A LIFE THREATENING TIME BOMB IN YOUR LUNG: A RARE CAUSE OF HEMODYNAMIC INSTABILITY IN YOUNG ADULT

Introduction: Spontaneous hemopneumothorax (SHP) is a rare and potentially life-threatening but treatable condition which is defined as the accumulation of more than 400 mls of blood within the pleural space. From all spontaneous pneumothorax cases, the incidence of SHP has been reported about 1-12%. It occurs predominantly in adolescent and adult males, and the male to female ratio approximately 15:1. Its clinical presentation varies from the early course of SHP to the life threatening stage of SHP. In this case report, we described a case of a 38year-old male patient who presented with first episode of sudden chest pain and respiratory distress. Case Report: A 38-year-old Asian gentleman with no known medical illness presented with sudden onset of left sided chest pain for 1 day, and exacerbated with shortness of breath.He complaint of sudden onset of left sided chest pain after cleaning his backyard.On examination, he was an average body built man, appearing to be mild tachypneic with respiratory rate of 20-24 breaths/minute and oxygen saturation of 95-96% under room air. His heart rate was ranging from 80-100 beats/minute with blood pressure of 95/57mmHg. Cardiopulmonary examination revealed significant reduced air entry over left lower zone with hyper-resonance on percussion. There is no tracheal deviation or jugular vein distension. An electrocardiogram showed sinus rhythm with no acute ischemic changes. Chest X-ray demonstrated left pneumothorax with left lower zone homogenous opacity with air fluid level.  Thoracostomy tube insertion was performed immediately over the left lung and it drained out 300cc of blood with intermittent bubbling into the water-seal chamber. Subsequently, patient became lethargic and his blood pressure was reducing in trend.Repeated full blood count done urgently and it showed a significant drop of 3g/dL Hb. Patient then underwent blood transfusion and referred to surgical team for assessment. A CECT thorax revealed left massive hemopneumothorax with significant mediastinal shift and adjacent collapse consolidation of the left lung. Besides, it also demonstrated multiple bullae noted at the right lung apex. A CT Angiography thorax showed abnormal vessel with contrast blush at the left apical segment. Patient then proceed with another thoracostomy tube insertion over left safety triangle area by surgical team. Within the 6 hours in emergency room, a total of 1.9 liters of blood was drained out from both chest tubes. Patient was then transferred to cardiothoracic center (CTC) Hospital Penang for surgical intervention. Discussion: Spontaneous hemopneumothorax (SHP) is a rare disorder, but the incidence rate has been reported as high as 12% of all patients with spontaneous pneumothorax. Nan-Yung Hsu et al. reported that in their study, the incidence rate ranged from 2.0% to 7.3%.(1)  The risk of SHP appears to be significantly predo-minantly in male patient. Eung-Soo Kim et al. revealed that 17 (100%) patients with SHP were males with the average age of 19.5 years, except for 1 male patient with 60 year-old. Eung-Soo Kim et al. also reported among 17 patients, total 13 of them were smokers. (2) Early detection the present of lung bullae before thoracotomy prevent us from catastrophic moment. Computed tomography (CT) has been recognized as standard investigation to differentiate a lung bullae from pneumothorax. However, in Emergency department we have difficulty to transport unstable patient to a CT suite especially is in a remote area. Sinan Karacabey et al have conducted a prospective blinded study to prove the use of lung ultrasound to detect lung bullae. The result showed sensitivity of the presence of pleural sliding in the diagnosis of bullae was 97.50%, and specificity was 100%.(6) In spontaneous hemopneumothorax, the goals of treatment include early resuscitation, hemodynamically stability and the re-expansion of the lungs. Therapeutic protocols in conservative management versus surgical intervention are determined individually based on the patient’s clinical condition.In handling spontaneous hemopneumothorax patient, attention to volume and circulatory status is paramount. Stamatios Kakaris et al. reported that among 71 spontaneous hemopneumothorax cases, 16 (22.5%) treated conservatively with thoracostomy tube, 28 (39.4%) underwent emergency thoracotomy, and 27 (38%) underwent elective thoracotomy. (4) In Eung-Soo Kim et al. study, conservative treatment with tube thoracotomy alone is adequate in most of the hemodynamically stable patient.(2) However, operative management with video-assisted thoracoscopic surgery (VATS) or thoracotomy is indicated for hemorrhage control in hemodynamically unstable patient. Conclusion: Spontaneous hemopneumothorax is a rare and potentially lifethreatening disorder. It is important to correlate the patient’s chief complaint and symptoms with our clinical examination. The early recognition and management of spontaneous hemopneumothorax can improve the prognosis of the patients. Conservative treatment with thoracostomy tube or urgent thoracotomy is mainly based on patient’s hemodynamic stability.