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Spontaneous hemothorax
CASE REPORT
Spontaneous Hemothorax Philip S. Schwarzman, MD Los Angeles, California
A 31-year-old man presented to the emergency department with dyspnea and pleuritic chest pain resulting from a spontaneous hemothorax. A tube thoracostomy was performed on the left side and 700 cc of blood removed. Another 1800 cc of blood oozed from the chest tube. Open thoracotomy was performed in the operating room. There were approximately 1 to 2 liters of blood and clot in the chest cavity. Multiple bleeding points in the apex were ligated and wedge resection was done. Spontaneous hemothorax may represent a form of spontaneous hemopneumothorax or it may be a complication of a variety of situations, Open thoracotomy may be n e c e s s a r y for definitive diagnosis and treatment. Schwarzman PS: Spontaneous hemothorax. JACEP 8:235-237, June, 1979. hemothorax
INTRODUCTION
Spontaneous h e m o t h o r a x is the a c c u m u l a t i o n of blood w i t h i n t h e pleural cavity w i t h o u t any k n o w n t r a u m a . 1 Although as a complication of chest injury it is a well k n o w n phenomenon, h e m o t h o r a x has also been described in association w i t h various p u l m o n a r y diseases, coagulopathies, and o t h e r disorders, and m a y also complicate spontaneous pneumothorax. T M Spontaneous h e m o t h o r a x is a r a r e phenomenon2, ~5 and in some cases m a y be r e l a t e d to spontaneous hemop n e u m o t h o r a x 2 6 The following case i l l u s t r a t e s the diagnosis, p a t h o g e n e s i s and m a n a g e m e n t of this entity. CASE REPORT
A 31-year-old m a n h a d a history of i n c r e a s i n g d y s p n e a a n d left-sided chest p a i n t h a t worsened w i t h inspiration. The p a i n s t a r t e d suddenly, a p p r o x i m a t e l y five hours prior to admission, and was not associated w i t h t r a u m a . The p a t i e n t was a n o n s m o k e r and h a d been in excellent health. No other r e l e v a n t history was obtained. On i n i t i a l p h y s i c a l e x a m i n a t i o n , t h e p a t i e n t a p p e a r e d a c u t e l y ill and d i a p h o r e t i c . S u p i n e blood p r e s s u r e was 80/40 m m Hg w i t h a p u l s e of 130 beats/min. The t r a c h e a was shifted slightly to the right. B r e a t h sounds were a b s e n t on the left. H e a r t sounds were d i s t a n t and best h e a r d in the subxiphoid area. The a b d o m e n was soft and nontender; bowel sounds normal. The distal pulses were equal a n d p r e s e n t in all extremities. I n i t i a l portable chest r a d i o g r a p h revealed complete opacification of the left h e m i t h o r a x w i t h a m e d i a s t i n a l shift to the r i g h t (Figure). A r t e r i a l blood gases showed pH, 7.36; pO2, 62 m m Hg; pCO2, 36 m m Hg, and HCO3, 20 mEq/liter. The h e m a t o c r i t and hemoglobin r e a d i n g s were 33.2% and 11.2 gm respectively. The white blood cell count was 18,000/cu mm. The p l a t e l e t s were a d e q u a t e and the p r o t h r o m b i n and p a r t i a l t h r o m b o p l a s t i n t i m e s were w i t h i n n o r m a l limits. A tube thoracostomy was performed in the left fifth i n t e r c o s t a l space and From the Department of Emergency Medicine, Los Angeles County/Universityof SouthernCalifornia Medical Center, Los Angeles, California. Address for reprints: Philip S. Schwarzman, MD, Department of Emergency Medicine, St. Joseph Medical Center, Buena Vista and Alameda, Burbank, California 91505. 8"6 (June) 1979
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700 cc o f blood evacuated. The patient was hospitalized. Because a n o t h e r 1800 cc of blood oozed from t h e chest tube, the patient was t a k e n to the o p e r a t i n g room. Open thoracotomy r e v e a l e d a p p r o x i m a t e l y 1 to 2 l i t e r s of blood a n d clot in t h e left p l e u r a l cavity. T h e r e were m u l t i p l e blebs a t the apex of the upper lobe. The r u p t u r e d p l e u r a l adhesions a t the apex of the left upper lobe were l i g a t e d a n d a wedge resection of t h i s a r e a was done. The d i a p h r a g m was n o r m a l on e x a m i n a t i o n . The p a t i e n t recovered u n e v e n t fully and was subsequently discharged. The pathologic e x a m i n a t i o n of the resected specimen r e v e a l e d a m a r k e d l y t h i c k e n e d fibrous p l e u r a w i t h an u n u s u a l n u m b e r of s m a l l a n d medium-sized vessels.
