Chest Infections |

A Unique Case of Chest Pain FREE TO VIEW

Chirag Patel, MD; Van Holden, MD
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Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ

Chest. 2014;146(4_MeetingAbstracts):198A. doi:10.1378/chest.1993969
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SESSION TITLE: Miscellaneous Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Iatrogenic intercostal lung hernia is a rare clinical entity. Sternotomy resulting in costocondral separation along with injury to the intercostal muscles are important factors in the development of hernia. We report a case of a 57-year-old woman with acquired lung hernia 5 years after CABG and left internal mammary artery harvesting.

CASE PRESENTATION: A 57 year-old woman with a past medical history of morbid obesity, CABG with left internal mammary artery harvesting 5 years ago, and asthma presents with progressively worsening dyspnea over a month. She noted increased lower extremity edema, paroxysmal nocturnal dyspnea, 3-pillow orthopnea, and productive cough. On admission, patient had dyspnea at rest despite using her nebulizers four times a day and medication compliance with furosemide and metoprolol. She was in moderate respiratory distress saturating 90%. She was placed on bipap and given lasix, however she continued to have vigorous coughing spells despite antitussives. On hospital day five, she reported having sharp, pleuritic, left-sided chest pain after a coughing spell. A focal bulge around the left parasternal area that was non-tender to palpation was noted along with a 30 mm Hg systolic blood pressure difference in the arms. CT angiography of the chest was obtained to evaluate for aortic dissection, however it reveal a diastasis between the 4th and 5th ribs where a 5.2 x 2.6 cm section of left upper lobe herniated. Adjacent to the defect was a metal clip from her cardiac surgery, suggestive of an intercostal muscle defect.

DISCUSSION: Harvesting left internal mammary artery for coronary bypass grafting along with the use of parasternal steel wires may interfere and damage the intercostal arteries leading to local ischemia. Consequently, thoracic wall integrity is compromised, increasing the risk of herniation, especially during vigorous coughing spells. Unique to our case is that the lung herniation occurred years after her CABG. Most lung herniations due to surgical intervention described in the literature occurred weeks to months in the post-operative period. Numerous factors including body habitus, respiratory disease, and previous cardiac surgery contributed to her condition.

CONCLUSIONS: Iatrogenic intercostal lung hernia is a rare pathology especially years after sternotomy. Several factors including previous cardiac surgery, parasternal clipping resulted, periodic steroid use and increased intrathorasic pressure contributed to the condition. This case illustrates the importance of understanding the clinical and radiologic findings of lung herniation.

Reference #1: Çelik, Sezai, et al. "Symptomatic Intercostal Lung Hernia Secondary to Sternal Dehiscence Surgery." American Journal of Case Reports 14 (2013): 198-200, Web. 26 Mar. 2014.

Reference #2: La Hei ER, Deal CW. Intercostal lung hernia subsequent to harvesting of the left internal mammary artery. Ann Thorac Surg. 1995;59:1579-80.

DISCLOSURE: The following authors have nothing to disclose: Chirag Patel, Van Holden

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