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• The differential diagnosis should include dissecting aneurysm of the aorta
  oscar,m jolobe
  Published on: 30 January 2020

• Published on: 30 January 2020

  The differential diagnosis should include dissecting aneurysm of the aorta

  • oscar,m jolobe, retired geriatrician manchester medical association

  The differential diagnosis of pneumothorax with haemodynamic compromise(1) ought to include the two subtypes of tension pneumothorax associated with dissecting aneurysm of the aorta(DAA), namely, tension pneumothorax with concurrent haemothorax(2), and tension pneumothorax without concurrent haemothorax(3)(4).
  In the report of DAA-related haemopneumothorax(2), antemortem chest radiography clearly documented the presence of tension pneumothorax without concurrent fluid collection in the pleural space. The patient collapsed and died soon after insertion of a chest drain intended to relieve the pneumothorax. Autopsy revealed an adhesion between the visceral lung pleura and the aortic aneurysm through which the dissection had penetrated the lung parenchyma. The parenchymal haematoma had subsequently “spouted out” from a 20 mm tear on the pleura, giving rise to haemothorax(2). The sequence of events might have been similar, in some respects, to the sequence of events in a 79 year old man who experienced a haemopneumothorax which was, however, much less striking in its severity(5). In the latter case there was no haemodynamic compromise. The patient had initially complained of “spitting” blood, without concurrent chest pain, back pain or breathlessness. Chest radiography revealed an abnormal air-fluid level in middle lung field on the right side. Subsequent contrast-enhanced tomography revealed Type B aortic dissection, a pneumothorax adjacent to the dissection(pre...

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  The differential diagnosis of pneumothorax with haemodynamic compromise(1) ought to include the two subtypes of tension pneumothorax associated with dissecting aneurysm of the aorta(DAA), namely, tension pneumothorax with concurrent haemothorax(2), and tension pneumothorax without concurrent haemothorax(3)(4).
  In the report of DAA-related haemopneumothorax(2), antemortem chest radiography clearly documented the presence of tension pneumothorax without concurrent fluid collection in the pleural space. The patient collapsed and died soon after insertion of a chest drain intended to relieve the pneumothorax. Autopsy revealed an adhesion between the visceral lung pleura and the aortic aneurysm through which the dissection had penetrated the lung parenchyma. The parenchymal haematoma had subsequently “spouted out” from a 20 mm tear on the pleura, giving rise to haemothorax(2). The sequence of events might have been similar, in some respects, to the sequence of events in a 79 year old man who experienced a haemopneumothorax which was, however, much less striking in its severity(5). In the latter case there was no haemodynamic compromise. The patient had initially complained of “spitting” blood, without concurrent chest pain, back pain or breathlessness. Chest radiography revealed an abnormal air-fluid level in middle lung field on the right side. Subsequent contrast-enhanced tomography revealed Type B aortic dissection, a pneumothorax adjacent to the dissection(presumably attributable to aorto bronchial fistula), and concurrent pooling of blood in the thoracic cavity. He subsequently experienced massive haemoptysis, and collapsed and died. Autopsy revealed a ruptured aortic dissection and a pleural fissure which was tightly adherent to the aortic wall(5). In the two patients in whom pneumothorax was not associated with haemothorax(3)(4) the initiating event was believed to be rupture of a bulla. The subsequent accumulation of air in the pleural space was believed to have triggered the occurrence of aortic dissection in the context of pre-existing aortic aneurysm(3).

  I have no funding and no conflict of interest

  References
  (1)Nawakami N., Aoki H., Ito M et al
  Shock after treatment of spontaneous pneumothorax
  Postgrad Med J doi.org/10.1136/postgradmedj-2019-137105
  (2)Kurosaki K., Fushimi Y., Hara S et al
  Sudden death caused by tension pneumothorax after rupture of a thoracic aortic aneurysm
  The American Journal of Forensic Medicine and Pathology 2001;22;250-252
  (3)Hifumi T., Kiriu N., Inoue J., Koido Y
  Tension pneumothorax accompanied by type A aortic dissection
  BMJ Case Reports 2012;doi:10.1136/bcr-2012-007142
  (4)Nihira T., Yamada N
  Type A aortic dissection associated with tension pneumothorax
  Am J Emerg Med 2019;37:1218.e1-1218.e3
  (5)Suu K., Kato T., Inoko M
  A 79 year old man with “niveau” on a chest radiograph
  BMJ case Reports 2015; doi.10.1136/bcr-2014-208423

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  Conflict of Interest:
  None declared.

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