DISCUSSION Spontaneous hemopneumothor a x was first recognized in 1828 by Laennec ~7 who found air u n d e r pressure and blood p r e s e n t in the p l e u r a l c a v i t y in a case at autopsy. S h o r t l y thereafter, W h i t t a k e r TM reported t h e s u c c e s s f u l t r e a t m e n t of a c a s e o f spontaneous hemopneumothorax using r e p e a t e d aspirations. In 1900, Pitt, 19 Boland, 2° a n d Rolleston 2~ each r e p o r t e d cases of spontaneous hemop n e u m o t h o r a x . In the first, the lungs and p l e u r a were n o r m a l at autopsy. In the second, the bleeding was from a ruptured pleural adhesion. The e t i o l o g y in t h e t h i r d p a t i e n t , who survived, could not be determined. In 1938, P e r r y ~5 described a pat i e n t who collapsed w i t h severe stabb i n g p a i n in t h e r i g h t side of his chest, shortness of breath, and shock. The p a t i e n t died six hours after admission and autopsy revealed a hemothorax with ruptured pleural adhesions. The m o s t p r o b a b l e e t i o l o g y of s p o n t a n e o u s h e m o t h o r a x a n d spont a n e o u s h e m o p n e u m o t h o r a x is rupt u r e of a s u b p l e u r a l bleb, usually. apical in location 1 as in our patient. As the l u n g collapses, adhesions between the visceral and parietal p l e u r a a r e torn. If the adhesions a r e vascular, h e m o t h o r a x m a y be added to t h e e x i s t i n g p n e u m o t h o r a x . ~ F r a g i l e s u b p l e u r a l air vesicles often form at t h e i n s e r t i o n of a d h e s i o n s into t h e visceral pleura, probably due to scar tissue also in the u n d e r l y i n g lung. 15 R e s p i r a t o r y movement which is sufficient to t e a r an a d h e s i o n is commonly also severe enough to t e a r one of t h e s e v e s i c l e s . ~ In t h e 21 cases t h a t P e r r y 15 reported, e i g h t autopsies were performed. In t h r e e in-
44/236
F i g . Anteroposterior chest roentgenogram showing complete opacification of the left hemithorax with a shift of the mediastinum to the right.
