Hemothorax and incidental lymphoma in a multitrauma patient
This patient was brought in by ambulance after being involved in a motor vehicle accident. He had a CT trauma series performed which showed multiple traumatic findings.
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- There is a large retroperitoneal soft tissue density mass, (74 x 86 x 112 mm) extending from the level of the infrahepatic IVC to the bifurcation with associated para-aortic subcentimeter adenopathy, compatible with lymphoma. Associated prominent mediastinal adenopathy in the superior mediastinum, prevascular and subcarinal region.
- Large right hemothorax with associated basal atelectasis.
- Undisplaced fractures of the left anterolateral ribs seven and eight.
1 case question available
In this case, the large retroperitoneal soft tissue mass was mistaken for a post traumatic hemorrhage initially. It is a good learning point to demonstrate the differential diagnoses of hemorrhage in a traumatic context.
The features of this mass suggesting that it is solid versus liquid include:
- well demarcated border
- homogoenous hypodensity of the mass
This gentleman also has a traumatic hemothorax. Traumatic hemothorax is a common finding in both blunt and penetrating trauma. This is because chest trauma is found in up to 60% of trauma cases 1.
Chest tube insertion for drainage of the hemothorax is the mainstay of management. That being said, insertion of chest tubes has a high complication rate, with figures of 21-30% quoted in the literature 4. In patients who have excessive blood loss (1500 ml in 24 hours or 200 ml per hour for successive hours), surgical exploration is indicated 2. This can be with video-assisted thorascopic surgery (VATS) in haemodynamically stable patients, or thoracotomy in unstable patients.
After initial management, certain patients will have persistent thoracic clot loculation. If these clots are greater than 500 ml in volume or account for over 1/3 of the hemithoracic volume, surgical intervention is required, either VATS or thoracotomy 3.
In this case, the coronal views show considerable homogenous hypoattenuating fluid in the right posterior hemithoracic region, with some active extravasation of hyperattenuating contrast via the pulmonary arteries.
Case contributed by A/Prof. Pramit Phal.
- 1. Ali HA, Lippmann M, Mundathaje U et-al. Spontaneous hemothorax: a comprehensive review. Chest. 01;134 (5): 1056-65. doi:10.1378/chest.08-0725 - Pubmed citation
- 2. Maxwell RA, Campbell DJ, Fabian TC et-al. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia-a multi-center trial. J Trauma. 2005;57 (4): 742-8. Pubmed citation
- 3. Meyer DM, Jessen ME, Wait MA et-al. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann. Thorac. Surg. 1997;64 (5): 1396-400. doi:10.1016/S0003-4975(97)00899-0 - Pubmed citation
- 4. Etoch SW, Bar-Natan MF, Miller FB et-al. Tube thoracostomy. Factors related to complications. Arch Surg. 1995;130 (5): 521-5. Pubmed citation