Cardiothoracic Surgery |

An Uncommon Cause of Dyspnea: A Case of Chronic Expanding Thoracic Hematoma FREE TO VIEW

Danae Delivanis, MD; Vanessa Yap, MD; Daniel Fusco, MD; Debapriya Datta, MD
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University of CT Health Center, Farmington, CT

Chest. 2014;145(3_MeetingAbstracts):31A. doi:10.1378/chest.1835855
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SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Chronic expanding thoracic hematoma (CETH) is a rare clinical entity mimicking invasive soft-tissue neoplasms in the thorax. It is reported to occur in patients with a history of trauma or surgery or tuberculosis. It is considered a form of chronic empyema and has also been designated as chronic hemorrhagic empyema. We present a case of a CETH, treated successfully with surgical resection.

CASE PRESENTATION: A 30- year old male presented with complaints of left-sided chest pain and exertional shortness of breath for 3 months. No history of fever, chills, night sweats or cough or weight loss. Past medical history was significant for a motor vehicle accident two year back, that necessitated abdominal surgery at that time but old records of the procedure were unavailable. Examination revealed normal vital signs. No pallor, icterus or cyanosis. No JVD or lymphadenopathy. Lung exam revealed diminished breath sounds at left base with increased dullness to percussion. Cardiac exam normal heart sounds without any murmur. No organomegaly or localized tenderness on abdominal exam. Chest-xray showed opacity at left base suggestive of pleural effusion with atelactasis. CT Chest revealed a large heterogeneous mass (8.5 X 6.7 X 8.2 cm) with large central fluid component in the left lower hemithorax. Contiguous diaphragmatic margin was indistinct with absence of fat plane with the spleen. A sulphur colloid scan was performed which ruled out the possibility of this representing a splenic pseudocyst. Patient deferred further diagnostic tests initially but returned a few months later with worsening complaints. Repeat CT chest showed mild increase in the size of the mass. A biopsy was attempted; the needle aspirate revealed necrotic material and the patient was sent for surgical resection of the lesion. On thoracotomy, extensive adhesions were noted involving the left lower lobe of the lung and the chest wall. Extensive dissection and lysis of adhesions were performed. The left lower lobe of the lung appeared destroyed by the loculated collection which was drained and necrotic material obtained was sent for routine bacterial, AFB and fungal stain and culture. The left lower lobe was resected and the residual collection in the lobe on sectioning appeared as a rubbery, fibrinous mass with an abscess cavity. Histopathology of this mass revealed multifocal chronic inflammation with dense scar. No evidence of malignancy was seen. Microbiological studies were all negative. The final diagnosis was chronic expanding hematoma with liquefactive necrosis, aka chronic hemorrhagic empyema. Following surgery, the patient has done well with resolution of symptoms.

DISCUSSION: CETH presents as a progressively enlarging thoracic mass in patients with history of trauma or surgery. In Japan and Korea, CETH has been reported to occur with a history of tuberculosis. It is considered a form of chronic empyema and has also been designated as chronic hemorrhagic empyema. The pathogenesis of CETH is poorly understood but hypothesized to be an inflammatory process caused by the breakdown products of blood and fibrin that damages the capillaries of the hematoma capsule causing intermittent bleeding that makes it expand over time. Commonest presenting symptom is dyspnea, usually related to lung compression from a slowly growing mass. On CT chest, CETH appears as a heterogeneous mass with variable wall thickness. Surgical resection at an early stage is the treatment of choice. Surgery is warranted as it is often difficult to differentiate CETH from malignancies. Surgery should be a complete resection as drainage and curettage of contents or removal of the inner substance without whole capsule excision, has been reported to cause uncontrollable bleeding from residual hypervascular capsule or recurrence of the hematoma within several years.

CONCLUSIONS: 1) CETH is a rare condition. 2) The diagnosis should be considered in patients with a thoracic mass who have a history of trauma, surgery or tuberculosis. 3) Surgical resction is the treatment of choice.

Reference #1: Roper CL, Cooper JD. Chronic expanding hematoma of the thorax. J Thorac Cardiovasc Surg 2001; 122:1046-1048

Reference #2: Kwon YS, Koh W, Kim TS et al. Chronic expanding hematoma of the thorax. Yonsei Medical Journal 2007;48(2):337-340.

Reference #3: Hata Y, Sakamoto S, Shiraga N et al. A case of chronic expanding hematoma resulting in fatal hemoptysis. J Thorac Dis 2012; 4(5):508-511.

DISCLOSURE: The following authors have nothing to disclose: Danae Delivanis, Vanessa Yap, Daniel Fusco, Debapriya Datta

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