stances ruptured adhesions were found. In t h r e e others, this was considered to be the most probable etiology. No d e f i n i t e e t i o l o g y could be f o u n d i n t w o of t h e cases. Of t h e e i g h t p a t i e n t s p r e s e n t e d by D e a t o n et al, 1 four were found to have bleeding apical adhesions at operation. It is possible t h a t s p o n t a n e o u s h e m o t h o r a x is simply a form of spontaneous hemopneumothorax in which t h e air h a s been resorbed by the time the diagnosis is made. And r e a s s i a n et al 2 reported six cases of spontaneous hemothorax without evidence of associated p n e u m o t h o r a x in w h i c h t h e d e l a y from o n s e t of s y m p t o m s to radiologic e x a m i n a t i o n was short, in our patient, radiographic e x a m i n a t i o n of the chest five h o u r s a f t e r the o n s e t of s y m p t o m s did not r e v e a l a n y air. This supports the notion that this patient had a spontaneous hemothorax that was not associated w i t h a prior spontaneous p n e u m o t h o r a x . T h e e t i o l o g y of s p o n t a n e o u s h e m o t h o r a x c a n be found in m o s t cases. It h a s been described in a var i e t y of s i t u a t i o n s : p u l m o n a r y art e r i o v e n o u s fistula, 3 systemic l u p u s e r y t h e m a t o s u s , 4 complication of anticoagulant therapy, 5 osteosarcoma of the rib, 2 ectopic pregnancy, ° Ewing's sarcoma, 1° myeloid leukemia, 11 h i s t i o c y t o s i s , 12 t h r o m b o c y t o p e n i a , ~2 end0metriosis, 13 a n d b l e e d i n g from a n i n t e r c o s t a l a r t e r y . ~4 S l i n d a n d Rodarte 12 reported a case without an i d e n t i f i a b l e c a u s e . A r e n t in t h e
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d i a p h r a g m w a s f o u n d a n d they s p e c u l a t e d t h a t an i n t r a m u s c u l a r h e m a t o m a r u p t u r e d into the pleura[ space w i t h subsequent developn~eat of m a s s i v e hemothorax. Spontaneous hemopneumotho. r a x is most common in m e n betwee~ the age of 20 to 40 years.2,15, 2a This is s i m i l a r to t h e occurrence of spoa. taneous pneumothorax. 22 Of the six cases of spontaneous hemothorax re. p o r t e d .by A n d r e a s s i a n , 2 three were m e n a n d t h r e e were women with a r a n g e in age from 10 to 72 years. The difference in sex and age of the pat i e n t s s u p p o r t s t h e c o n c e p t that spontaneous h e m o p n e u m o t h o r a x and s p o n t a n e o u s h e m o t h o r a x a r e separ a t e e n t i t i e s . The sex and age dist r i b u t i o n of the p a t i e n t s with spont a n e o u s h e m o t h o r a x is r a n d o m be. cause it is u s u a l l y related to an und e r l y i n g disorder. However, the pat i e n t w i t h s p o n t a n e o u s hemopneumothorax usually has a ruptured bleb a n d torn p l e u r a l adhesions that bleed into t h e p l e u r a l space. Our case is u n u s u a l because we had expected to find a h e m o p n e u m o t h o r a x since m u l t i p l e b l e b s w e r e f o u n d a t the apex. Microscopic e x a m i n a t i o n of the specimen r e v e a l e d a m a r k e d l y thicke n e d f i b r o u s p l e u r a w i t h a n unu s u a l n u m b e r of small- and mediumsized v e s s e l s . T h e r e f o r e , t h i s may have been a v a s c u l a r malformation t h a t was t o r n and then bled, which would e x p l a i n t h e absence of a i r in the p l e u r a l cavity. C l i n i c a l l y , t h e r e is n o t h i n g to d i f f e r e n t i a t e s p o n t a n e o u s hemopneumothorax from spontaneous hemothorax. The onset m a y be acute a n d associated w i t h shock, or it may be g r a d u a l and insidious. 18 The signs of i n t e r n a l h e m o r r h a g e depend more on the r a p i d i t y of blood loss t h a n the a c t u a l v o l u m e . 