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Multiple persistent circumscribed pulmonary hematomas due to a blunt chest trauma
1752
CASE REPORT SVANE PULMONARY HEMATOMAS
Ann Thorac Surg 2001;72:1752–3
Multiple Persistent Circumscribed Pulmonary Hematomas Due to a Blunt Chest Trauma Sivert Svane, MD* Department of Surgery, Buskerud Central Hospital, Drammen, Norway
A case of multiple sharply circumscribed pulmonary hematomas (“coin” lesions) following blunt, nonpenetrating thoracic trauma, is reported. The finding mimicked cancerous “cannon ball” metastatic deposits. A computed tomographic scan combined with puncture biopsy provided the correct diagnosis. Spontaneous complete resolution of the hematomas took 3 years. (Ann Thorac Surg 2001;72:1752–3) © 2001 by The Society of Thoracic Surgeons
I
njury to the chest and its structures may be secondary to a blunt, non-penetrating trauma. Such disasters may result in pulmonary hematomas [1], which very infrequently may be sharply circumscribed and persistent with the round or oval appearances of the so-called “coin” lesions. A patient who developed multiple posttraumatic round pulmonary hematomas is presented. The complete resolution of the hematomas took three years, and as far as the author is aware, a similar case has hitherto not been reported. A 69-year-old, previously healthy male pedestrian was hit by a car coming from the right. He developed severe pain in the right half of the chest, extensive subcutaneous emphysema and considerable dyspnea, but no hemoptysis. There were no external injuries. A chest x-ray taken on admission to hospital (Fig 1) showed fractures of the 6th to 10th rib on the right side without appreciable dislocation, as well as a diffuse pulmonary infiltrate. There was also an unimportant fracture of the right superior pubic ramus. Initially, a slender thoracic drain was inserted, which was removed when neither air nor blood were found. Because of falling blood pressure, he was given a transfusion of 3 units (1.5 L) of whole blood. After starting epidural anesthesia and administering oxygen, he improved considerably with better respiration and lung function. During the days following, he was given 5 more units of blood. An x-ray 13 days after the accident showed a more well-defined basal lung infiltrate on the right side. He now had neither chest pain nor dyspnea. After 30 days he obviously was in better health, but very surprisingly a chest x-ray showed several comparatively well-defined circumscribed basal lung infiltrates
Accepted for publication Jan 13, 2001. * Dr Svane passed away on May 30, 2001.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Initial chest radiograph showing extensive opacification of the right lung, rib fractures, and subcutaneous emphysema.
(Fig 2). The possibility of a malignant, metastatic disease could not be excluded. However, a computed tomography (CT) scan (Fig 3) indicated hematomas, which was confirmed by two puncture biopsies. Nevertheless, after a chest x-ray at another hospital 20 weeks after the accident, he was told that there was a malignant neoplasm of unknown origin spreading to the lung. He was returned to our hospital, where he was checked at regular intervals. The lung changes slowly disappeared (Fig 4), but it was not until 3 years after the accident that there was complete radiologic regression with the exception of scattered, small calcified spots. At the latest follow-up, 11 years after the accident (at age 80), he was in good physical form, and the radiologic findings were almost normal.
Comment Radiologic demonstration of round lung hematomas (“coin” lesions) after blunt thoracic injuries was probably first mentioned in 1940 [2]. It has been suggested [3] that persistent, circumscribed, intrapulmonary hematomas must be either extremely rare in occurence or generally unrecognized, judging from the few cases which have appeared in literature [1– 8]. In recent publications, such hematomas are reported en passant, without further documentation [9, 10]. In nearly all of the published cases there has been one hematoma. Multiple hematomas, as in the present case, 0003-4975/01/$20.00 PII S0003-4975(01)02610-8
Ann Thorac Surg 2001;72:1752–3
CASE REPORT SVANE PULMONARY HEMATOMAS
1753
Fig 4. Chest radiograph 19-months after the injury.
