Mohammed Afraz Pasha, MD,
Internal Medicine Resident
North Alabama Medical Center
Florence, Alabama
Disclosure information not submitted.
Sangeetha Isaac, MD
North Alabama Medical Center
Florence, Alabama
Disclosure information not submitted.
Syed Muzzammiluddin, MD
Internal Medicine Resident
North Alabama Medical Center, United States
Disclosure information not submitted.
Kavitha Juvvala, MD
Internal medicine resident
n/a, United States
Disclosure information not submitted.
Priyanka Kapoor, Resident Physician Internal Medicine PGY 3
MD
North Alabama Medical Center, United States
Disclosure information not submitted.
Utibe Ndebbio, Resident Physician Internal Medicine PGY 3
MD
North Alabama Medical Center, United States
Disclosure information not submitted.
Saquib Anjum, MD
Associate Program Director
North Alabama Medical Center, United States
Disclosure information not submitted.
Title: Secondary Spontaneous Pneumothorax Associated With Pulmonary Embolism
Introduction: Secondary Spontaneous Pneumothorax is a life-threatening condition occurring in patients aged above 55 years, secondary to underlying pulmonary pathology. Pulmonary embolism is complicated by pulmonary infarction in about 10% of cases, with resultant cavitary lesions occurring in 4-7% cases of pulmonary infarctions. The average reported interval between pulmonary embolism and associated pneumothorax is 1-7 weeks. The association between pulmonary embolism related pulmonary infarction, lung cavity and secondary spontaneous pneumothorax is rare and poorly understood. We present a case of secondary spontaneous pneumothorax occurring in the setting of pulmonary embolism.
Description: A 28-year-old type 1 diabetic patient presented to ER in a lethargic state. She was found to be in diabetic ketoacidosis(DKA) secondary to insulin non-compliance. She was admitted to the ICU and was managed with intravenous insulin, fluids and electrolyte replacement. On day 3, she developed fever with acute hypoxic respiratory failure. Chest x ray demonstrated bilateral lung infiltrates prompting initiation of oxygen support and antibiotics. CT pulmonary angiography done in view of persistent tachycardia and hypoxia revealed bilateral pulmonary emboli(PE). There was no right ventricular strain noted on echocardiogram. Therapeutic anticoagulation with apixaban was initiated and DVT scan of limbs showed right axillary vein DVT, without any evidence of lower limb DVT. Serial chest x rays showed subsequent development of right sided lung cavity. Patient remained tachycardic and hypoxic requiring oxygen support. 2 weeks post development of PE, she had a cardiac arrest secondary to right sided tension pneumothorax. She was resuscitated successfully, mechanically ventilated and chest tube was placed. Following eventful hospital course, she was discharged on oral anticoagulation after removal of chest tube.
Discussion: This occurrence of pneumothorax two weeks after the diagnosis of pulmonary embolism highlights the rare association between pneumothorax and PE. This association can be explained by rupture of pulmonary infarct at the pleural surface leading to air entry into the pleural space. Additionally, infection of the infarcted lung can lead to necrosis and resultant breach in the pleural surface resulting in pneumothorax.