2 The p a t i e n t m a y c o m p l a i n o f d y s p n e a , c o u g h , and chest pain. The p a i n m a y r a d i a t e to t h e neck, s h o u l d e r or u p p e r abdomen, p r e s u m a b l y due t o i r r i t a t i o n of the d i a p h r a g m . 15 Physical examination of t h e chest shows the classical signs of p l e u r a l e f f u s i o n . Respiratory compromise m a y ensue if a tension h e m o p n e u m o t h o r a x develops and the m e d i a s t i n u m is d i s p l a c e d to the opposite side. The diagnosis m a y not be r e a d i l y a p p a r e n t u n t i l a chest r o e n t g e n o g r a m is done. Myocardial infarction and p u l m o n a r y embolism also m a y be suggested by the clinical picture. S u b d i a p h r a g m a t i c pai n may s u g g e s t a n a c u t e a b d o m i n a l emergency, while nausea, vomiting, and abdominal rigidity may suggest a b l e e d i n g or perforated :peptic ulcer,
8:6 (Ju he) 1979
acute p a n c r e a t i t i s
or a p p e n d i c i -
~is.l~,l~ B l e e d i n g is a s s o c i a t e d w i t h p n e u m o t h o r a x in 5% to 10% o f es 23 and should . be kept in m i n d as cas . a potentially sermus complication. Most deaths occur w i t h i n 48 hours after the onset of bleeding. 2~ In the past, h e m o p n e u m o t h o r a x has b e e n associated w i t h 20% m o r t a l i t y r a t e indicating t h a t the bleeding adds greatly to t h e risk of simple pneumothorax. 23
TREATMENT The p a t i e n t in shock obviously needs fluid an d blood r e p l a c e m e n t . However, the bleeding can be insidious, and clinically l a t e n t u n t i l 1 to 1.5 liters h a v e been lost. TM A t u b e thoracostomy using a l a r g e bore chest t u b e s h o u l d be d o n e to evacuate the air and/or blood and to prevent a tension h e m o p n e u m o t h o rax. Deaton et al I suggest t h a t if less than 1000 cc of blood is obtained and a chest r o e n t g e n o g r a m shows t h a t all of t h e b l o o d h a s b e e n r e m o v e d , watchful w a i t i n g can be employed. However, if more t h a n 1000 cc of blood is obtained on thoracentesis or from t h e t u b e t h o r a c o s t o m y , or i f x-ray studies show persistent density after thoracentesis, an open thoracotomy is indicated for definite diagnosis, control of bleeding, and evacuation of any r e m a i n i n g blood in the pleural space. I would like to thank Ron Stewart, MD, and Ralph Jung, MD, for their review of the manuscript and Ms. Gwen Jones and
8=6 (June) 1979
Ms. Pam LeNoue for their clerical assistance.
luc~mie my~loide chronique. Lille Med 7:703, 1962.
REFERENCES
12. Slind RO, Rodarte JR: Spontaneous hemothorax in an otherwise he a l t hy young man. Chest 66:81, 1974.
1. Deaton RW Jr, Johnston FR: Spontaneous hemopneumothorax. J Thorac Cardiovasc Surg 43:413-415, 1962. 2. Andreassian B, Beyredieu G, Nusgaume O, et al: Hemopneumothorax et hemothorax dits spontanes. A propos de 21 cas. A n n Chir Thorac Cardiovasc 10:367-373, 1971. 3. Spear BS, Sully L, Lewis CT: Pulmonary arteriovenous fistula presenting as spontaneous haemothorax. Thorax 30: 355-356, 1975. 4. Mulkey D, Hudson L: Massive spontaneous unilateral hemothorax. A m J Med 56:570-574, 1974. 5. Diamond MT, Fell SC: Anticoagulantinduced massive hemothorax. N Y S t a t e J Med 73:691-692, 1973. 6. Gangi H, Vidrine A Jr: Ectopic pregnancy presenting as hemothorax. A m J Surg 120:807-809, 1970.
13. Pierou R, Bonnet JL, Demay CL, et al: Pneumothorax puis h~mothorax r~cidivants r~v~lateurs d'une endom~triose. J Franc Med Chir Thor 236:147, 1969. 14. Davidson P: Massive hemothorax caused by bleeding from an intercostal artery. J Iowa Med Soc 60:389-392, 1970. 15. Perry KMA: Spontaneous hemothorax. Lancet 2:829-831, 1938. 16. Borrie J: Management of Emergencies in Thoracic Surgery. New York, Appleton-Century-Crofts, 1972, p 150. 17. Hopkins HV: Spontaneous hemopneumothorax. Report of three cases with review of the literature. A m J Med Sci 193:763-772, 1937. 18. Whittaker JT: Case of hemopneumothorax, relieved by the aspirator. Clinic (Cincinnati) 10:793, 1876.
