The Journal of Emergency Medicine, Vol. 48, No. 1, pp. 77–78, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.09.003

Visual Diagnosis in Emergency Medicine

DELAYED HEMOTHORAX CAUSED BY THYMIC BLEEDING AFTER BLUNT CHEST TRAUMA Hsiao-Chia Wang, MD,*† Wei-Lung Chen, MD, PHD,*† Chung-Tai Yao, MD,*†‡ and Jiann-Hwa Chen, MD, MPH*† *Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan, †School of Medicine, Fu Jen Catholic University, Taipei, Taiwan, and ‡Division of Trauma, Department of Surgery, Cathay General Hospital, Taipei, Taiwan Reprint Address: Jiann-Hwa Chen, MD, MPH, Department of Emergency Medicine, Cathay General Hospital, No. 280 Sec 4, Jen-Ai Road, Taipei, Taiwan

pnea, tachycardia, and impending shock. The repeat chest x-ray revealed right pleural effusion that was not seen in the earlier chest x-ray (Figure 1). A tubal thoracostomy was performed, and 1200 mL fresh blood drained instantly. Under the impression of massive hemothorax, an emergency thoracotomy was done. The intraoperative finding was a ruptured thymus with massive bleeding. We performed a total thymectomy, and the pathology of the thymus showed Langerhans cell histiocytosis. He was discharged 7 days later with the prognosis for a good recovery.

INTRODUCTION Hemothorax is a blood accumulation in the pleural cavity. Symptoms can include anxiety; chest pain; low blood pressure; pale, cool, and clammy skin; rapid heart rate; rapid shallow breathing; restlessness; and shortness of breath. The most common cause of hemothorax is chest trauma. Here we present a case of delayed massive right hemothorax caused by thymic bleeding after blunt chest trauma. CASE REPORT

DISCUSSION A 26-year-old man visited our emergency department (ED) with chest pain after being struck by his brother’s fist over the anterior chest wall 2 days before. On arrival, his vital signs were stable without hypotension or dysrhythmia. He did not complain of dyspnea or referred pain. Our physical examination showed local tenderness over the right 5th and 6th rib area. The chest x-ray showed a suspicious bulky mass over the right mediastinum (Figure 1). Electrocardiography revealed normal sinus rhythm without ischemic change. After a short period of observation, he was discharged in stable condition with oral analgesics. Unfortunately, the patient returned to our ED 12 h later with new-onset symptoms of dys-

This is the first report of hemothorax as the manifestation of traumatic thymic bleeding. A literature search performed revealed only a few cases of traumatic thymic bleeding and most of the cases were children. The common manifestation on the chest x-ray is widening of the mediastinum or a mediastinal mass (1–3). The initial chest x-ray of this patient had only shown a suspicious mediastinal lesion. However, the second chest x-ray revealed hemothorax, which was a late sign of massive thymic bleeding. Traumatic hemothorax is an emergency disease in the ED. It most commonly occurs from blunt chest trauma,

RECEIVED: 6 September 2012; FINAL SUBMISSION RECEIVED: 11 February 2014; ACCEPTED: 2 September 2014 77

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Figure 1. Chest x-ray showed a bulky mass (arrow) over the right mediastinum after chest trauma (left). Massive hemothorax was found when he revisited the emergency department 12 h later (right).

such as rib fractures, but also occurs when the lung parenchyma blood vessels are torn, the intercostal arteries and veins are injured, or there is damage to the heart and great vessels (4,5). Underlying thoracic tumors, coagulopathy, or arteriovenous malformations are predisposing factors (6). The pathological change in this patient’s thymus had predisposed it to traumatic bleeding. Langerhans cell histiocytosis is a neoplastic proliferation of Langerhans cells that occurs in a range of nodal and extranodal sites. It is rarely seen as an isolated lesion of the thymus. In most cases, Langerhans cell histiocytosis presents in older children and adults as a unifocal disease that typically affects bone, and is less commonly found in the skin, lungs, or lymph nodes (7). CONCLUSIONS Blunt chest trauma is seen commonly in the ED, and most physicians pay attention to whether there is pneumothorax, hemothorax, or fractured ribs. If adult patients

present with blunt chest trauma accompanied by mediastinal widening on the chest x-ray, then thymic bleeding should be one of the differential diagnoses.

REFERENCES 1. Gschwentner M, Gruber G, Oberladsta¨tter J, et al. Mediastinal widening after blunt chest trauma in a child: a very rare case of thymic bleeding in a child and possible differential diagnosis. J Trauma 2007;63:E51–4. 2. Takahashi Y, Toyoda Y, Okada Y. Thymic intracapsular hematoma caused by blunt chest trauma. Ann Thorac Surg 2003;76:2107. 3. Breckler IA. Hemorrhage into thymic tumors: produced by rapid deceleration and trauma. Dis Chest 1957;31:705–8. 4. Meyer DM. Hemothorax related to trauma. Thorac Surg Clin 2007; 17:47–55. 5. Shorr RM, Crittenden M, Indeck M, et al. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987;206:200–5. 6. Ali HA, Lippmann M, Mundathaje U, et al. Spontaneous hemothorax: a comprehensive review. Chest 2008;134:1056–65. 7. Lee BH, George S, Kutok JL. Langerhans cell histiocytosis involving the thymus. A case report and review of the literature. Arch Pathol Lab Med 2003;127:e294–7.

Delayed hemothorax caused by thymic bleeding after blunt chest trauma.

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