Signs and Symptoms of Chest Diseases: Student/Resident Case Report Poster - Signs and Symptoms of Chest Disease |

Failing All Therapy for COPD: Time to Think Outside the Box FREE TO VIEW

Robert Brammer, MD; Kumar Vipul, MD
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Wellspan York Hospital, York, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1249A. doi:10.1016/j.chest.2016.08.1362
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SESSION TITLE: Student/Resident Case Report Poster - Signs and Symptoms of Chest Disease

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Dyspnea and worsening cough in a patient with prolonged history of smoking leads clinicians toward the diagnosis and treatment of COPD. When escalating therapy of COPD does not lead to recovery, alternative diagnoses should be sought. A rare complication of left sided thoracotomy for hiatal hernia repair is intercostal lung herniation. Without correction, patients are prone to recurrent pulmonary infections masquerading as an acute exacerbation of COPD and lung parenchyma incarceration may cause sepsis.

CASE PRESENTATION: A 63-year-old female with 60 pack-year tobacco use, recent recurrent pulmonary infections, bronchiectasis and prior thoracotomy for hiatal hernia repair presented with increasing dyspnea and productive cough. She was treated with oral steroids, antibiotics and bronchodilator therapy. Despite completing pulmonary rehabilitation and following all recommendations, her clinical decline continued. At an office visit, a soft mass was palpated on left hemi- thorax. This expanded with inspiration and produced an expiratory wheeze on auscultation. CT thorax demonstrated a large lung herniation between 7th and 8th intercostal space. The patient underwent decompression thoracotomy and mesh repair of the herniation. A chronic displacement of the 7th rib was noted that likely induced the herniation. She had good recovery with complete resolution of chronic cough. A repeat spirometry confirmed resolution of obstruction and her dyspnea on exertion resolved well.

DISCUSSION: Intercostal lung herniation is seen in patients with a history of chest wall trauma, thoracotomy, chronic lung disease, or situations requiring repeatedly Valsalva. Lung herniation is classified according to its location and the mechanism of occurrence. A plain chest film on Valsalva can show lung beyond the rib sign or lucent lung sign. CT imaging is used to visualize the herniation and assess for possible focal complications. A lung herniation will seldom heal spontaneously, and early surgical intervention reduces morbidity and mortality. Avoidance of aggravating factors such as smoking and repeated Valsalva are necessary. Classification of the lung hernia is based on location; cervical, intercostal and diaphragmatic; and cause; spontaneous, traumatic and congenital.

CONCLUSIONS: In patients with COPD, rapid clinical decline maybe a clue towards another co-existing process. Lung herniation is a potentially reversible extra-thoracic etiology in patients with prior thoracic cavity breach.

Reference #1: O'Shea M, Cleasby M. Images in clinical medicine. Lung herniation after cough-induced rupture of intercostal muscle. N England J Med. 2012 Jan 5;366(1):74.

Reference #2: Sulaiman A, et al. Tronc F. Cough-induced intercostal lung herniation requiring surgery: Report of a case. Surg Today. 2006;36(11):978-80. PubMed PMID: 17072718

Reference #3: Detorakis EE, Androulidakis E. Intercostal lung herniation--the role of imaging. J Radiol Case Rep. 2014 Apr 1;8(4):16-24

DISCLOSURE: The following authors have nothing to disclose: Robert Brammer, Kumar Vipul

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