7. Islam N, Islam A: Haemorrhagic pleural effusion in tropical eosinophilia (a case report). J Trop Med Hyg 72:304, 1969.
19. Pitt GN: A case of rapidly fatal hemopneumothorax, apparently due to r u p t u r e of an emphysematous bulla. Transactions of the Clinical Society of London 33:95, 1900.
8. Bowes JB: Anaesthetic management of hemothorax and haemoptysis due to von Willebrand's disease. A case report. Br J Anaesth 41:894-897, 1969.
20. Boland kS: Idiopathic pneumo-hemothorax with recovery after aspiration. Boston Medical and Surgical Journal 142:321, 1900.
9. Turiaf J, Battesti JP, Menault M, et al: H~mothorax spontan~ r~v~lant une hemophilie. Paumon 26:253, 1970.
21. Rolleston HD: A case of fatal hemopneumothorax of unexplained origin. Transactions of the Clinical Society of London 33:90, 1900.
10. Voog R, Couderg P, Barrie J: Sarcome d'Ewing Costal rgv~le par un h~mothorax spontan~. J Franc Med Chir Thor 18: 449, 1964.
22. Baum GL: Textbook of Pulmonary Diseases. Boston, Little, Brown and Company, 1965, p 688.
11. Warembourg H, Goudemand M, Jaillard J: H~mothorax spontan~ r~v~lant une
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23. Rydell JR~ Emergency thoracotomy for massive spontaneous hemopneumothorax. J Thorac Surg 37:382-386, 1959.
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Spontaneous Hemothorax Philip S. Schwarzman, MD Los Angeles, California
A 31-year-old man presented to the emergency department with dyspnea and pleuritic chest pain resulting from a spontaneous hemothorax. A tube thoracostomy was performed on the left side and 700 cc of blood removed. Another 1800 cc of blood oozed from the chest tube. Open thoracotomy was performed in the operating room. There were approximately 1 to 2 liters of blood and clot in the chest cavity. Multiple bleeding points in the apex were ligated and wedge resection was done. Spontaneous hemothorax may represent a form of spontaneous hemopneumothorax or it may be a complication of a variety of situations, Open thoracotomy may be n e c e s s a r y for definitive diagnosis and treatment. Schwarzman PS: Spontaneous hemothorax. JACEP 8:235-237, June, 1979. hemothorax
INTRODUCTION
Spontaneous h e m o t h o r a x is the a c c u m u l a t i o n of blood w i t h i n t h e pleural cavity w i t h o u t any k n o w n t r a u m a . 1 Although as a complication of chest injury it is a well k n o w n phenomenon, h e m o t h o r a x has also been described in association w i t h various p u l m o n a r y diseases, coagulopathies, and o t h e r disorders, and m a y also complicate spontaneous pneumothorax. T M Spontaneous h e m o t h o r a x is a r a r e phenomenon2, ~5 and in some cases m a y be r e l a t e d to spontaneous hemop n e u m o t h o r a x 2 6 The following case i l l u s t r a t e s the diagnosis, p a t h o g e n e s i s and m a n a g e m e n t of this entity. CASE REPORT
A 31-year-old m a n h a d a history of i n c r e a s i n g d y s p n e a a n d left-sided chest p a i n t h a t worsened w i t h inspiration. The p a i n s t a r t e d suddenly, a p p r o x i m a t e l y five hours prior to admission, and was not associated w i t h t r a u m a . The p a t i e n t was a n o n s m o k e r and h a d been in excellent health. No other r e l e v a n t history was obtained. On i n i t i a l p h y s i c a l e x a m i n a t i o n , t h e p a t i e n t a p p e a r e d a c u t e l y ill and d i a p h o r e t i c . S u p i n e blood p r e s s u r e was 80/40 m m Hg w i t h a p u l s e of 130 beats/min. The t r a c h e a was shifted slightly to the right. B r e a t h sounds were a b s e n t on the left. H e a r t sounds were d i s t a n t and best h e a r d in the subxiphoid area. The a b d o m e n was soft and nontender; bowel sounds normal. The distal pulses were equal a n d p r e s e n t in all extremities. I n i t i a l portable chest r a d i o g r a p h revealed complete opacification of the left h e m i t h o