Massive hemoptysis due to mild and focal contusion on an emphysematous lung / Amfizematoz akciger zemininde hafif ve fokal kontuzyona bagli olusan masif hemoptizi.
We hereby present the case of a young man who had only a focal lung contusion following a low-moderate chest trauma due to a common ball-crash while playing football but presented acutely with massive hemoptysis. He had been followed-up and treated with the diagnosis of emphysema since childhood. Our case illustrates that even a low-moderate blunt trauma-related mild lung contusion may lead to massive hemoptysis. (Tur Toraks Der 2071; 12: 44-6)
Key words: Lung contusion, hemoptysis, blunt chest trauma, emphysema Received: 18.03.2008
Bu yazida, futbol oynadigi sirada olagan bir top carpmasi ile olusan hafif-orta siddeteki bir toraks travmasini takiben gelisen fokal akciger kontuzyonu ve buna bagli akut masif hemoptizi tablosu ile klinigimize basvuran olgu sunuldu. Hasta cocukluk doneminden beri amfizem tan'si ile takip altinda idi. Sunulan bu olgu, thisuk-orta siddetli bir toraks travmasina bagli hafif akcig-er kontuzyonunda bile masif hemoptizinin ortaya arneklemektedir. (Tur Toraks Der 2011; 12: 44-6)
Anahtar sazciikler: Akciger kontuzyonu, hemoptizi, kiint toraks travmasi, amfizem
Gelis Tarthi: 18.03.2008
Kabul Tarihi: 17072008
Understanding and identifying emergent conditions while treating the patient with blunt chest trauma is a critical skill of the advanced practice nurse (1). Usually, pulmonary contusion (PC) induced by high-energy-related blunt chest trauma rarely requires intervention, so it is possible that low-impact trauma related PC is generally not important and may be underestimated (2). In a review of the literature, few cases of pulmonary contusion resulting from non-severe blunt injuries are described (3,4). On the other hand, massive hemoptysis due to localised and mild lung contusion caused by a low-moderate chest trauma on an emphysematous lung is an extremely rare condition and has not been previously described.
In this paper, we present a unique experience with a patient who had only a focal lung contusion following a low-moderate chest trauma due to a common ball-crash while playing football but presented acutely with massive hemoptysis.
CASE A 32-year-old man presented to our emergency department with severe hemoptysis which occured just after a ball-crash to the left anterior chest wall while playing football. Just prior to admission he had had approximately 400 cc hemoptysis induced by a low-moderate blunt chest injury. His medical history revealed that he had been in follow-up and on medical treatment for emphysematous pulmonary (panaciner emphysema) disease since childhood. He used to be a smoker with 17 package/year but had been a non-smoker for 4 years. The etiology regarding his panaciner empyhsematous disease was undetermined. He had been hospitalised and received medical treatment many times before. On physical examination, he appeared healthy, in no acute distress and normal breathing. Vital signs included a blood pressure of 117/62 mm Hg, heart rate 84 beats/ min. and respiration at 19 breaths/min. Breath sounds were diminished bilaterally and crepitant rales were present over the left anterior areas of the chest. No echymo-sis or crepitation was detected in the region of the trauma. No associated injury was observed. The hemoglobin value was 12,6 g/dL, white blood cell count was 14,000 cells/mL and platelet count was 340,000 cells/ mL. Results of his coagulation profile and other laboratory survey studies were normal. With the patient breathing 2 L of oxygen by nasal cannula, the saturation level was 98%. Admission chest radiograph demonstrated pulmonary emphysema and left hilar infiltration, but no evidence of any fractured ribs, hemo/pneumothorax or any other pulmonary pathology (Figure 1). Chest computed tomography scans revealed a panacinar emphysematous pattern predominantly in the lower lung fields associated with a ground glass opacity and alveolar hemorrhage in the left upper lobe consistent with contusion (Figure 2a-d). After the initial evaluation the conservative approach including cardiopulmonary and hemodynamic monitorisation, pulmonary physiotherapy associated with medical treatment (analgesics, bronchodilators, aprotinin, N-acetylcysteine) was carried out. Shortly after, during follow-up the patient expectorated a total of 200 mL of blood over a 4 hour period. Fiberoptic bronchoscopy revealed a blood clot extending from the left upper lobe to the left main bronchus and trachea with no evidence of an active focus of bleeding. Serial bronchial washing with cold saline was performed. During the days following, his condition was improved and hemoptysis was diminished, amounting to10-20 cc/ day. At the end of the 10-day-follow-up, hemoptysis completely disappeared and hilar infiltration improved on control chest x-ray. He was discharged and returned for control.
