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| CASE REPORT |
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| Year : 2023 | Volume
: 6
| Issue : 2 | Page : 84-86 |
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Pulmonary cavities following blunt chest injury
K Kalaiyarasan, A Sharmila Begam
Department of Respiratory Medicine, Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry, India
| Date of Submission | 24-May-2023 |
| Date of Decision | 02-Jun-2023 |
| Date of Acceptance | 16-Jun-2023 |
| Date of Web Publication | 13-Jul-2023 |
Correspondence Address:
Dr. A Sharmila Begam
Department of Respiratory Medicine, Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/japt.japt_21_23
Road traffic accidents (RTAs) are the most common cause of chest injuries. In this case report, a 17-year-old male presented with left-sided chest pain and hemoptysis after an RTA. Radiological investigations showed a left-sided pneumothorax with multiple cavities in the left lower lobe of the lung and surrounding ground glass opacities, which was suggestive of pulmonary lacerations. We managed the patient conservatively and followed up after 1 month. The computed tomography thorax showed near-complete radiological resolution after 1 month. In all patients with injuries to the chest, we have to suspect pulmonary lacerations, which can present with cavities in the lung parenchyma, and manage them accordingly. As demonstrated in this case, a pulmonary laceration following a RTA can present with pulmonary cavities. Hence, this should be kept in mind during the management of the patient with a chest wall injury.
Keywords: Blunt trauma, cavity, chest injury, pneumothorax, pulmonary laceration
How to cite this article:
Kalaiyarasan K, Begam A S. Pulmonary cavities following blunt chest injury. J Assoc Pulmonologist Tamilnadu 2023;6:84-6 |
How to cite this URL:
Kalaiyarasan K, Begam A S. Pulmonary cavities following blunt chest injury. J Assoc Pulmonologist Tamilnadu [serial online] 2023 [cited 2023 Sep 30];6:84-6. Available from: https://www.japt.in//text.asp?2023/6/2/84/381417 |
| Introduction | |  |
Blunt chest trauma is more common than penetrating injuries and can be seen in up to 70% of patients following road traffic accidents (RTAs).[1] Blunt force trauma can produce chest wall contusions, multiple rib fractures, hemothorax, pneumothorax, pulmonary contusions and lacerations, and very rarely, rupture of bronchus.[2]
A pulmonary laceration is a tear in the lung parenchyma seen after penetrating injuries. It may be caused by rib fractures and usually results in a pneumothorax or hemothorax. Most lacerations resolve spontaneously. Here, we are reporting a patient with a RTA presenting with pneumothorax and multiple cavities in the computed tomography (CT) thorax.
| Case Report | | |
A 17-year-old male migrant laborer with an alleged history of self-fall from a bike 10 days ago presented with complaints of left-sided chest pain for 10 days, aggravated for 4 days, hemoptysis, 4 episodes in the last week, 1 ml each episode, and loss of appetite for 10 days.
On examination, multiple abrasions and scars over the face and hands were present. The patient's vitals were stable, and he was not tachypneic at rest. On palpation, we noted left-side chest wall tenderness over the 4th–9th ribs. On auscultation, decreased breath sounds were heard over the left infraclavicular and left mammary areas.
His routine blood investigations were as follows: hemoglobin – 14.7 g/dl, total blood counts – 8200/μl, platelet count – 219,000/μl, and renal function tests were within normal limits. CT thorax taken on the day of the road traffic accident and 10 days later are shown in [Figure 1] and [Figure 2], respectively. | Figure 1: Computed tomography thorax showing moderate pneumothorax with multiple thick-walled cavities with surrounding ground glass opacities noted on the left lower lobe
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 | Figure 2: Computed tomography thorax showing minimal pneumothorax with enlarged cavities and surrounding ground glass opacities in the left lower lobe
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We proceeded with bronchoscopy to rule out the causes of hemoptysis, such as bronchial injury, and also to look for any air leak and any infective cause of the cavity, particularly tuberculosis. Bronchoscopic findings were normal. Bronchial washings sent for aerobic culture showed no growth, and the cartridge based nucleic acid amplification test (CBNAAT) for Mycobacterium tuberculosis was negative.