r a x w i t h a m e d i a s t i n a l shift to the r i g h t (Figure). A r t e r i a l blood gases showed pH, 7.36; pO2, 62 m m Hg; pCO2, 36 m m Hg, and HCO3, 20 mEq/liter. The h e m a t o c r i t and hemoglobin r e a d i n g s were 33.2% and 11.2 gm respectively. The white blood cell count was 18,000/cu mm. The p l a t e l e t s were a d e q u a t e and the p r o t h r o m b i n and p a r t i a l t h r o m b o p l a s t i n t i m e s were w i t h i n n o r m a l limits. A tube thoracostomy was performed in the left fifth i n t e r c o s t a l space and From the Department of Emergency Medicine, Los Angeles County/Universityof SouthernCalifornia Medical Center, Los Angeles, California. Address for reprints: Philip S. Schwarzman, MD, Department of Emergency Medicine, St. Joseph Medical Center, Buena Vista and Alameda, Burbank, California 91505. 8"6 (June) 1979
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700 cc o f blood evacuated. The patient was hospitalized. Because a n o t h e r 1800 cc of blood oozed from t h e chest tube, the patient was t a k e n to the o p e r a t i n g room. Open thoracotomy r e v e a l e d a p p r o x i m a t e l y 1 to 2 l i t e r s of blood a n d clot in t h e left p l e u r a l cavity. T h e r e were m u l t i p l e blebs a t the apex of the upper lobe. The r u p t u r e d p l e u r a l adhesions a t the apex of the left upper lobe were l i g a t e d a n d a wedge resection of t h i s a r e a was done. The d i a p h r a g m was n o r m a l on e x a m i n a t i o n . The p a t i e n t recovered u n e v e n t fully and was subsequently discharged. The pathologic e x a m i n a t i o n of the resected specimen r e v e a l e d a m a r k e d l y t h i c k e n e d fibrous p l e u r a w i t h an u n u s u a l n u m b e r of s m a l l a n d medium-sized vessels.
DISCUSSION Spontaneous hemopneumothor a x was first recognized in 1828 by Laennec ~7 who found air u n d e r pressure and blood p r e s e n t in the p l e u r a l c a v i t y in a case at autopsy. S h o r t l y thereafter, W h i t t a k e r TM reported t h e s u c c e s s f u l t r e a t m e n t of a c a s e o f spontaneous hemopneumothorax using r e p e a t e d aspirations. In 1900, Pitt, 19 Boland, 2° a n d Rolleston 2~ each r e p o r t e d cases of spontaneous hemop n e u m o t h o r a x . In the first, the lungs and p l e u r a were n o r m a l at autopsy. In the second, the bleeding was from a ruptured pleural adhesion. The e t i o l o g y in t h e t h i r d p a t i e n t , who survived, could not be determined. In 1938, P e r r y ~5 described a pat i e n t who collapsed w i t h severe stabb i n g p a i n in t h e r i g h t side of his chest, shortness of breath, and shock. The p a t i e n t died six hours after admission and autopsy revealed a hemothorax with ruptured pleural adhesions. The m o s t p r o b a b l e e t i o l o g y of s p o n t a n e o u s h e m o t h o r a x a n d spont a n e o u s h e m o p n e u m o t h o r a x is rupt u r e of a s u b p l e u r a l bleb, usually. apical in location 1 as in our patient. As the l u n g collapses, adhesions between the visceral and parietal p l e u r a a r e torn. If the adhesions a r e vascular, h e m o t h o r a x m a y be added to t h e e x i s t i n g p n e u m o t h o r a x . ~ F r a g i l e s u b p l e u r a l air vesicles often form at t h e i n s e r t i o n of a d h e s i o n s into t h e visceral pleura, probably due to scar tissue also in the u n d e r l y i n g lung. 15 R e s p i r a t o r y movement which is sufficient to t e a r an a d h e s i o n is commonly also severe enough to t e a r one of t h e s e v e s i c l e s . ~ In t h e 21 cases t h a t P e r r y 15 reported, e i g h t autopsies were performed. In t h r e e in-
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F i g . Anteroposterior chest roentgenogram showing complete opacification of the left hemithorax with a shift of the mediastinum to the right.
