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Cardiovascular Disease |

Lung Hernia After Vigorous Cough in a Patient With a Recent History of Celiac Artery Segmental Arterial Mediolysis (SAM)

Jilalu Kelbe, MD; Gene Schwartz, MD; Jayshil Patel, MD
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Medical College of Wisconsin, Milwaukee, WI


Chest. 2015;148(4_MeetingAbstracts):49A. doi:10.1378/chest.2281581
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Abstract

SESSION TITLE: Cardiovascular Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Herniation of the lung through a defect in the intercostal muscles is a rare condition which is usually associated with either chest trauma or thoracic surgery. There are a few reports of lung hernia following vigorous cough in the absence of trauma or surgery. SAM is a rare non inflammatory vasculopathy characterized by vacuolar degeneration of smooth muscle cells of the medial layer of arteries. It usually affects abdominal visceral arteries. We report a case of intercostal lung herniation after vigorous cough in a patient with a history of celiac artery aneurysm due to SAM.

CASE PRESENTATION: A 42-yr-old male with history of ruptured celiac artery aneurysm 10 months prior presented with severe, sharp left lateral chest pain and mild shortness of breath. He had severe non-productive cough for a week. No history of chest trauma or surgery. Chest examination revealed decreased air entry on the left side with tenderness and subcutaneous emphysema over the left lower ribs laterally. A chest radiograph showed subcutaneous gas along the left lower chest wall. A computerized tomography (CT) scan of the chest revealed rupture of the intercostal muscles between the left lateral 7th and 8th ribs with herniation of the lung through the defect and a small left pneumothorax. Complete blood count and basic metabolic panel were unremarkable. Acid fast stain from sputum and bronchial washings were negative whereas Quantiferon-TB test was indeterminate. The sputum culture grew Mycobacterium mucogenicum. A left thoracotomy with repair of intercostal muscle defect was performed.

DISCUSSION: Acquired lung hernias are usually posttrauma or postsurgery. Spontaneous lung hernias occur in association with increased intra-thoracic pressure usually from vigorous cough, valsalva maneuver and heavy weight lifting. Our patient had vigorous cough which may explain the spontaneous lung herniation. There are no reports of association with SAM; however, a similar process may have predisposed the patient to a defect in intercostal muscles and subsequent lung herniation precipitated by cough.

CONCLUSIONS: Lung herniation should be considered in the differential diagnosis of patients who present with localized pain and subcutaneous emphysema after vigorous cough.

Reference #1: Tack, D et al Spontaneous lung herniation after a single cough. European Radiology 2000, 10:500-502

Reference #2: Jastrow KM, et al. Posterior lung herniation after a coughing spell: a case report. Cases journal. 2009;2(1):86.

DISCLOSURE: The following authors have nothing to disclose: Jilalu Kelbe, Gene Schwartz, Jayshil Patel

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