D. Herniated lung
Discussion
This CT scan demonstrates an extra-thoracic herniation of the left
lung (answer choice D). Lung tissue can be visualized anterior to the
ribs as pointed out by the red arrow.
Teratoma (answer choice A) is incorrect as this would usually appear
in the mediastinum and may contain variable imaging features such as a
well-demarcated shape, evidence of fat, and calcifications. Necrotizing
fasciitis (answer choice B) is incorrect as this would involve gas
within fluid collections, as well as fat stranding. Finally, chest wall
abscess (answer choice C) is incorrect as abscesses tend to have a
well-defined capsule with inflammatory changes. The patient did not
demonstrate signs of active infection.
The patient sustained multiple rib fractures during resuscitative
efforts when he suffered a cardiac arrest three years ago. The
herniation of his left lung was an incidental finding on CT imaging.
Treatment of herniated lungs can include approximation of the ribs. The
patient’s presentation of dyspnea was not attributed to this finding;
thus, treatment was not pursued. His dyspnea was attributed to pneumonia
and he was treated with antibiotics.
A herniated lung is not a common finding. In one study performed in
1968, only 260 cases had been reported globally [1]. It is most commonly
acquired from trauma to the chest or after operative procedures with
inadequate chest wall closure [2]. Herniation of the lung can also be a
spontaneous process. When it does occur spontaneously, the patient
usually has a history of chronic obstructive pulmonary disease or
prolonged steroid use [1]. Sometimes it is precipitated by a cough,
sneeze, or other process that abruptly increases intrathoracic pressure
[3].
Herniated lung can present immediately after these events or can be
delayed by several years. It often presents as localized pleuritic chest
pain, dyspnea, and cough that does not respond to conservative therapy
[3]. Physical examination findings may include a chest wall defect or
mass [1]. The Valsalva maneuver can cause the lung to bulge from the
chest and become more visible, aiding in diagnosis [2].
Asymptomatic lung hernias are usually treated conservatively, but
when symptomatic they can be surgically treated [1]. Complications such
as pleural scarring, recurrent pneumonia, and pneumonitis can occur and
would be indications for surgical intervention [1]. Fortunately, this
was the patient’s first episode of pneumonia and therefore he did not
meet the indications for surgical intervention.
References
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Cox M, Thota D, Trevino R, “Spontaneous Lung Herniation Through the Chest Wall” Military Medicine, vol. 183, issue 3-4, pp. 233-234, 2018. https://doi.org/10.1093/milmed/usx063.
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Weissberg D, Refaely Y, “Hernia of the lung” Ann Thorac Surg, vol. 74, no. 6, pp. 1963-1966, 2002. doi: 10.1002/rcr2.354.
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Hamid M, et al. “Spontaneous Lung Herniation Leading to Extensive
Subcutaneous Emphysema, Pneumothorax, Pneumomediastinum, and
Pneumopericardium” Cureus, vol 10, pp. 2861, 2018. doi: 10.7759/cureus.2861.