stances ruptured adhesions were found. In t h r e e others, this was considered to be the most probable etiology. No d e f i n i t e e t i o l o g y could be f o u n d i n t w o of t h e cases. Of t h e e i g h t p a t i e n t s p r e s e n t e d by D e a t o n et al, 1 four were found to have bleeding apical adhesions at operation. It is possible t h a t s p o n t a n e o u s h e m o t h o r a x is simply a form of spontaneous hemopneumothorax in which t h e air h a s been resorbed by the time the diagnosis is made. And r e a s s i a n et al 2 reported six cases of spontaneous hemothorax without evidence of associated p n e u m o t h o r a x in w h i c h t h e d e l a y from o n s e t of s y m p t o m s to radiologic e x a m i n a t i o n was short, in our patient, radiographic e x a m i n a t i o n of the chest five h o u r s a f t e r the o n s e t of s y m p t o m s did not r e v e a l a n y air. This supports the notion that this patient had a spontaneous hemothorax that was not associated w i t h a prior spontaneous p n e u m o t h o r a x . T h e e t i o l o g y of s p o n t a n e o u s h e m o t h o r a x c a n be found in m o s t cases. It h a s been described in a var i e t y of s i t u a t i o n s : p u l m o n a r y art e r i o v e n o u s fistula, 3 systemic l u p u s e r y t h e m a t o s u s , 4 complication of anticoagulant therapy, 5 osteosarcoma of the rib, 2 ectopic pregnancy, ° Ewing's sarcoma, 1° myeloid leukemia, 11 h i s t i o c y t o s i s , 12 t h r o m b o c y t o p e n i a , ~2 end0metriosis, 13 a n d b l e e d i n g from a n i n t e r c o s t a l a r t e r y . ~4 S l i n d a n d Rodarte 12 reported a case without an i d e n t i f i a b l e c a u s e . A r e n t in t h e
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d i a p h r a g m w a s f o u n d a n d they s p e c u l a t e d t h a t an i n t r a m u s c u l a r h e m a t o m a r u p t u r e d into the pleura[ space w i t h subsequent developn~eat of m a s s i v e hemothorax. Spontaneous hemopneumotho. r a x is most common in m e n betwee~ the age of 20 to 40 years.2,15, 2a This is s i m i l a r to t h e occurrence of spoa. taneous pneumothorax. 22 Of the six cases of spontaneous hemothorax re. p o r t e d .by A n d r e a s s i a n , 2 three were m e n a n d t h r e e were women with a r a n g e in age from 10 to 72 years. The difference in sex and age of the pat i e n t s s u p p o r t s t h e c o n c e p t that spontaneous h e m o p n e u m o t h o r a x and s p o n t a n e o u s h e m o t h o r a x a r e separ a t e e n t i t i e s . The sex and age dist r i b u t i o n of the p a t i e n t s with spont a n e o u s h e m o t h o r a x is r a n d o m be. cause it is u s u a l l y related to an und e r l y i n g disorder. However, the pat i e n t w i t h s p o n t a n e o u s hemopneumothorax usually has a ruptured bleb a n d torn p l e u r a l adhesions that bleed into t h e p l e u r a l space. Our case is u n u s u a l because we had expected to find a h e m o p n e u m o t h o r a x since m u l t i p l e b l e b s w e r e f o u n d a t the apex. Microscopic e x a m i n a t i o n of the specimen r e v e a l e d a m a r k e d l y thicke n e d f i b r o u s p l e u r a w i t h a n unu s u a l n u m b e r of small- and mediumsized v e s s e l s . T h e r e f o r e , t h i s may have been a v a s c u l a r malformation t h a t was t o r n and then bled, which would e x p l a i n t h e absence of a i r in the p l e u r a l cavity. C l i n i c a l l y , t h e r e is n o t h i n g to d i f f e r e n t i a t e s p o n t a n e o u s hemopneumothorax from spontaneous hemothorax. The onset m a y be acute a n d associated w i t h shock, or it may be g r a d u a l and insidious. 