Case Report: Spontaneous lung intercostal hernia series and literature review

Abstract

Spontaneous lung intercostal hernia (SLIH) is a rare condition potentially carrying severe morbidity. About 120 cases have been described so far, with an apparently increasing number of reports in recent years. The main presenting findings are chest pain and bulging, with ecchymosis in the affected area, hemoptysis, respiratory distress, and signs of infection or incarceration being described as well. The gold standard treatment has not been established, and conservative management has been advocated as first-line treatment for asymptomatic patients. Here, we report a case series of five patients, and surgical repair was deemed necessary for four of them either at first evaluation or after failure of conservative management. One patient remains under surveillance and conservative management. We believe that SLIH surgical repair should be considered as first-line treatment for fit patients, due to the uncertainty of its mid- and long-term impact and described pejorative trend/defect enlargement. A proposed algorithm for SLIH management is also presented.

Keywords: 12 Spontaneous; Cough; Fracture; Hernia; Lung; Pleura; Rupture; Spontaneous.

Figure 1

67-year-old man of BMI 42.5 who failed SLIH conservative management: the diagnostic and follow-up radiological pathway is shown. At first presentation, a chest x-ray (A) and CT abdomen were done to investigate for abdominal and lumbar pain: the defect was not evident at the x-ray and not described on the CT report (though being visible at the scan images). A large known hiatus hernia was reported at CT containing almost the entire stomach (with no signs of obstruction/strangulation) and the midportion of the body of pancreas. The patient presented again after 8 days with a second episode of acute pain and was admitted in the hospital: a new chest x-ray and CTPA (B) recorded an atelectasis of the lingula and suspicion for infection/aspiration. The herniation of the right lower lobe was still not visible at the x-ray, but it was characterized at the CTPA (B) and addressed as the possible cause of pain in the report. At repeat radiological evaluation for the new onset of shortness of breath 3 weeks after first presentation, the herniation of the right lower lobe was partially visible at the x-ray (C). The CTPA described an acute fracture of the right lateral eighth rib with associated lung contusion and atelectasis and small focal anterior right pneumothorax (D).

Figure 2

36-year-old man, BMI 40.3, with a left SLIH presenting with extensive bruising, abdominal pain, and shortness of breath. (A) chest x-ray at presentation showed an subcutaneous emphysema within the left axillary region and supraclavicular fossa. (B) CTPA revealed a moderate left pneumothorax without tension, a left abdominal wall and neck subcutaneous emphysema, left effusion, and a displaced fracture of the left lateral 8th rib. Lung herniation was not reported; however, on a retrospective review, a small left-sided lung hernia could be identified. (C) A CT scan revealed a herniation of a small lingula portion, abdominal fat, and lateral aspect of the diaphragm, and old rib fractures of the 6th lateral rib, 7th non-united lateral rib with a 15-mm gap, and 8th posterior rib with callus formation with displacement of the anterior portion of the eighth rib more anteriorly with a wide separation of the distracted fragments.

Figure 3

Algorithm proposal for spontaneous intercostal hernia management.