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The clinical presentation of patients with PC varies widely and ranges from minor discomfort to life-threatening conditions. Severe contusion generally requires large forces often seen in motor vehicle accidents or falls from height, and subsequently results in pulmonary bleeding with microscopic disruption of alveoli. Intraalveolar hemorrhage can progress to acute respiratory distress which can increase mortality due to severe hypoxia. Moreover, significant hemoptysis may be associated and ameorilate the course (1), (3). Given the fact that the presence of serious hemoptysis in PC can potentially compromise the clinical picture, in our case massive hemoptysis produced the chance of early hospitalisation of the patient.
Meese and Sebastianelli (3) reported a similar scenario which occured while playing football and was associated with nonserious hemoptysis. However, as in our case, massive hemoptysis due to such low-moderate chest trauma related lung contusion has not been described so far. Moreover, as a quite rare coincidence, our patient had panacinar emphysema whose association we suspect might contribute and aggravate this innocent course, although contusion occured on the upper lobe of the patient, where the ball crashed. Compared to emphysema due to cigarette smoking, panacinar emphysema may result in very dilated and damaged alveolar spaces and dilated bronchi. Hemoptysis therefore can be encountered in some patients with panacinar emphysema (5). Our suspicion may be supported by the fact that hemoptysis in otherwise healthy subjects is a quite rare event in such cases (6).
The diagnosis of pulmonary injury due to chest trauma sometimes may be overlooked at first presentation due to the impression that the trauma is insignificant. Besides, a reasonable delay in respiratory symptoms may contribute to a misleading diagnosis (4). There are known complications of PC that the patient and the physician must be aware of. These include pneumonia and acute respiratory distress syndrome, which will worsen the patient's clinical picture and may actually progress to death in severe cases (3). Thus, early diagnosis and prompt management plays a vital role. In a similar paper described by Norrashidah et al. (4), blunt injury which did not produce any evidence of external body injury was reported to cause a delayed significant hemoptysis. In contrast, the onset of hemoptysis in our case had an acute character, the severity of the trauma was moderate and our patient was not otherwise healthyas he had an underlying pulmonary disease.
It is widely known that any patient who experienced a severe blunt chest injury should be evaluated for a serious pulmonary contusion, and several complications may develop. However, one shoud be aware of serious clinical pictures such as hemoptysis even in the presence of a low-moderate chest injury caused by a common ball crash.
(1.) Keough V, Pudelek B. Blunt chest trauma: review of selected pulmonary injuries focusing on pulmonary contusion. AACN Clin Issues 2001; 12: 270-81.
(2.) Hafen GM, Massie J. Lung contusion from focal low-moderate chest trauma. Pediatr Pulmonol 2006; 41: 1005-7.
(3.) Meese MA, Sebastianelli WJ. Pulmonary contusion secondary to blunt trauma in a colleiate football player. Clin J Sport Med 1997; 7: 309-10.
(4.) Norrashidah AW, Henry RL, Hartman S. Hemoptysis following blunt trauma: case report. Pediatr Pulmonol 2002; 34: 395-7.
(5.) Tsushima K, Koyama S, Takematsu H et al. Massive pulmonary hemorrhage due to cytomegalovirus infection in Japanese patient with alpha-1-antitrypsin-deficient emphysema. Respiration 1999; 66: 373-6.
(6.) Fabian MC, Smitherinqale A. Hemoptysis in children: the hospital for sick children experience. J Otolaryngol 1996; 25: 44-5.
Kahramanmaras Sutcu Imam University Medical School, Department of Thoracic Surgery, Kahramanmaras, Turkey
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|Title Annotation:||CASE REPORT OLGU SUNUMU / THORACIC SURGERY GOGUS CERRAHiSi|
|Publication:||Turkish Thoracic Journal|
|Date:||Mar 1, 2011|
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