INTRODUCTION: Hemothorax refers to the presence of significant amounts of blood in the pleural space as a result of thoracic trauma, iatrogenic reasons, and nontraumatic causes. This case serves to highlight an unusual nontraumatic cause of a right sided hemothorax.
CASE PRESENTATION: CC: Shortness of breath and coughing blood HPI: 23-year-old white male presented with 3–4 weeks of hemoptysis with intermittently coughing up teaspoons of frank blood. He also had exertional shortness of breath without any aggravating/alleviating factors. He denied chest trauma or pain. Past Medical History:Hemorrhagic Pericardial Effusion- 6 months ago emergent pericardiocentesis drained 1.5 liters of blood. Pericardial biopsy showed inflammation. Investigations unrevealing. Past Surgical History: pericardial window Allergies, Medications, FHx, SHx: negativeROS: fully negative except for symptoms noted in HPI.Physical Exam:Vital Signs: Blood pressure 116/61, pulse 96/minute, afebrile, respirations 20 breaths/minute, 96% on 2 liters oxgenHEENT: normal Respiratory: Breath sounds are diminished on the right side but no adventitial sounds, no dullness to percussion Cardiovascular: S1 and S2 normal without gallop, rub or murmur. P2 accentuatedAbdomen: Normal Extremities: normal Data: All normal except for hemoglobin of 12 g/dlInitial CXR: Bilateral pulmonary nodulesCT Thorax (1 day before admission): Multiple noncalcified pulmonary nodules and dense enlarged pericardial effusion Admission CXR: Cardiac enlargement/Right Pleural effusionEchocardiogram:Estimated ejection fraction 50 to 55% with an organized pericardial effusion Hospital CourseTo evaluate hemoptysis and ascertain etiology of the pulmonary nodules, the patient was scheduled for bronchoscopy. Prior to the procedure decreased breath sounds were noted in the right hemithorax. Flouoroscopy revealed a “pleural stripe” and concern for a large right sided pneumothorax and effusion. To address the patient's dyspnea, a 20 French right sided thoracostomy tube was placed which drained 900 ml of blood. The patient was hemodynamically stable but taken to the intensive care unit and electively intubated due to his work of breathing. No further blood loss occurred from his thoracostomy tube after initial placement. Due to the apparent spontaneous hemothorax and previous echocardiogram findings, a cardiac MRI was quickly obtainedCardiac MRI:Defect in the lateral wall of the right atrium with resulting righthemopericardium/pneumothorax. Operating Room Course: Emergent cardiac surgical consultation was obtained and the MRI findings provided the surgeon appropriate information to put the patient on bypass via the femoral approach before the sternotomy incision decompressed the pericardial thrombus. Operative evaluation revealed multiple perforations in the right atrium and ventricle. The perforations were closed with a gore tex graft, and the patient was taken back to the ICU and extubated several days later. Final Diagnosis: Cardiac Angiosarcoma.
DISCUSSIONS: Nontraumatic hemothorax is uncommon in occurrence. Most common etiologies are metastatic malignant pleural disease, complication of anticoagulant therapy for pulmonary embolism, and catamenial hemothorax in decreasing incidence. Other causes mentioned in literature include ruptured thoracic aorta, ruptured pulmonary arterio-venous fistuala, spontaneous pneumothorax, osteochondroma of the rib, and bronchopulmonary sequestration. (1) Greater than 139 cases of cardiac angiosarcoma have been described in literature. (2) This is the first case in literature describing cardiac angiosarcoma as cause of a right sided hemothorax. Brief review of the mediastinal tissue plane anatomy provides an understanding of this mechanism. The mediastinal surface of the right lung is related to the right atrium and ventricle separated by the parietal pleura and pericardium respectively. Thus, blood moved from the right heart into the right pleural space via this route.
CONCLUSION: This is the first case in literature implicating cardiac angiosarcoma as a cause of a right sided hemothorax. Mediastinal tissue plane anatomy highlights the importance of evaluating for cardiac tumors as an additional etiology of nontraumatic hemothorax.
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