Eur J Cardiothorac Surg 2007;32:679-681. doi:10.1016/j.ejcts.2007.06.035
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Delayed massive hemoptysis 20 years after lung stabbing: an unusual presentation
Mohsen Sokouti*,
Vahid Montazeri
Department of Thoracic Surgery, Imam Khomeini Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
Received 14 April 2007;
received in revised form 23 June 2007;
accepted 26 June 2007.
* Corresponding author. Tel.: +411 3347054 57; fax: +411 3366634. (Email: sokouti_m{at}yahoo.com).
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Abstract
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The management of penetrating chest injury by bullet or shrapnel for prevention of later complications has remained controversial. A 45-year-old man presented with a history of 3 years recurrent hemoptysis. He had massive hemoptysis 20 h before admission. He underwent tube thoracostomy for the left hemothorax due to a penetrating chest injury that occurred 20 years previously during the Iran–Iraq war. Since then he had only vague pain in the left side of thorax without any respiratory sign. Chest radiography and computerized tomography revealed a 60 mm x 30 mm x 20 mm abnormal density in the hilum of the left lung near the main pulmonary artery. The hemoptysis was controlled by an emergency resection of the lower segment of left upper lobe and lingulae lobectomy. A large metallic foreign body was extracted. Pathology of the resected specimen revealed a metallic foreign body with chronic pneumonia of the lingulae lobe. This rare case reveals the important clinical fact that a penetrating chest trauma can present as massive life-threatening hemoptysis 20 years later.
Key Words: Shrapnel injury • Lung • Delayed hemoptysis • Massive
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1. Introduction
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Retained intrathoracic foreign bodies resulting from penetrating chest trauma rarely cause symptoms during post injury period. When scarring and healing have occurred, foreign bodies usually remain in a fixed position throughout the patients’ life. Only occasionally do they erode into surrounding structures. If erosion does occur, surgical or bronchoscopic removal may be required [1,2]. We report a patient with life-threatening hemoptysis 20 years after the penetrating trauma by a large metallic piece of shrapnel to his chest. He had no history of any clinical problem during that period.
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2. Case presentation
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A 45-year-old man presented with a history of two bouts of massive hemoptysis (each of 600–800 ml). He coughed out frothy bright red blood in the 12 h before admission. The patient was pale with bronchial breathing. Blood pressure was 100/60 mmHg. He had tachypnea and respiratory distress. Previous chest X-rays and computed tomography of the chest revealed a 60 mm x 30 mm x 20 mm abnormal density in the hilum of the left lung near the main pulmonary and superior pulmonary vein (Figs. 1 and 2
). He had been wounded by a shrapnel penetrating injury of the lung 20 years previously in the Iran–Iraq war. Since then he had not any symptoms except vague thoracic pain that led to repeated admissions in hospital. Twelve hours before admission he developed a low grade fever of 37.6 °C followed by a cough and intermittent massive hemoptysis. Laboratory findings included a total white blood cell count of 12000/mm and hemoglobin of 8.2 mg/dl. He was treated with 750 cc whole blood transfusion and lactated ringer and antibiotics. Because of two bouts of massive hemoptysis (1500 cc) during the first night of admission, the patient underwent an emergency left posterolateral thoracotomy. On exploration the lingular lobe was firm and had chronic pneumonia. After removing the adhesions and splitting the left lobe, a dense metallic foreign body (shrapnel) was found in the hilum of the lung. An incision was made in the lung and missile. An oxidized large metallic shrapnel bulged up from the incision. Its cavity was infiltrated with pus and two opened bronchial branches were sutured with 3(O) fine prolen. The cavity protruded to the lower part of the pulmonary lobe, so its lowest part was resected. The patient got severe dyspnea during the 3 days after the operation because of the retention of clotted blood and respiratory secretions in the respiratory system. We did a bronchoscopy and suctioned all retained clot and secretions from the left bronchus. The left lung expanded and respiratory distress improved. After getting intravenous ceftriaxone, amikacin for 3 days followed by oral cefixime and metronidazole for 7 additional days he was discharged from hospital. One-year follow up of the patient is good.
