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Pneumomediastinum Following a Surgical Renal Biopsy
Vol. 116, July Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
PNEUMOMEDIASTINUM FOLLOWING A SURGICAL RENAL BIOPSY C. MAS MARTINEZ, M. LLORACH GASPAR, E. ANDRES RIBES, A. MARTINEZ AMENOS, E. FERRER PREVOST! AND L. PIERA ROBERT From the Ciudad Sanitaria de la Seguridad Social "Francisco Franco" de Barcelona, Servicio de Nefrolog{a, Departamento de M edicina Interna, Paseo del Valle de Hebron sin, Barcelona, Spain
ABSTRACT
A case of pneumomediastinum, which appeared after a biopsy of the right kidney by minimal lumbotomy, is reported. The anatomicopathological condition of the renal fragment obtained was judged to be focal and segmental hyalinosis. We wish to emphasize the rarity of such a complication, the type of electrocardiographic changes observed, and the rapid and spontaneous recuperation of the patient without further repercussions. diogram registered mesosystolic vibrations, which varied in intensity in every cardiac cycle. There were numerous cracking sounds of varying intensity in the diastole that were not constant in later cycles. Evolution. The clinical symptomatology disappeared 48 hours later and the exploration was negative. An electrocardiogram showed that the ischemia on the diaphragmatic side had disappeared (fig. 1, B). The radiological exploration of the thorax and abdomen was normal. The incision remained free of infection.
CASE REPORT
A 24-year-old woman had suffered for a year from a clinical nephrotic syndrome, which was in clinical remission during the last 6 months. With the patient under local anesthesia a biopsy was done on the right kidney by minimal lumbotomy for diagnostic purposes. Six hours later a sudden pain developed in the lumbar fossa and at the base of the right hemithorax, radiating to the right shoulder, and in the precordial region, reaching the base of the neck. The pain, which lasted 15 or 20 minutes, was continuous, increasing with the respiratory movements and accompanied by dyspnea. Physical examination. The patient was apyretic, blood pressure was normal and there was crepitation of air in the
DI
D II
D Ill
aVR
aVL
DISCUSSION
Renal biopsy performed by minimal lumbotomy with the patient under a local anesthesia 1 has all of the advantages of
aVF
FIG. 1
suprasternal fossa. Auscultation of the thorax revealed a creaking in time to the beating of the heart in the mesocardium (Hamman's sign), which was unaffected by body position. This creaking was synchronous with respiratory movements at the base of the right hemithorax. There was no jugular ingurgitation and palpation revealed air crepitation in the right lumbar fossa. Complementary examinations. An electrocardiogram showed subepicardiac ischemia of diaphragmatic predominance with T negative waves in II, III and aVF (fig. 1, A). Anteroposterior radiography of the thorax revealed air in the mediastinum at the level of the left edge of the cardiac silhouette (fig. 2), as well as between the diaphragm and right diaphragmatic pleura and reflexion of the mediastinal pleura on the same side. Radiography of the abdomen showed air in the right lumbar fossa and the infradiaphragmatic region on the right side. Laboratory studies, including determination of transaminase, creatine phosphokinase and lactic dehydrogenase, were within normal limits. During inspiration, a phonocar-
techniques done in the open• and, thus, avoids the complications brought about by operation with the patient under a general anesthesia. The sample of renal tissue obtained is larger than that obtained by percutaneous puncture and the anatomicopathological interpretation is more reliable. There have been reported few complications caused by this technique (macroscopic hematuria, pain spreading into the genitals and abdominal pain caused by irritation of the posterior parietal peritoneum). The only noteworthy complication is retroperitoneal hematoma. To our knowledge this is the first case of pneumomediastinum secondary to renal biopsy, and there is no mention of it in any descriptions of other techniques. 1-• The diagnosis of pneumomediastinum is based on the presence of air crepitation in the suprasternal fossa and in the appearance of air on the radiograms.•-• There are usually alterations in the electrocardiogram in cases of pneumomediastinum and pneumopericardium, giving images of a lesion and accompanied by a pathological elevation of the enzymes. 7 In our patient the changes in the electrocardiogram were owing to ischemia, unaccompanied by a lesion and with normal enzymes.
