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Persistent cough, chest pain, and dyspnea in a young man Waqas Shuaib, MD; Hira Shahzad, MD; Ateeq Rehman, MD; Richard Alweis, MD; Edward A. Stettner, MD; Michelle D. Lall, MD; Faisal Khosa, MD

CASE A 20-year-old man presented to the ED with a 2-week history of mild chest pain and dyspnea that usually worsened after running or weight lifting. At this visit, he complained of increased sharp chest pain (6 on a 0-to-10 pain intensity rating scale), persistent cough without any evidence of blood or sputum, and mild shortness of breath. Apart from allergic rhinitis, the patient had no past medical or surgical history. His family history was positive for asthma and diabetes in his father. A physical examination revealed normal oxygen saturation and decreased breath sounds on the left side. No wheezes or crackles were detected. An upright posteroanterior chest radiograph was obtained (Figure 1). Which of the following is the most likely diagnosis? • Pneumothorax • Pneumocystis jiroveci pneumonia (PCP) • Asthma • Chronic obstructive pulmonary disease (COPD) • Rib fracture DISCUSSION The patient was diagnosed with pneumothorax, based on his age, presentation, and radiograph. The patient’s young age and presentation meant malignancy or infection were unlikely. A pneumothorax can arise spontaneously, iatrogenically, or post-traumatically and can be categorized as tension or nontension. Spontaneous pneumothoraces can further At the time this article was written, Waqas Shuaib practiced at the Department of Radiology and Imaging Sciences at Emory University Hospital in Atlanta, Ga. Hira Shahzad is a research collaborator at the Medical College of Aga Khan University Hospital in Karachi, Pakistan. Ateeq Rehman is an attending physician in internal medicine at Marshfield Clinic in Marshfield, Wis. Richard Alweis is an attending physician in internal medicine at Reading Health System in West Reading, Pa. Edward A. Stettner and Michelle D. Lall are attending physicians in emergency medicine at Emory University Hospital. Faisal Khosa was an assistant professor in the Department of Emergency Radiology at Emory University Hospital when this article was written. The authors have disclosed no potential conflicts of interest, financial or otherwise. Bryan Walker, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000476221.42561.d9 Copyright © 2016 American Academy of Physician Assistants

FIGURE 1. The patient’s initial radiograph

be characterized as primary or secondary; both types can lead to tension pneumothorax without appropriate treatment. The incidence of primary spontaneous pneumothorax ranges from 7.4 to 18 people per 100,000 population annually in men, and from 1.2 to 6 people per 100,000 population annually in women. 1 Pneumothorax is most common in tall, thin males between ages 10 and 30 years. Spontaneous rupture of a subpleural bleb or bulla that leads to a pneumothorax is commonly recognized as the underlying cause; predisposing factors that contribute to development of blebs and bullae include airway inflammation, distal bronchial tree anomaly, disorders of connective tissue formation, local ischemia, and malnutrition.1 Secondary spontaneous pneumothorax usually occurs in older adults with underlying pulmonary disease, including emphysema, asthma, acute or chronic infections, and

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FIGURE 3. Coronal reformations from a CT demonstrating FIGURE 2. Radiograph of the patient’s spontaneous pneumo-

thorax, showing absence of lung marking on the left (A), complete collapse of the lung (B), and no mediastinal shift to suggest tension pneumothorax (C)

FIGURE 4. Chest radiograph of the case patient after chest

tube (A) insertion. Reexpansion edema appears as opacity (B) in the left lung. 48

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tension pneumothorax, showing mediastinal and tracheal deviation away from the collapsed lung (A) and a depressed left hemidiaphragm (B)

lung cancer; as a sequela of congenital diseases including cystic fibrosis; or in patients with lymphangioleiomyomatosis.2,3 Catamenial pneumothorax, which is rare, is pneumothorax associated with menstruation and endometriosis.2,3 Iatrogenic pneumothorax can be caused by medical procedures, such as central venous access placement or thoracentesis. Primary spontaneous pneumothorax usually occurs at rest, and patients present with acute onset of local pleuritic chest pain accompanied by shortness of breath. This pain may be mild or severe, sharp and steady in nature, and often resolves within 24 hours although the pneumothorax still exists. On physical examination, the patient will have decreased breath sounds on auscultation, decreased chest wall movement on inspection, tympany on percussion, and reduced tactile fremitus on palpation of the chest. Consider the diagnosis of tension pneumothorax if the patient has severe tachycardia, cold sweating, hypotension, and cyanosis. Additional physical findings suggesting tension pneumothorax include tracheal deviation and jugular venous distension. TREATMENT In patients who are hemodynamically unstable with suspected tension pneumothorax, immediate treatment with either emergent needle or tube thoracostomy is indicated before obtaining radiographs, as delays in treatment can increase morbidity and mortality. In stable Volume 29 • Number 2 • February 2016

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Persistent cough, chest pain, and dyspnea in a young man

patients, an upright chest radiograph is the best initial diagnostic imaging test.4 Figures 2 and 3 describe important features of spontaneous and tension pneumothoraces. More recently, bedside emergency ultrasonography has been shown to be an excellent rapid modality for the detection of pneumothorax, with multiple studies demonstrating better sensitivity when compared with upright chest radiograph.5 Failing to insert a chest tube or performing needle decompression in a patient with a tension pneumothorax can lead to rapid clinical deterioration and cardiac arrest. However, medical professionals differ on the medical management of spontaneous pneumothorax and feel that the risk stratification framework should determine therapy.6 Large pneumothoraces are defined as greater than 20% of the hemithoracic volume and are almost always treated with tube or pigtail catheter thoracostomy. Pneumothoraces smaller than 20% can sometimes be treated conservatively with supplemental oxygen or aspiration followed by repeat radiography to demonstrate resolution. Additional therapeutic options include vacuum-assisted thoracostomy with pleurodesis and/or closure of leaks,

bullectomy, and open surgical procedures, but these are determined on a case-by-case basis. Reexpansion pulmonary edema (Figure 4) is an uncommon complication of pneumothorax treatment leading to unilateral noncardiogenic pulmonary edema, and should be treated with supplementary oxygen and/or ventilation.1-3 JAAPA REFERENCES 1. Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008;76(2):121-127. 2. Luh SP, Tsai TP, Chou MC, et al. Video-assisted thoracic surgery for spontaneous pneumothorax: outcome of 189 cases. Int Surg. 2004;89(4):185-189. 3. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-874. 4. Sharma A, Jindal P. Principles of diagnosis and management of traumatic pneumothorax. J Emerg Trauma Shock. 2008;1(1): 34-41. 5. Husain LF, Hagopian L, Wayman D, et al. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock. 2012;5(1): 76-81. 6. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2): 590-602.

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Persistent cough, chest pain, and dyspnea in a young man.

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