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Correspondence |

Both Spontaneous Pneumothorax and Spontaneous Pneumomediastinum May Constitute a Complication in Underweight Patients Response FREE TO VIEW

Apostolos I. Hatzitolios, MD; George Ntaios, MD, MSc; Michalis L. Sion, MD
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Affiliations: First Propedeutic Department of Internal Medicine, AHEPA Hospital,  Third Department of Internal Medicine, Papageorgiou Hospital, Aristotle University, Thessaloniki, Greece,  Tri-Service General Hospital, Taipei, Republic of China

Correspondence to: George Ntaios, MD, MSc, S. Kiriakidi 1, AHEPA Hospital, Thessaloniki, 54636, Greece; e-mail: ntaiosgeorge@yahoo.gr


Chest. 2008;134(1):216-217. doi:10.1378/chest.08-0164
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Published online

We read with great interest the article by Huang et al that was recently published in CHEST (October 2007),1in which the factors associated with contralateral recurrence of primary spontaneous pneumothorax (PSP) were investigated. Being underweight (body mass index [BMI] < 18.5 kg/m2) was an independent risk factor for controlateral recurrence of PSP (odds ratio, 5.327). Moreover, patients with controlateral recurrence of PSP had significantly lower BMI values (p < 0.001). In another recent article2 by the same authors, it was found that patients with simultaneous bilateral PSP had significantly lower weight (p = 0.018) and BMI (p < 0.001) compared to patients without simultaneous bilateral PSP. In particular, their mean weight was 52 ± 8.4 kg and their mean BMI was 17.6 ± 2 kg/m2. BMI was found to be the most important independent predictor of simultaneous bilateral PSP (p = 0.008).

Together, these two articles indicate that spontaneous pneumothorax may be associated with low BMI and, consequently, malnutrition and nutrient deficiency. In a similar manner, it was shown that spontaneous pneumomediastinum may constitute a complication in anorexia nervosa patients, even if they did not exhibit purging behavior.34 In these patients, spontaneous pneumomediastinum has been attributed to atrophic changes in connective tissue such as thin alveolar walls due to malnutrition.5

It is obvious that both spontaneous pneumothorax and spontaneous pneumomediastinum may constitute a complication in underweight patients. It would be really interesting to prospectively estimate the prevalence of these two conditions in a large cohort of underweight patients and to compare these results with patients of normal weight. Moreover, it would be of interest to further define the local biochemical and pathological background involved in the pathogenesis of both conditions in underweight patients.

The authors have no conflicts of interest to disclose.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Huang, TW, Lee, SC, Cheng, YL, et al (2007) Contralateral recurrence of primary spontaneous pneumothorax.Chest132,1146-1150
 
Lee, SC, Cheng, YL, Huang, CW, et al Simultaneous bilateral primary spontaneous pneumothorax.Respirology2008;13,145-148
 
Hatzitolios, A, Ntaios, G Spontaneous pneumomediastinum may be associated with both anorexia nervosa and obesity [letter].Lung2007;185,373
 
Hatzitolios, AI, Sion, ML, Kounanis, AD, et al Diffuse soft tissue emphysema as a complication of anorexia nervosa.Postgrad Med J1997;73,662-664
 
Fukudo, S, Tanaka, A, Muranaka, M, et al Reversal of severe leukopenia by granulocyte colony-stimulating factor in anorexia nervosa.Am J Med Sci1993;305,31-47
 
To the Editor:

We appreciate the thoughtful comments by Hatzitolios et al on our article in CHEST (October 2007),1which demonstrated that contralateral recurrence of primary spontaneous pneumothorax (PSP) is significantly more common in patients who are underweight (body mass index, < 18.5 kg/m2) and have visible blebs/bullae in the contralateral lung. Baumann et al2 reaffirmed that underweight status is a known driver of PSP and that a high-resolution CT scan (HRCT) of the lung demonstrating the presence of blebs/bullae might play a certain role in the treatment of PSP. Whether spontaneous pneumomediastinum is associated with underweight patients is an issue of interest, but we think it needs further investigation.

Despite documentation of the current clinical practice guidelines for the treatment of PSP,34 recurrence is still a major complication and a bothersome problem for patients with PSP. A single-stage bilateral approach for recurrence prevention in bilateral apical lungs was presented for contralateral recurrence occurring in certain population of patients with PSP,5 but there was no valid criterion. In the “Results” section of our article, we suggested that single-stage bilateral video-assisted thoracoscopic surgery for PSP might be considered if the patient is underweight and the high-resolution CT scan of the lung revealed blebs/bullae in the contralateral lung. Because our study was a retrospective analysis, a prospective study or clinical trial will be needed for the confirmation of these results.

The pathogenesis of the PSP is also an interesting entity. Biomolecular or pathologic methods for the evaluation of ischemic, hypoxic, or inflammatory molecules may be helpful to elucidate the mechanism. But, in our experience, estimating the levels of molecular markers in blebs/bullae did not clarify the nature of the mechanism. We think that this subject needs clearer definition and the cooperation of experienced pulmonary pathologists.

References
Huang, TW, Lee, SC, Cheng, YL, et al Contralateral recurrence of primary spontaneous pneumothorax.Chest2007;132,1146-1150
 
Baumann, MH Management of spontaneous pneumothorax.Clin Chest Med2006;27,369-381
 
Baumann, MH, Strange, C, Heffner, JE, et al Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.Chest2001;119,590-602
 
Herry, M, Arnold, T, Harvey, JE BTS guidelines for the management of spontaneous pneumothorax.Thorax2003;58(suppl),39-52
 
Lang-Lazdunski, L, de Kerangal, X, Pons, F, et al Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy.Ann Thorc Surg2000;70,412-417
 

Figures

Tables

References

Huang, TW, Lee, SC, Cheng, YL, et al (2007) Contralateral recurrence of primary spontaneous pneumothorax.Chest132,1146-1150
 
Lee, SC, Cheng, YL, Huang, CW, et al Simultaneous bilateral primary spontaneous pneumothorax.Respirology2008;13,145-148
 
Hatzitolios, A, Ntaios, G Spontaneous pneumomediastinum may be associated with both anorexia nervosa and obesity [letter].Lung2007;185,373
 
Hatzitolios, AI, Sion, ML, Kounanis, AD, et al Diffuse soft tissue emphysema as a complication of anorexia nervosa.Postgrad Med J1997;73,662-664
 
Fukudo, S, Tanaka, A, Muranaka, M, et al Reversal of severe leukopenia by granulocyte colony-stimulating factor in anorexia nervosa.Am J Med Sci1993;305,31-47
 
Huang, TW, Lee, SC, Cheng, YL, et al Contralateral recurrence of primary spontaneous pneumothorax.Chest2007;132,1146-1150
 
Baumann, MH Management of spontaneous pneumothorax.Clin Chest Med2006;27,369-381
 
Baumann, MH, Strange, C, Heffner, JE, et al Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.Chest2001;119,590-602
 
Herry, M, Arnold, T, Harvey, JE BTS guidelines for the management of spontaneous pneumothorax.Thorax2003;58(suppl),39-52
 
Lang-Lazdunski, L, de Kerangal, X, Pons, F, et al Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy.Ann Thorc Surg2000;70,412-417
 
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