Simultaneous bilateral spontaneous pneumothorax: a case report.

To the Editor: Pneumothorax is the presence of air in the pleural space with secondary lung collapse. Simultaneous bilateral spontaneous pneumothorax (SBSP), defined as the concurrent occurence of pneumothorax in both hemithoraces is a rare clinical condition in the literature, mainly seen in patients with underlying lung disease.1 The incidence of spontaneous pneumothorax is 9 per 100 000 and 1.3 percent of these cases are bilateral and simultaneous.2 We describe a young patient with simultaneous bilateral spontaneous pneumothorax.

A 23-year-old patient was admitted to our emergency service 1 hour after the sudden onset of dyspnea and chest pain. There was no history of trauma to the chest. He denied any history of smoking. Physical examination showed that the patient was a tall, thin man. He was tachycardic and normotensive. He was in apparent distress with a respiratory rate of 22 breaths/minute. The examination of the chest revealed that breath sounds were decreased bilaterally. The percussion note was resonant in all areas of the chest. The trachea was not displaced. Laboratory findings were normal.

The chest radiograph confirmed total pneumothorax on the right side and partial pneumothorax on the left side (Figure 1). Simultaneous tube thoracostomy was carried out on both the right and left hemithorax. Both lungs were soon fully reexpanded. A computed tomography scan was normal. No underlying emphysematous change or bullous disease was identified. We decided to operate on the left side because the air leak was continuous. But the patient did not accept the operation. As the air leak stopped on the right side on the fifth day and on the left side on the seventh day, the thoracic tubes were removed. To prevent any recurrence, bilateral chemical pleurodesis with tetracycline was performed. The patient was discharged on day 9 and was asymptomatic at 5 months follow-up.

Figure 1

Chest radiograph taken on the day of admission showing bilateral pneumothoraces with complete collapse of the right lung and partial collapse of the left lung.

Spontaneous pneumothorax is more frequent in young, tall and thin males, and more common in smokers. The most common cause of spontaneous pneumothorax is the rupture of small subpleural bleps. Simultaneous bilateral spontaneous pneumothorax is a rare clinical event. There are isolated reports of bilateral pneumothorax secondary to trauma, malignancy, high-pressure ventilation and catheterization.

Most case reports in the literature were associated with malignancy.1,3 A few cases of simultaneous bilateral primary spontaneous pneumothorax have been reported in the literature, as in our case.

The clinical presentation of SBSP can be variable. Patients have presented with clinical signs and symptoms ranging from cardiopulmonary failure to as little as mild dyspnea.4 Symptoms may be equal bilaterally. Spontaneous pneumothorax is generally diagnosed by the clinical features. The diagnosis should be based on radiological findings. The chest radiograph constitutes the basis of radiological examination. CT of the chest is indicated to detect underlying causes of spontaneous pneumothorax.3,4 Our patient presented with typical signs and symptoms of pneumothorax and the CT scan was normal.

The treatment options for pneumothorax range from observation to thoracotomy. These treatment options include needle aspiration, percutaneous catheter drainage, tube thoracostomy with or without chemical pleurodesis, and video-assisted thoracic surgery. There are some controversies about the treatment of simultaneous bilateral spontaneous pneumothorax. Initially, chest drainage is essential in the treatment.3–5

The main goals of pneumothorax treatment are to obtain complete lung expansion and to attempt recurrence prevention. We think that simultaneous bilateral primary spontaneous pneumothorax can be managed initially by chest tube drainage. Then one side of the hemithorax should be operated to reduce the risk of recurrence.