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Interactive Cardiovascular and Thoracic Surgery 3 (2004) 243–244

www.icvts.org

Case report - Thoracic general

Rapidly accumulating spontaneous pulmonary hematoma


complicating a small parenchymal aneurysm
Ibrahim Sameh Sersar*, Mohammed Fouad Ismaeil, Nabil Abdel Raouf Abdel Mageed,
Mohammed Mounir Elsaeid
Department of Cardiothoracic Surgery and Anaesthesia and Intensive Care Unit, Mansoura University, Mansoura, Egypt
Received 13 August 2003; received in revised form 13 November 2003; accepted 17 November 2003

Abstract
A 20-year-old male is presented with hemoptysis since 3 months. Plain chest X-ray and computed tomography (CT) chest at that time
showed bilateral hilar shadows. Recent X-ray showed a huge right-sided well-defined opacity. CT chest and magnetic resonance angiography
were ordered for him revealing a huge intrapulmonary hematoma.
q 2003 Elsevier B.V. All rights reserved.
Keywords: Spontaneous pulmonary hematoma

1. Introduction evaluation. Computed tomography (CT) scan can be helpful


in distinguishing between contusion and hematoma. It is a
Pulmonary hematoma consists of hemorrhage into the more sensitive and accurate means of diagnosing pulmonary
alveolar and interstitial spaces. It is usually associated with hematoma. Magnetic resonance imaging (MRI) allows
surrounding intraparenchymal hemorrhage [1]. However, documentation of pulmonary hematoma and exclusion of
24 –48 h after the trauma, a hematoma typically develops more ominous lesions [6].
into a discrete mass with distinct margins. It usually resolves Indications for surgery were as follows: infection,
in approximately 2 –4 weeks. Occasionally, these hemato- hemoptysis and suspicions of malignant lesion. The early
mas may cavitate if they become secondarily infected and and late results are excellent [7].
present as an abscess requiring drainage [2].
Post-traumatic pulmonary hematoma may result from
direct blunt trauma, blast injury, or indirect forces from the 2. Case report
ballistics of a missile. Pulmonary hematomas may also
result from overdosage of anticoagulants, or rarely as a A 20-year-old male was admitted to our center with
complication of subclavian vein catheterization. Although hemoptysis since 3 months. He had no history of smoking or
Nakayama and coworkers [4] have reported that pulmonary any significant pulmonary disease. No history of trauma or
hematoma can occur as isolated injuries in children, in anticoagulation was present.
adults they are typically associated with other injuries and A postero-anterior and lateral chest X-ray 3 months
have an overall mortality rate of 22 –30%, as recorded by previously showed only bilateral hilar shadows. CT chest
Besson and Saegesser [7] and Stellin [1 – 3,5]. showed enlarged both pulmonary arteries and pneumonic
The most frequent clinical sign is hemoptysis. Chest pain patch on the right lung mid zone (Fig. 1a).
and compression symptoms may be present. Pulmonary Recent chest X-ray and CT revealed the same findings
hematoma should be suspected in any patient with major with a huge well-defined rounded mass adjacent to the right
chest wall injury; it can be confirmed by radiologic pleura (Fig. 1b and c). Magnetic resonance angiography
(MRA) was done revealing a laminated heterogenous signal
* Corresponding author. Tel.: þ 20-50-225-5471; fax: þ20-50-223-411. intensity on all pulse sequences. It measures 10 £ 6.5 cm2
E-mail address: sameh001@yahoo.com (I.S. Sersar). (Fig. 1d and e).
1569-9293/$ - see front matter q 2003 Elsevier B.V. All rights reserved.
doi:10.1016/j.icvts.2003.11.011
244 I.S. Sersar et al. / Interactive Cardiovascular and Thoracic Surgery 3 (2004) 243–244

Fig. 2. The histopathological examination of the lobe resected using


hematoxylin and eosin ( £ 250).

3. Discussion

Fig. 1. (a) The first CT chest 3 months before. (b) Recent chest X-ray. (c) Very little if any is written or known about the
Recent CT chest shows a huge intrapulmonary hematoma with an aneurysm spontaneous pulmonary hematoma. It should be suspected
inside. (d, e) MRA showing the hematoma and the aneurysm inside it. in a patient with bleeding tendency. It should be
differentiated from a lung tumor. Its diagnosis, anesthesia,
Doppler ultrasound revealed a free flow within this mass. operative and postoperative management are challenging.
Echocardiography showed calcific pericardium and dilated
pulmonaries.
His physical examination showed no abnormalities.
Blood chemistry and serology were normal apart from References
very low prothrombin concentration (34%). Tuberculin
and fibreoptic bronchoscopy (FOB) were done as our [1] Trinkle JK, Richardson JD, Franz JL. Management of flail chest
routine in cases of hemoptysis. It was negative apart from without mechanical ventilation. Ann Thorac Surg 1975;19:355.
some old blood trickling through the right upper lobe [2] Mathai M, Byrd Jr RP, Roy TM. The posttraumatic pulmonary mass.
J Tenn Med Assoc 1996;89:41.
bronchus and BAL (brush and lavage were done through
[3] Colebunders R, Parizel P, De Backer W, De Schepper A, Vermeire P.
the FOB). They were negative. CT guided biopsy Pulmonary haematoma caused by oral anticoagulant therapy. Report of
suggested a fibrous tumor compatible with fibrous a case. Acta Radiol Diagn (Stockholm) 1983;24:445.
histiocytoma. General anesthesia and muscle paralysis [4] Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in
were done and the patient was intubated with a Double childhood. Ann Surg 1989;210:770.
lumen endotracheal tube. After pleural adhesions were [5] Stellin G. Survival in trauma victims with pulmonary contusion. Am
Surg 1991;57:780.
dissected, a well-circumscribed lobulated mass of
[6] Obretenov E, Petrov D, Alaidzhiev G, Plochev M. Surgical treatment of
15 £ 10 £ 8 cm3 in the anterior segment of the right post-traumatic intrapulmonary haematomas (Article in Bulgarian).
upper lobe was found. The right upper lobe was resected. Khirurgiia (Sofiia) 2002;58:24.
Pathological examination revealed a pulmonary hematoma [7] Besson A, Saegesser F, Color atlas of chest trauma and associated
(Fig. 2). injuries, vol. 1. Oradell, NJ: Medical Economics; 1983.

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