Fig 2. Chest radiograph 30-days after the injury showing several circular hematomas.
have previously only been described once [8]. In accordance with our experience, round hematomas may initially be completely obscured for days or weeks by surrounding lung contusion [6]. This fact distinguishes the hematomas from the posttraumatic pulmonary cysts, which are usually diagnosed by the appearance of air inside the involved area less than 48 hours after the injury [11]. Slow healing, sometimes combined with lack of detail
Fig 3. Computed tomography scan 40-days after the injury reveals the presence of circumscribed hematomas in the posterior and medial part of the right lung.
of past medical history, has in some cases, led to thoracotomy because of suspected neoplasm (3,4,7,8). The management of hematomas of this kind is expectant observation. A CT scan combined with puncture biopsy will generally provide the correct diagnosis. A review of literature gives a clear impression that such hematomas disappear spontaneously usually 2– 6 months after the trauma. In this case, healing took an extremely long time (3 years), which, as far as the author is aware, has not been described previously.
References 1. Errion AR, Houk VN, Kettering DL. Pulmonary hematoma due to blunt, non-penetrating thoracic trauma. Am Rev Respir Dis 1963;88:384–92. 2. Schmitt HG. Rundschatten auf der Lunge, durch Ha¨ matome hervorgerufen. Ro¨ ntgenpraxis 1940;12:332–3. 3. Buechner HA, Thompson J. Circumscribed intrapulmonary hematoma presenting as a “coin” lesion. Dis Chest 1958;34: 47–54. 4. Salyer JM, Blake HA, Forsee JH. Pulmonary hematoma. J Thorac Surg 1953;25:336– 40. 5. Williams JR. The vanishing lung tumor-pulmonary hematoma. Am J Roentgenol 1959;81:296 –302. 6. Milne E, Dick A. Circumscribed intrapulmonary haematoma. Br J Radiol 1961;34:587–95. 7. Joynt GHC, Jaffe F. Solitary pulmonary hematoma. J Thorac Cardiovasc Surg 1962;43:291–302. 8. Engelman RM, Boyd AD, Blum M, Worth MH. Multiple circumscribed pulmonary hematomas masquerading as metastatic carcinoma. Ann Thorac Surg 1973;15:291– 4. 9. Dee PM. The radiology of chest trauma. Radiol Clin North Am 1992;30(2):291–306. 10. Boyd AD, Glassman LR. Trauma to the lung. Chest Surg Clin North Am 1997;7(2):263– 84. 11. Ganske JG, Dennis DL, Vanderveer JB Jr. Traumatic lung cyst: case report and literature review. J Trauma 1981;21: 493– 6.
CASE REPORT SVANE PULMONARY HEMATOMAS
Ann Thorac Surg 2001;72:1752–3
Multiple Persistent Circumscribed Pulmonary Hematomas Due to a Blunt Chest Trauma Sivert Svane, MD* Department of Surgery, Buskerud Central Hospital, Drammen, Norway
A case of multiple sharply circumscribed pulmonary hematomas (“coin” lesions) following blunt, nonpenetrating thoracic trauma, is reported. The finding mimicked cancerous “cannon ball” metastatic deposits. A computed tomographic scan combined with puncture biopsy provided the correct diagnosis. Spontaneous complete resolution of the hematomas took 3 years. (Ann Thorac Surg 2001;72:1752–3) © 2001 by The Society of Thoracic Surgeons
I
njury to the chest and its structures may be secondary to a blunt, non-penetrating trauma. Such disasters may result in pulmonary hematomas [1], which very infrequently may be sharply circumscribed and persistent with the round or oval appearances of the so-called “coin” lesions. A patient who developed multiple posttraumatic round pulmonary hematomas is presented. The complete resolution of the hematomas took three years, and as far as the author is aware, a similar case has hitherto not been reported. A 69-year-old, previously healthy male pedestrian was hit by a car coming from the right. He developed severe pain in the right half of the chest, extensive subcutaneous emphysema and considerable dyspnea, but no hemoptysis. There were no external injuries. A chest x-ray taken on admission to hospital (Fig 1) showed fractures of the 6th to 10th rib on the right side without appreciable dislocation, as well as a diffuse pulmonary infiltrate. There was also an unimportant fracture of the right superior pubic ramus. Initially, a slender thoracic drain was inserted, which was removed when neither air nor blood were found. Because of falling blood pressure, he was given a transfusion of 3 units (1.5 L) of whole blood. After starting epidural anesthesia and administering oxygen, he improved considerably with better respiration and lung function. During the days following, he was given 5 more units of blood. An x-ray 13 days after the accident showed a more well-defined basal lung infiltrate on the right side. He now had neither chest pain nor dyspnea. After 30 days he obviously was in better health, but very surprisingly a chest x-ray showed several comparatively well-defined circumscribed basal lung infiltrates
Accepted for publication Jan 13, 2001. * Dr Svane passed away on May 30, 2001.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Initial chest radiograph showing extensive opacification of the right lung, rib fractures, and subcutaneous emphysema.
