Massive hemoptysis and hemothorax caused by pleuropulmonary angiosarcoma.
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The haematothorax not induced by a trauma is very uncommon in childhood. Its presence may be the leading symptom of a malignant tumour that needs further investigation, but a correct diagnosis cannot always be made before thoracotomy. We report on 3 cases which had been operated on for suspected malignant disease, but in 1 case we found a diaphragmatic hernia, in another one an extralobal sequestration of the lung and only in the third patient a malignant teratoma. The diagnostic and therapeutic procedure of a spontaneous haemothorax is discussed.
A 65-year-old woman with dermatomyositis for which she had been treated for ten years with prednisone (latterly 15 mg daily) suddenly experienced severe pain in the left thoracolumbar region. Cardiovascular, pulmonary and vertebral causes of the pain were excluded. But serological tests indicated inflammatory disease and the haemoglobin concentration was low (10.4 g/dl). Left pleural effusions were repeatedly aspirated and some haemorrhagic fluid obtained (haematocrit 0.31 in blood, 0.28 in the pleural effusion). Five days after admission her cardiovascular status became unstable and she developed respiratory failure (haemoglobin 7.6 g/dl). Chest radiograph showed increased pleural effusion. Subsequent thoracotomy revealed a left coagulothorax which was removed and flushed. During this procedure severe bleeding occurred from a covered perforation of the descending aorta, 1.5 x 1.5 cm in size. Although the aortic wall was thin, there was no aneurysm but arteriosclerotic changes and an external erosion near an abscessing mediastinitis, originating from a chronic purulent pleuritis and bronchopneumonia. The severe blood loss caused circulatory failure from which the patient could not be resuscitated.
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In a group of seven patients with percutaneous subclavian catheters in the pleural space, three were found to have continued blood loss from the catheter tip, and in four patients thoracotomy was prevented by discontinuing blood administration through the subclavian catheter during a re-evaluation phase.
Penetrating wounds to the anterior chest wall are associated with injury to the heart and great vessels. If injury to these structures is suspected, early surgical intervention is indicated. The internal mammary artery also can be involved in penetrating trauma and can present a clinical situation similar to heart injury, as in the case reported.
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