Accepted for publication November 7, 1975.
94
PNEUMOMEDIASTINUM FOLLOWING SURGICAL RENAL BIOPSY
95
The phonocardiographic tracing, because of its irregularity and the presence of multiple creaks in the systole and diastole along with the variability in intensity in different cycles, suggested that the nature of these noises was pericardia!. The evolution of the entire process must be described as benign and resolved spontaneously in 48 hours. The radiological and electrocardiographical studies were normal at that time. REFERENCES
1. Ramon-Soler, R.: Ventajas de la lumbotomia minima sobre la
FIG. 2
puncion percutanea en la biopsia renal. Med. Clin., 54: 199, 1970. 2. Leadbetter, G. W. and Halverstadt, D. B.: Open renal biopsy. J.A.M.A., HJ4: 1391, 1965. 3. Kark, R. M., Muehrcke, R. C., Pollak, V. E., Pirani, C. L. and Kiefer, J. H.: An analysis of five hundred percutaneous renal biopsies. Arch. Intern. Med., Hll: 439, 1958. 4. Slotkin, E. A. and Madsen, P. 0.: Complications of renal biopsy: incidence in 5000 reported cases. J. Urol., 87: 13, 1962. 5. Kark, R. M.: Renal biopsy. J.A.M.A., 205: 220, 1968. 6. Fraser, R. G. and Pare, J. A.: Diagnosis of Diseases of the Chest: An Integrated Study Based on the Abnormal Roentgenogram. Philadelphia: W. B. Saunders Co., vol. I, p. 11, 1970. 7. Fraser, R. G. and Pare, ,J. A.: Diagnosis of Diseases of the Chest: An Integrated Study Based on the Abnormal Roentgenogram. Philadelphia: W. B. Saunders Co., vol. II, pp. 1174-1179, 1970. '3. Hamman, L.: Mediastinal emphysema. J.A.M.A., 128: 1, 1945. 9. Munsell, W. P.: Pneumomediastinum. A report of 28 cases and review of the literature. J.A.M.A., 202: 689, 1967.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
PNEUMOMEDIASTINUM FOLLOWING A SURGICAL RENAL BIOPSY C. MAS MARTINEZ, M. LLORACH GASPAR, E. ANDRES RIBES, A. MARTINEZ AMENOS, E. FERRER PREVOST! AND L. PIERA ROBERT From the Ciudad Sanitaria de la Seguridad Social "Francisco Franco" de Barcelona, Servicio de Nefrolog{a, Departamento de M edicina Interna, Paseo del Valle de Hebron sin, Barcelona, Spain
ABSTRACT
A case of pneumomediastinum, which appeared after a biopsy of the right kidney by minimal lumbotomy, is reported. The anatomicopathological condition of the renal fragment obtained was judged to be focal and segmental hyalinosis. We wish to emphasize the rarity of such a complication, the type of electrocardiographic changes observed, and the rapid and spontaneous recuperation of the patient without further repercussions. diogram registered mesosystolic vibrations, which varied in intensity in every cardiac cycle. There were numerous cracking sounds of varying intensity in the diastole that were not constant in later cycles. Evolution. The clinical symptomatology disappeared 48 hours later and the exploration was negative. An electrocardiogram showed that the ischemia on the diaphragmatic side had disappeared (fig. 1, B). The radiological exploration of the thorax and abdomen was normal. The incision remained free of infection.
