Geriatric man with a mass in the chest.

CASE PRESENTATION

A 91‐year‐old man with chronic obstructive pulmonary disease (COPD) was sent to the emergency department (ED) from a nursing facility with shortness of breath. He had a 2L oxygen requirement with stable hemodynamics. Physical examination was remarkable for a mass on his right chest, which expanded with exhalation and contracted with inhalation (Figure 1 and 2). The patient reported a mass present on his chest wall for several years after undergoing a mitral valve repair with a right thoracotomy approach. His respiratory polymerase chain reaction (PCR) was notable for parainfluenza virus. Chest x‐ray was obtained (Figure 3).

FIGURE 1

Hernia sac; exhalation

FIGURE 2

Hernia sac; inhalation

FIGURE 3

Anterior‐posterior view (AP) chest x‐ray demonstrating large right‐sided pneumothorax including lung hernia sac

DIAGNOSIS

Spontaneous pneumothorax in the setting of chronic lung herniation

Review of the patient's prior imaging revealed a right lung hernia in the 4th intercostal space (Figure 4). Computed tomography (CT) now demonstrated a pneumothorax that included the hernia sac (Figure 5), likely due to bleb rupture in the setting of viral infection and COPD. The patient was managed with placement of a 14F pigtail catheter under ultrasound guidance, avoiding the hernia sac and subdiaphragmatic structures. The chest wall mass reduced with re‐expansion of the lung (Figure 6). The catheter was removed on hospital day 4 and patient discharged on day 7.

FIGURE 4

CT chest from prior medical visit demonstrating right‐sided lung herniation through right lateral chest wall between fourth and fifth ribs

FIGURE 5

CT chest demonstrating right‐sided pneumothorax including lung hernia sac

FIGURE 6

Anterior‐posterior view (AP) chest x‐ray post insertion 14F pigtail catheter demonstrating resolution of pneumothorax

This case demonstrates an unusual presentation of simple pneumothorax with hypoxic respiratory failure in a patient with chronic lung herniation. Lung hernia may be congenital or acquired secondary to trauma, complication of surgery, weakening of intercostal muscles or increased intrathoracic pressure. Many are asymptomatic and managed conservatively, although surgical repair may be completed.

CONFLICTS OF INTEREST

Laura J Walker reports no conflict of interest. Michael Sonnier reports no conflict of interest. Christopher Berry reports no conflict of interest.