Post-traumatic pulmonary pseudocsyt

Manuscript type : Case Report | Article Date : 2015/02/20

  • Autors

    1. Tugrul Zeytin Ahmet
    2. Suat Patlakoglu Mehmet
    3. Seyit Murat
    4. Kaya Seyhmus
  • Abstract

    Traumatic pulmonary pseudocysts are rare cavitary lesions of the lungs that develop after chest trauma. The lesions often occur in young adults and males. Other cavitary lesions of the lungs must be taken into consideration when distinguishing the diagnosis, and it must be kept in mind that computerized tomography is more effective than chest radiography in the diagnosis of traumatic pulmonary pseudocysts. Conservative therapy is recommended in its treatment. The current report presents an 18-year-old patient who was admitted to emergency department and then thoracic surgery clinic, after sustaining a motor vehicle accident and discharged as a healthy person. .
  • Description

    INTRODUCTION

    Injuries to the lung parenchyma after blunt trauma to the chest often result in lung contusion or hematoma. The cavitary lesions of the lungs and pseudocysts rarely occur in association with lung trauma. These lesions mostly occur in young adults and childre.1 Traumatic pulmonary pseudocysts (TPP) generally do not require specific surgical therapy and can be treated by conservative therapies.2 The current report presents a young adult patient who sustained a traffic accident.

    CASE REPORT

    An 18-year-old male patient was admitted to the emergency department after having sustained a traffic accident. The patient was intubated upon admission. The following values were reported: BP: 100/60 mmHg, PR: 115/min, sPO2: 84%. On physical examination, Glasgow coma scale score was 8 (E2M5V1); there was tenderness on palpation on both hemithoraces, lung sounds on the left side were diminished on auscultation; and there were bilateral crackles which were more prominent on the right side. Other systems were normal with the exception of skin abrasions on the scalp and the left femur. Computerized tomography (CT) revealed bilateral pneumothorax, which was more prominent on the left side, lung contusion, and bilateral cavitary lesions particularly on the right side Figure 1 (Fig. 1). A thoracic surgeon was consulted. The patient then underwent bilateral tube thoracostomy. The cavitary lesions observed on CT were regarded as traumatic pulmonary pseudocyst (TPP) due to the presence of multiple cysts and the detection of post-trauma lesions. The patient did not have any other conditions that would necessitate emergency intervention and the patient was moved to the intensive care unit of the department of thoracic surgery for further follow-up and treatment. No additional surgical processes were performed during the follow-up of the patient, and he was discharged from the hospital after 13 days of stay in the intensive care unit and eight days of hospitalization in the regular ward. CT scans obtained at the time of discharge showed complete resolution of the pseudocysts Figure 2 (Fig. 2).
    Figure 1 Computerized tomography views at the arrival to the emergency department.
    Figure 2 Computerized tomography view at the discharge from thoracic surgery department.

    DISCUSSION

    Traumatic pulmonary pseudocyst is a cavitary lesion that can occur after thorax trauma. These lesions mostly occur after blunt trauma; however, there are rare reports of cases associated with penetrating trauma.3 TPP accounts for 2.9% of all parenchymal injuries of the lungs, and males younger than 30 years of age comprise the majority of the affected patients.4 This can be explained by higher exposure to high energy traumas in males such as motor vehicle accidents or a falls from a height. Various mechanisms have been proposed for the development of TPP after thorax trauma. Bursts in the peripheral airways and ruptures of the alveolar walls by trapped air due to a sudden increase in the pressure as a result of trauma are among the possible mechanisms, and propagation of shock waves throughout the lung parenchyma may also result in parenchymal tears.5 The chest wall is more elastic and flaccid in young adults, and this allows the transmission of higher kinetic energy to the lung parenchyma, which explains higher incidence of TPP in the young age group.6, 7 The current case was also a young male, consistent with these reports. Patients with TPP may be asymptomatic, but may also exhibit such symptoms as coughing and hemoptysis. These symptoms are associated not only with TPP, but also with injuries to the pulmonary parenchyma[4]. Traumatic pulmonary pseudocysts have thins walls filled completely with air, but air-fluid level can also be seen. These lesions are often located in the center or the region of pulmonary contusions. The diagnosis of TPP is established by radiologic imaging. Chest radiographs can detect these lesions; however, computerized tomography (CT) is a more effective and a more sensitive technique.4, 6 In one study, the diagnosis of TPP could not be made on the first day of trauma in all 100 patients, but CT detected these lesions[8]. Furthermore, CT allows the detection of other accompanying traumatic conditions.6 TPP must be considered in patients who have cavitary lesions through CT scans obtained after thorax trauma. The lesions can occur in the first hours or in some cases, days following trauma. Bullas, esophageal rupture, discharged hematoma, drained hematoma, tuberculosis cavity, bronchial carcinoma, lung abscess, hydatid cysts, and bronchogenic cysts must be kept in mind in the differential diagnosis.2, 3 However, the diagnosis of TPP is not difficult. Trauma history and the radiological regression of the lesions during follow-up are findings suggesting TPP. Other pathological conditions can be evaluated in the case of non-regressing lesions.3-5 Traumatic pulmonary pseudocysts are treated conservatively. Resolution of the lesion can be seen after six weeks; however, surgery can be required in certain circumstances. Progressively-enlarging and infected lesions, abscessed cysts, and cysts that are associated with hemorrhage or rupture into the pleural cavity can require surgical intervention.1, 7 The mean time for spontaneous radiologic resolution has been reported to be three months in TPPs.4 The mean time for complicated cysts or those filled with blood was reported as 17 weeks.2 In the current case, surgical intervention was not required during the patient’s stay in the intensive care unit after bilateral insertion of the thorax tube upon admission to the emergency department, and the patient was discharged from the hospital 20 days later.

    CONCLUSION

    Traumatic pulmonary pseudocysts are rare complications occurring after blunt thorax trauma. TPPs filled with air, fluid, or blood in the lung parenchyma frequently occur in children and young adults due to their hyperflexible chest wall. Although most TPPs show spontaneous resolution with supportive therapy, rarely, patients develop various clinical conditions during their follow-up that may require surgical intervention. Chest radiographs may fail to identify these lesions. Computerized tomography is a more efficient technique in diagnosis, and thoracic computerized tomography scans must be obtained in patients with blunt chest trauma.

  • Reference

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