The perils of sneezing: Bilateral spontaneous pneumothorax.

This is a brief case report of an adolescent male who developed bilateral spontaneous pneumothorax after sneezing.

INTRODUCTION

Bilateral spontaneous pneumothorax is rare, but when it does occur is frequently life-threatening. This case illustrates the presentation of a bilateral spontaneous pneumothorax in a relatively asymptomatic individual.

CASE REPORT

A 15-year-old male with no reported past medical history presented to an urgent care with atraumatic chest pain. The pain was intermittent, sharp, pleuritic, substernal, and non-radiating. It started two days prior after sneezing. Review of symptoms was negative, specifically denying cough or dyspnea. One week prior, he had mild rhinorrhea and dry cough, which resolved. The patient denied smoking or illicit drug use. Vital signs were normal, including an oxygen saturation of 100% on room air. On examination, he appeared tall, thin, and acutely well. He was in no respiratory distress and lungs sounds were present, but slightly diminished bilaterally. There were no other remarkable examination findings. Chest X-ray study Figures 1 and 2 showed spontaneous bilateral pneumothorax and evidence of surgical correction for pectus excavatum. The patient was admitted without intervention. Daily chest X-rays showed progressive improvement and he was discharged home four days later, after an uneventful hospital course.

Figure 1

Chest X-ray anterior posterior view

Figure 2

Chest X-ray lateral view

A primary spontaneous pneumothorax is atraumatic without underlying evidence of lung disease and is common in young adults.[1] A bilateral spontaneous pneumothorax is very rare with a reported incidence of only 1.6% of cases of spontaneous pneumothorax.[2] Independent risk factors associated with bilateral spontaneous pneumothorax are lower weight, lower body mass index, higher height/weight ratio, and a higher frequency of blebs/bullae on high-resolution computed tomography.[23] A secondary spontaneous pneumothorax is due to underlying pulmonary pathology. In this patient, collagen vascular disease including, Marfan's syndrome was considered. Surgical correction of pectus excavatum has been associated with pneumothorax, but within the peroperative period.[4]

DISCUSSION

Although rare, bilateral spontaneous pneumothorax is imperative to recognize and frequently leads to a life-threatening event.[2] This patient's benign presentation is unusual. Invasive treatment is often indicated in the acute setting as well as long-term to avoid recurrence.[5] High clinical suspicion and recognition of risk factors are critical.