CASE REPORT
A 24-year-old woman had suffered for a year from a clinical nephrotic syndrome, which was in clinical remission during the last 6 months. With the patient under local anesthesia a biopsy was done on the right kidney by minimal lumbotomy for diagnostic purposes. Six hours later a sudden pain developed in the lumbar fossa and at the base of the right hemithorax, radiating to the right shoulder, and in the precordial region, reaching the base of the neck. The pain, which lasted 15 or 20 minutes, was continuous, increasing with the respiratory movements and accompanied by dyspnea. Physical examination. The patient was apyretic, blood pressure was normal and there was crepitation of air in the
DI
D II
D Ill
aVR
aVL
DISCUSSION
Renal biopsy performed by minimal lumbotomy with the patient under a local anesthesia 1 has all of the advantages of
aVF
FIG. 1
suprasternal fossa. Auscultation of the thorax revealed a creaking in time to the beating of the heart in the mesocardium (Hamman's sign), which was unaffected by body position. This creaking was synchronous with respiratory movements at the base of the right hemithorax. There was no jugular ingurgitation and palpation revealed air crepitation in the right lumbar fossa. Complementary examinations. An electrocardiogram showed subepicardiac ischemia of diaphragmatic predominance with T negative waves in II, III and aVF (fig. 1, A). Anteroposterior radiography of the thorax revealed air in the mediastinum at the level of the left edge of the cardiac silhouette (fig. 2), as well as between the diaphragm and right diaphragmatic pleura and reflexion of the mediastinal pleura on the same side. Radiography of the abdomen showed air in the right lumbar fossa and the infradiaphragmatic region on the right side. Laboratory studies, including determination of transaminase, creatine phosphokinase and lactic dehydrogenase, were within normal limits. During inspiration, a phonocar-
techniques done in the open• and, thus, avoids the complications brought about by operation with the patient under a general anesthesia. The sample of renal tissue obtained is larger than that obtained by percutaneous puncture and the anatomicopathological interpretation is more reliable. There have been reported few complications caused by this technique (macroscopic hematuria, pain spreading into the genitals and abdominal pain caused by irritation of the posterior parietal peritoneum). The only noteworthy complication is retroperitoneal hematoma. To our knowledge this is the first case of pneumomediastinum secondary to renal biopsy, and there is no mention of it in any descriptions of other techniques. 1-• The diagnosis of pneumomediastinum is based on the presence of air crepitation in the suprasternal fossa and in the appearance of air on the radiograms.•-• There are usually alterations in the electrocardiogram in cases of pneumomediastinum and pneumopericardium, giving images of a lesion and accompanied by a pathological elevation of the enzymes. 7 In our patient the changes in the electrocardiogram were owing to ischemia, unaccompanied by a lesion and with normal enzymes.
Accepted for publication November 7, 1975.
94
PNEUMOMEDIASTINUM FOLLOWING SURGICAL RENAL BIOPSY
95
The phonocardiographic tracing, because of its irregularity and the presence of multiple creaks in the systole and diastole along with the variability in intensity in different cycles, suggested that the nature of these noises was pericardia!. The evolution of the entire process must be described as benign and resolved spontaneously in 48 hours. The radiological and electrocardiographical studies were normal at that time. REFERENCES
1. Ramon-Soler, R.: Ventajas de la lumbotomia minima sobre la
FIG. 2
puncion percutanea en la biopsia renal. Med. Clin., 54: 199, 1970. 2. Leadbetter, G. W. and Halverstadt, D. B.: Open renal biopsy. J.A.M.A., HJ4: 1391, 1965. 3. Kark, R. M., Muehrcke, R. C., Pollak, V. E., Pirani, C. L. and Kiefer, J. H.: An analysis of five hundred percutaneous renal biopsies. Arch. Intern. Med., Hll: 439, 1958. 4. Slotkin, E. A. and Madsen, P. 0.: Complications of renal biopsy: incidence in 5000 reported cases. J. Urol., 87: 13, 1962. 5. Kark, R. M.: Renal biopsy. J.A.M.A., 205: 220, 1968. 6. Fraser, R. G. and Pare, J. A.: Diagnosis of Diseases of the Chest: An Integrated Study Based on the Abnormal Roentgenogram. Philadelphia: W. B. Saunders Co., vol. I, p. 11, 1970. 7. Fraser, R. G. and Pare, ,J. A.: Diagnosis of Diseases of the Chest: An Integrated Study Based on the Abnormal Roentgenogram. Philadelphia: W. B. Saunders Co., vol. II, pp. 1174-1179, 1970. '3. Hamman, L.: Mediastinal emphysema. J.A.M.A., 128: 1, 1945. 9. Munsell, W. P.: Pneumomediastinum. A report of 28 cases and review of the literature. J.A.M.A., 202: 689, 1967.