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3. Discussion
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Retained intrapulmonary foreign bodies presenting with hemoptysis have been previously reported [3]. Hemoptysis is a rare complication of stabbing of the lung. The mechanism of hemoptysis may be due to pressure erosion of a bronchus. This may in turn lead to further erosion into a branch arterial supply leading to hemoptysis [1,4]. Traumatic pulmonary arteriovenous malformation, intrathoracic and intravascular migratory foreign bodies rarely occur after penetrating chest trauma, but may cause delayed massive hemoptysis [4,5].
Although cough and chest pain are common manifestations of lung stabbing reported spontaneously, resolving hemoptysis and infection can occur. The management of these latter complications, particularly hemoptysis, is controversial [6,7]. Medical management of stabbing of the lung is generally not recommended. About one half of patients on medical treatment developed life-threatening complications requiring surgical intervention.
Erosion of the nearby bronchus, localized infection and migration of foreign metallic materials (bullets and missiles) are the main pathologic mechanisms of manifestation, which may cause these bodies to either be expectorated or fixated by a pleural reaction [2]. Injuries to pulmonary vasculature occasionally result in a pulmonary artery to pulmonary vein fistula with right to left shunting. The latter by itself may increase the risk of cerebral abscess and cause a variety of manifestations specific for arterial desaturation. Besides these chronic sequels, traumatic pneumatocele and pulmonary artery aneurysm are rarely seen [6].
Management of pulmonary foreign bodies largely depends on the complications. According to Mattox, the presence of a missile or bullet in and around the heart or great vessels does not necessitate its removal [7]. However, Symbas and Gott believe that elective removal of asymptomatic lung or sharp foreign bodies located near the major vessels or airways is mandatory because of their possible catastrophic risk and life-threatening complications [6]. Otherwise, once a complication has arisen, the offending foreign body should be removed either by bronchoscopy or resection of the involved lobe and sometimes pneumonectomy [4,7,8].
In the present report, the patient had a large metallic piece of shrapnel in the hilum and had been asymptomatic for almost 17 years. However, he gradually developed hemoptysis and finally succumbed into a massive and life-threatening pulmonary hemorrhage. An urgent lobectomy and extraction of metallic foreign body was successfully done, and the patient remained asymptomatic upon 1-year follow-up.
A similar scenario has been reported by Bilello et al. [2], in a patient with a gunshot lung injury after 17 years. There is no rigid dictum concerning the prophylactic removal of retained foreign bodies after penetrating chest injuries, but consideration should be given to the removal of some objects known to have a higher propensity for migration and erosion [6].
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References
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- Saunders MS, Cropp AJ, Award M. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. J Trauma 1992;33:909-911.[Medline]
- Bilello JF, Kaups LK, Davis JW. Delayed pulmonary hemorrhage 17 years after gunshot wound to the chest. Ann Thorac Surg 2001;71:2011-2013.[Abstract/Free Full Text]
- Konvat DM, Anderson WM, Rath GS. Hemoptysis secondary to retained intrapulmonary foreign body: diagnosis by fiberoptic bronchoscopy 28 years after injury. Am Respir Dis 1997;109:279-282.
- Van Way CW. Intrathoracic and intravascular migratory foreign bodies. Surg Clin N Am 1989;69(1):125-133.[Medline]
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- Symbas PN, Gott JP. Delayed sequelae of thoracic trauma. Surg Clin N Am 1989;69(1):135-137.[Medline]
- Mattox KL. Indications for thoracotomy: Deciding to operate. Surg Clin N Am 1989;69(1):47-57.[Medline]
- Wisner DH. Trauma to the chest. In: Sabiston DC, Spencer FC, editors. Surgery of the chest. 6th ed. W.B Saunders Co.;1995. p. 475–81.
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Abstract
1. Introduction