18 The signs of i n t e r n a l h e m o r r h a g e depend more on the r a p i d i t y of blood loss t h a n the a c t u a l v o l u m e . 2 The p a t i e n t m a y c o m p l a i n o f d y s p n e a , c o u g h , and chest pain. The p a i n m a y r a d i a t e to t h e neck, s h o u l d e r or u p p e r abdomen, p r e s u m a b l y due t o i r r i t a t i o n of the d i a p h r a g m . 15 Physical examination of t h e chest shows the classical signs of p l e u r a l e f f u s i o n . Respiratory compromise m a y ensue if a tension h e m o p n e u m o t h o r a x develops and the m e d i a s t i n u m is d i s p l a c e d to the opposite side. The diagnosis m a y not be r e a d i l y a p p a r e n t u n t i l a chest r o e n t g e n o g r a m is done. Myocardial infarction and p u l m o n a r y embolism also m a y be suggested by the clinical picture. S u b d i a p h r a g m a t i c pai n may s u g g e s t a n a c u t e a b d o m i n a l emergency, while nausea, vomiting, and abdominal rigidity may suggest a b l e e d i n g or perforated :peptic ulcer,
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acute p a n c r e a t i t i s
or a p p e n d i c i -
~is.l~,l~ B l e e d i n g is a s s o c i a t e d w i t h p n e u m o t h o r a x in 5% to 10% o f es 23 and should . be kept in m i n d as cas . a potentially sermus complication. Most deaths occur w i t h i n 48 hours after the onset of bleeding. 2~ In the past, h e m o p n e u m o t h o r a x has b e e n associated w i t h 20% m o r t a l i t y r a t e indicating t h a t the bleeding adds greatly to t h e risk of simple pneumothorax. 23
TREATMENT The p a t i e n t in shock obviously needs fluid an d blood r e p l a c e m e n t . However, the bleeding can be insidious, and clinically l a t e n t u n t i l 1 to 1.5 liters h a v e been lost. TM A t u b e thoracostomy using a l a r g e bore chest t u b e s h o u l d be d o n e to evacuate the air and/or blood and to prevent a tension h e m o p n e u m o t h o rax. Deaton et al I suggest t h a t if less than 1000 cc of blood is obtained and a chest r o e n t g e n o g r a m shows t h a t all of t h e b l o o d h a s b e e n r e m o v e d , watchful w a i t i n g can be employed. However, if more t h a n 1000 cc of blood is obtained on thoracentesis or from t h e t u b e t h o r a c o s t o m y , or i f x-ray studies show persistent density after thoracentesis, an open thoracotomy is indicated for definite diagnosis, control of bleeding, and evacuation of any r e m a i n i n g blood in the pleural space. I would like to thank Ron Stewart, MD, and Ralph Jung, MD, for their review of the manuscript and Ms. Gwen Jones and
8=6 (June) 1979
Ms. Pam LeNoue for their clerical assistance.
luc~mie my~loide chronique. Lille Med 7:703, 1962.
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9. Turiaf J, Battesti JP, Menault M, et al: H~mothorax spontan~ r~v~lant une hemophilie. Paumon 26:253, 1970.
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11. Warembourg H, Goudemand M, Jaillard J: H~mothorax spontan~ r~v~lant une
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23. Rydell JR~ Emergency thoracotomy for massive spontaneous hemopneumothorax. J Thorac Surg 37:382-386, 1959.
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