely the cause of the patient's symptoms. This presentation is very rare and is undocumented in the literature. A high degree of suspicion for acute chest pathology should exist in every patient presenting to the ED with history of recent pleural violation. A 68-year-old woman presented to the emergency department (ED) complaining of bilateral leg swelling for 2 days. She endorsed use of home oxygen and reported that her breathing was no different from baseline. She was without shortness of breath, chest pain, or other respiratory complaints and had never had similar symptoms in the past. Her medical history was significant for chronic obstructive pulmonary disease, congestive heart failure, and metastatic lung cancer. Three days prior, the patient had a thoracentesis for bilateral malignant pleural effusions. Review of systems was otherwise negative. Blood pressure was normal at 123/79, oxygen saturation was 100% on home oxygen settings. The patient was tachycardic to 105, and her respiratory was rate was 18. The patient was in no acute distress and speaking in full sentences. Pulmonary examination revealed diffusely diminished and distant breath sounds. She exhibited symmetric 2 + pitting edema in the bilateral lower extremities up to her knees, and her distal pulses were palpable. The patient was cachectic. The physical examination was otherwise unremarkable. Laboratory workup was normal, including an unremarkable B-type natriuretic peptide. Chest radiograph demonstrated a large pneumothorax with shift of the mediastinum (Fig. 1). The patient was reassessed after diagnosis, and her clinical status remained unchanged. The decision was made to insert a 10F catheter at the second intercostal space in the midclavicular line. Catheter 0735-6757/© 2015 Elsevier Inc. All rights reserved.
placement returned copious air and 40 mL of yellow, cloudy fluid. Repeat imaging was obtained and demonstrated resolution of the tension phenomenon (Fig. 2). On hospital day 1, the intrapleural catheter was removed. The patient was discharged on hospital day 2 after no recurrence of the pneumothorax on repeat imaging and with improvement of lower extremity swelling during her stay. Another normal chest radiograph was obtained at 4-day follow-up after discharge. The patient's leg swelling was not the result of a congestive heart failure exacerbation but a subacute tension pneumothorax presumably caused by her thoracentesis 3 days prior. Iatrogenic pneumothoraces secondary to thoracentesis are relatively uncommon and occur in 0.61% of procedures. Occurrence is significantly increased with large volume effusion and unilateral procedures; neither of these risk factors were present in the patient above [1]. Inferior vena cava syndrome is caused by decreased venous return through the inferior vena cava, as a result of external compression, stricture, or thrombosis. Symptoms can include hepatic and splenic congestion, ascites, and lower extremity edema [2]. The tension pneumothorax would decrease venous return and was the most likely cause of her bilateral lower extremity edema. Given her health status, cachexia, and patient preference, a 10F intrapleural catheter was inserted at the second intercostal space in the midclavicular line, instead of a 28F (or greater) chest tube at the fourth intercostal space in the midaxillary line. Treatment of iatrogenic pneumothorax with small-caliber catheters has been well studied and is generally well accepted [3-8]. However, no literature exists that is specific to the case described above. A low threshold for obtaining a chest radiograph should exist in every patient presenting to the ED with history of recent pleural violation, and pneumothorax should always be high on the differential. Clinton C. Smithson III, MD* Jared C. Ham, BS Andrew L. Juergens II, MD Baylor Scott & White Health, MS-11-AG062 2401 South 31st Street, Temple, TX, 76502, USA *Corresponding author
http://dx.doi.org/10.1016/j.ajem.2015.04.036
References [1] Ault MJ, Rosen BT, Scher J, Feinglass J, Barsuk JH. Thoracentesis outcomes: a 12-year experience. Thorax 2015;70:127–32. http://dx.doi.org/10.1136/thoraxjnl-2014206114.
1841.e4
C.C. Smithson III et al. / American Journal of Emergency Medicine 33 (2015) 1841.e3–1841.e4 [2] Hartley JW, Awrich AE, Wong J, Stevens K, Fletcher WS. Diagnosis and treatment of the inferior vena cava syndrome in advanced malignant disease. Am J Surg 1986; 152(1):70–4. http://dx.doi.org/10.1016/0002-9610(86)90145-5. [3] Contou D, Razazi K, Katsahian S, Maitre B, Mekontso-Dessap A, Brun-Buisson C, et al. Small-bore catheter versus chest tube drainage for pneumothorax. Am J Emerg Med 2012;30:1407–13. http://dx.doi.org/10.1016/j.ajem.2011.10.014. [4] Galbois A, Zorzi L, Meurisse S, Kerneis S, Margetis D, Alves M, et al. Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes. Acta Anaesthesiol Scand 2012;56:507–12. http://dx.doi.org/10.1111/j.1399-6576.2011. 02602.x. [5] Iepsen UW, Ringbaek T. Small-bore chest tubes seem to perform better than larger tubes in treatment of spontaneous pneumothorax. Dan Med J 2013;60:A4644. [6] Laub M, Milman N, Müller D, Struve-Christensen E. Role of small calibre chest tube drainage for iatrogenic pneumothorax. Thorax 1990;45:748–9. http://dx.doi.org/10. 1136/thx.45.10.748. [7] Liman ST, Elicora A, Akgul AG, Topcu S, Ozbay S, Mehmetoğlu SS, et al. Is a small-bore catheter efficient for most pleural pathologies? Surg Today 2014;44:834–8. http://dx. doi.org/10.1007/s00595-013-0759-2. [8] Milman N, Laub MS, Müller DM, Struve-Christensen E. Iatrogenic pneumothorax treated with a small calibre pleural tube (in Danish). Ugeskr Laeger 1991;153: 978–80.
Fig. 1. Initial chest radiograph.
Fig. 2. Chest radiograph after pneumo-cath placement.