As the patient had only chest pain due to undisplaced rib fractures in the left 4th to 9th ribs, we managed the patient conservatively with analgesics. The patient was discharged with the advice to follow-up after 1 month. A repeat CT thorax [Figure 3] showed near-complete resolution of the cavity with complete resolution of the pneumothorax on the left side. | Figure 3: Computed tomography thorax showing resolved pneumothorax and near-complete resolution of cavity
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| Discussion | | |
A pulmonary laceration resulting from penetrating injuries due to rib fractures or blunt chest trauma may be associated with a pulmonary contusion.[3] Lacerations of the lung tissue can also occur by compression of the lung parenchyma against the ribs or spine. Several mechanisms causing lacerations, such as shear forces, alternate compression, and decompression of the chest wall, or a sudden rapid increase in intrathoracic pressure with a closed glottis leading to high intraalveolar pressure that causes shearing of parenchymal tissue, are often capable of tearing the lung.[4]
On chest X-ray, Around 50% of lacerations usually go unnoticed initially because they are associated with consolidation and pulmonary contusion.[5] On CT imaging, traumatic manifestations manifest as ovoid structures because of the elastic recoil of the lung. Blunt trauma can create multiple, small, air-filled lung cysts, referred to as pulverized or Swiss cheese appearances of the lungs.
The laceration may close by itself, which can cause it to trap blood and potentially form a cyst or hematoma. Because the lung is elastic, the tear forms a round cyst called a traumatic cyst that may be filled with air or blood and that usually shrinks over weeks or months. Lacerations that are filled with air are called pneumatoceles, and those that are filled with blood are called pulmonary hematomas. In some cases, both pneumatoceles and hematomas exist in the same injured lung. Lacerations filled with both blood and air display a distinctive air-fluid level.[6] Over time, the walls of lung lacerations tend to grow thicker due to edema and bleeding at the edges. In our case, we found pneumothorax with multiple thick-walled cavities with air-fluid levels in the CT thorax imaging.
Pulmonary lacerations are classified into four types based on CT thorax findings as shown in [Table 1].[6],[7],[8] | Table 1: Types of pulmonary lacerations based on mechanism of injury and computed tomography thorax findings
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Management
The majority of patients can be managed conservatively with supplemental oxygen. A thoracostomy tube may be required when there is significant pneumothorax or hemopneumothorax. About 5% may require surgical intervention such as a thoracotomy or lung-sparing techniques.
Thoracotomy is indicated when the lung fails to re-expand, if pneumothorax, bleeding, or hemoptysis persist, or to remove clotted blood from a hemothorax. Lung-sparing techniques include suturing, stapling, oversewing, wedging out of the laceration, lobectomy, or pneumonectomy.[6]
In our case, we managed the patient conservatively with only analgesics as he had only left-sided chest pain due to multiple rib fractures and was maintaining saturation in room air.
Prognosis
Full recovery is common with proper treatment. Pulmonary lacerations heal within 3–5 weeks, and lacerations filled with air will commonly heal within 1–3 weeks, leaving behind some scars.
| Conclusion | | |
In all patients with injuries to the chest, we have to suspect pulmonary lacerations, which can present with cavities in the lung parenchyma. We should also keep in mind that not all cavities are not due to infectious conditions such as pulmonary tuberculosis. We have to manage the patients according to the etiology, clinical presentation, and response to treatment.
| Declaration of patient consent | | |
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| Acknowledgment | | |
The authors would like to thank to the Department of Radiology, Sri Venkateshwara Medical College Hospital and Research Centre, Puducherry.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ketai L, Primack SL. Thoracic trauma. In: Hodler J, Kubik-Huch RA, von Schulthess GK, editors. Diseases of the Chest, Breast, Heart and Vessels 2019-2022: Diagnostic and Interventional Imaging (IDKD Springer Series). Cham (CH): Springer; 2019. Available from: http://www.ncbi.nlm.nih.gov/books/NBK553870/. [Last accessed on 2023 May 24].  |
| 2. | van Roozendaal LM, van Gool MH, Sprooten RT, Maesen BA, Poeze M, Hulsewé KW, et al. Surgical treatment of bronchial rupture in blunt chest trauma: A review of literature. J Thorac Dis 2018;10:5576-83. |
| 3. | Saito Y, Sakao Y. Traumatic lung injury. Kyobu Geka 2022;75:835-40. |
| 4. | Yeh DD, Lee J. 76 – Trauma and blast injuries. In: Broaddus VC, Mason RJ, Ernst JD, King TE, Lazarus SC, Murray JF, et al., editors. Murray and Nadel's Textbook of Respiratory Medicine. 6 th ed. Philadelphia: W.B. Saunders; 2016. p. 1354-66.e4. Available from: https://www.sciencedirect.com/science/article/pii/B9781455733835000762. [Last accessed on 2023 May 04]. |
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| 7. | Carboni Bisso I, Gemelli NA, Barrios C, Las Heras M. Pulmonary laceration. Trauma Case Rep 2021;32:100449. |
| 8. | Wagner RB, Crawford WO Jr., Schimpf PP. Classification of parenchymal injuries of the lung. Radiology 1988;167:77-82. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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