SESSION TITLE: Critical Care Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Bullous emphysema causing pneumothorax is a rare complication of Pulmonary Sarcoidosis (PS).
CASE PRESENTATION: A 36 year old African American man with a history of sarcoidosis since 4 years presented to our hospital with worsening dyspnea on exertion, occasional night sweats and intermittent pleuritic chest pain for two months. He also reported smoking two packs of cigarettes per day, snorting cocaine and occasionally uses ecstasy pills. Chest radiograph in the emergency department showed a moderate right-sided pneumothorax with underlying bullous changes (Fig 1). Further evaluation with a CT scan confirmed this pnuemothorax and bullae bilaterally at the apices that prompted emergent placement of a fluoroscopically guided pig tailed catheter resulting in near-complete improvement (Fig 2). 3 days post-procedure the catheter was removed without ensuing complications.
DISCUSSION: Bullous emphysema with underlying sarcoidosis has been reported in the past, association being casual or coincidental. Spontaneous pneumothorax is a rarely reported though known complication of pulmonary sarcoidosis, occurring more in advanced stages of the disease. A case series of 108 patients reports an incidence of 2-4%, though larger-scale evaluations are lacking.(1) Though not well elucidated, the likely mechanisms of formation of bullous sarcoidosis and possibly ensuing spontaneous pneumothorax include air trapping beyond endobronchial lesions or destruction of diseased alveolar tissue and an inciting event such as coughing or straining . An alternative explanation is retraction and collapse of surrounding diseased lung leading to bullae formation. Causation of pneumothoraces in earlier stages of PS is attributed to necrosis of smaller subpleural granulomata or blebs.(2) The relationship between smoking and incidence and manifestations of PS remain unclear.
CONCLUSIONS: Sarcoidosis can be complicated by bullae formation and and can result in pneumothorax. A small pneumothorax, especially in the setting of extensive lung disease may be missed on plain chest radiographs and a CT scan may be necessary to rule out a pneumothorax. Whether steroid therapy is necessary in therapy of bullous sarcoid needs to be evaluated further.
Reference #1: Sharma, O. P. "Sarcoidosis: Unusual Pulmonary Manifestations." Postgraduate Medicine 61.3 (1977): 67-73
Reference #2: Riley, E. A. "Boeck's Sarcoid; a Review Based upon a Clinical Study of Fifty-two Cases." American Review of Tuberculosis 62.3 (1950):231-85
DISCLOSURE: The following authors have nothing to disclose: Sparsha Kukunoor, Shireen Mirza, Anupam Kumar
No Product/Research Disclosure Information