(Fig 2). The possibility of a malignant, metastatic disease could not be excluded. However, a computed tomography (CT) scan (Fig 3) indicated hematomas, which was confirmed by two puncture biopsies. Nevertheless, after a chest x-ray at another hospital 20 weeks after the accident, he was told that there was a malignant neoplasm of unknown origin spreading to the lung. He was returned to our hospital, where he was checked at regular intervals. The lung changes slowly disappeared (Fig 4), but it was not until 3 years after the accident that there was complete radiologic regression with the exception of scattered, small calcified spots. At the latest follow-up, 11 years after the accident (at age 80), he was in good physical form, and the radiologic findings were almost normal.
Comment Radiologic demonstration of round lung hematomas (“coin” lesions) after blunt thoracic injuries was probably first mentioned in 1940 [2]. It has been suggested [3] that persistent, circumscribed, intrapulmonary hematomas must be either extremely rare in occurence or generally unrecognized, judging from the few cases which have appeared in literature [1– 8]. In recent publications, such hematomas are reported en passant, without further documentation [9, 10]. In nearly all of the published cases there has been one hematoma. Multiple hematomas, as in the present case, 0003-4975/01/$20.00 PII S0003-4975(01)02610-8
Ann Thorac Surg 2001;72:1752–3
CASE REPORT SVANE PULMONARY HEMATOMAS
1753
Fig 4. Chest radiograph 19-months after the injury.
Fig 2. Chest radiograph 30-days after the injury showing several circular hematomas.
have previously only been described once [8]. In accordance with our experience, round hematomas may initially be completely obscured for days or weeks by surrounding lung contusion [6]. This fact distinguishes the hematomas from the posttraumatic pulmonary cysts, which are usually diagnosed by the appearance of air inside the involved area less than 48 hours after the injury [11]. Slow healing, sometimes combined with lack of detail
Fig 3. Computed tomography scan 40-days after the injury reveals the presence of circumscribed hematomas in the posterior and medial part of the right lung.
of past medical history, has in some cases, led to thoracotomy because of suspected neoplasm (3,4,7,8). The management of hematomas of this kind is expectant observation. A CT scan combined with puncture biopsy will generally provide the correct diagnosis. A review of literature gives a clear impression that such hematomas disappear spontaneously usually 2– 6 months after the trauma. In this case, healing took an extremely long time (3 years), which, as far as the author is aware, has not been described previously.
References 1. Errion AR, Houk VN, Kettering DL. Pulmonary hematoma due to blunt, non-penetrating thoracic trauma. Am Rev Respir Dis 1963;88:384–92. 2. Schmitt HG. Rundschatten auf der Lunge, durch Ha¨ matome hervorgerufen. Ro¨ ntgenpraxis 1940;12:332–3. 3. Buechner HA, Thompson J. Circumscribed intrapulmonary hematoma presenting as a “coin” lesion. Dis Chest 1958;34: 47–54. 4. Salyer JM, Blake HA, Forsee JH. Pulmonary hematoma. J Thorac Surg 1953;25:336– 40. 5. Williams JR. The vanishing lung tumor-pulmonary hematoma. Am J Roentgenol 1959;81:296 –302. 6. Milne E, Dick A. Circumscribed intrapulmonary haematoma. Br J Radiol 1961;34:587–95. 7. Joynt GHC, Jaffe F. Solitary pulmonary hematoma. J Thorac Cardiovasc Surg 1962;43:291–302. 8. Engelman RM, Boyd AD, Blum M, Worth MH. Multiple circumscribed pulmonary hematomas masquerading as metastatic carcinoma. Ann Thorac Surg 1973;15:291– 4. 9. Dee PM. The radiology of chest trauma. Radiol Clin North Am 1992;30(2):291–306. 10. Boyd AD, Glassman LR. Trauma to the lung. Chest Surg Clin North Am 1997;7(2):263– 84. 11. Ganske JG, Dennis DL, Vanderveer JB Jr. Traumatic lung cyst: case report and literature review. J Trauma 1981;21: 493– 6.