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[Iatrogenic hemothorax and unknown spontaneous rupture of the oesophagus, double dramatic disease].

Iatrogenic haemothorax is a dramatic event and generally lethal if not treated appropriately and rapidly. Any thoracic co-morbidity increases the risk of death. Spontaneous rupture of the oesophagus is an equally lethal illness if not treated. We report a case of left haemothorax after a thoracic drain for spontaneous pneumothorax with ipsilateral effusion in a 77-year old male. The patient was operated on 6 hours after admission to hospital. We found a laceration of the left common carotid and an unsuspected rupture of the supradiaphragmatic oesophagus. Repair of the lesions in a single session led to no further complications. The patient was discharged in good condition. We know of only one case in the literature with Boerhaave's syndrome not treated surgically, whereas all the other cases had a negative outcome if surgery was not performed promptly. The non-specific symptoms in our case delayed the correct diagnosis of the spontaneous rupture of the oesophagus. The mortality rate is 31% in the literature even when there is an early diagnosis with well performed surgical reapair. A rapid decision as to the best surgical tactics and sending these patients to referral centres specialising in oesophageal disease are the keys to achieving good results.

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PubMed1996

[Pulmonary toxicity of drugs and thoracic irradiation in children].

The pathology of drug-induced pulmonary toxicity in children is poorly understood and probably under-estimated, in the absence of any prospective studies evaluating in a systematic fashion the side effect of medication on the respiratory apparatus. The pulmonary toxicity of thoracic irradiation has markedly receded with more restricted indications for this sort of treatment. Three clinical patterns are most commonly encountered in drug induced lung disease in children: interstitial lung disease, hypersensitivity lung disease and non-cardiogenic pulmonary oedema. The diagnosis is a diagnosis of exclusion and rests on a group of clinical arguments and also on the progress of the disease. Broncho-alveolar lavage rules out infectious disease. Respiratory function tests show non-specific anomalies. A lung biopsy may be indicated. The mechanism of the pulmonary toxicity are associated with disequilibrium of the oxidant/antioxidant and protease/antiprotease system as well as disturbance of the immune response or alteration of the pulmonary matrix by disease of the collagen system. Increased toxicity may be seen in children because of a very significant cumulative dose. The cytotoxic drugs which are most often implicated in causing this are bleomycin, methotrexate, cyclophosphamide and busulfan. Other drugs which are responsible for toxic lung disease are nitrofurantoin, sulfasalazine, D-penicillamine, betalactams, Diphenyl-hydantoin and carbamazepine. Acute post-radiation lung disease is rare. Post-radiation fibrosis is found six months after irradiation and hinders thoraco-pulmonary growth in the child. It is important to assess lung function in all children before any chemotherapy or thoracic irradiation. Cytotoxic drugs are the most common cause of toxic lung disease. This iatrogenic disease requires a multi-discipline approach to ensure the quality of care for these children.

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