An occult iatrogenic pneumothorax as a cosmetic procedure complication

Abstract

A pneumothorax is the abnormal gas accumulation within the pleural space. We present a case of a patient with an occult iatrogenic pneumothorax who presented with symptomatic anemia that substantially improved after a transfusion, diverting the clinical suspicion. As a result, she developed acute respiratory distress, initially considered secondary to a possible pulmonary embolism vs. fat embolism. After computed tomography confirmed the diagnosis, a chest tube was inserted. This case emphasizes the importance of suspecting pneumothorax secondary to cosmetic procedures and using computed tomography as the first diagnostic tool in complex cases since chest x-rays can miss pneumothorax.

Iatrogenic pneumothorax results from invasive therapeutic and diagnostic procedures, whereas occult pneumothorax is diagnosed using computed tomography (CT) without other radiological (chest x-ray) or clinical evidence.^1,2 Depending on the causal procedure, the incidence of iatrogenic pneumothorax ranges from 0.05% to 6.66%.² Although pneumothorax is rarely considered a complication of cosmetic procedures, it is thought to be considerably more common than previously reported.^3–5 We present a case of an occult iatrogenic pneumothorax incidentally seen by CT pulmonary angiography while ruling out pulmonary embolism vs. fat embolism.

CASE PRESENTATION

A 36-year-old woman presented to the emergency room with tachycardia, tachypnea, and increased serosanguineous output from an abdominal surgical drain. One day earlier, the patient had been discharged after a smooth recovery from an uncomplicated elective bilateral augmentation mammoplasty with implants and abdominoplasty with liposuction. On admission, her heart rate was 155 beats/min; respiratory rate, 22 breaths/min; and oxygen saturation, 96% on room air. She was dehydrated, with intercostal retractions. Her cardiopulmonary auscultation was normal, thoracic resonance was normal during percussion, and there was no asymmetry between her hemithoraces. Initial blood workup revealed normocytic normochromic anemia (hemoglobin 8.1 g/dL), and arterial blood gas evidenced respiratory alkalosis with mild hypoxemia.

An abdominal ultrasound was deferred since the continuous surgical drain output was considered acceptable. A complete blood count evidenced a drop in hemoglobin levels (7.0 g/dL), for which she received three units of packed red blood cells. A repeat test 15 minutes after the transfusion revealed improved hemoglobin levels (10 g/dL). Her vital signs returned to normal, she mentioned feeling better, she no longer was tachycardic (80 beats/min), and the surgical drain output significantly diminished. It was suspected that the anemia caused her symptoms.

The next day, the patient presented with sudden-onset dyspnea, tachycardia, and mild mesogastric tenderness without peritoneal irritation. A chest x-ray showed bibasal alveolar-reticular infiltrates and right basal atelectasis (Figure 1a). Her oxygen saturation was 91%, and an arterial blood gas showed respiratory alkalosis with moderate hypoxemia on a 32% fraction of inspired oxygen (partial pressure of oxygen in the arterial blood, 56 mm Hg; ratio of arterial oxygen partial pressure to fractional inspired oxygen, 175); the D-dimer was 1167 ng/mL. The patient was immediately transferred to the intensive care unit. Pulmonary embolism protocol CT angiography showed a left-sided 35% pneumothorax, with no evidence of pulmonary embolism or fat embolism (Figure 1b). An abdominal ultrasound was normal. A left-sided chest tube was inserted, and the marked hypoxemia and acute respiratory failure resolved. After 48 hours, chest CT showed small residual pneumothorax with complete left lung reexpansion. The thoracostomy tube was removed, and the patient was discharged.

Figure 1.

(a) Chest x-ray evidencing bibasal alveolar-reticular infiltrates and right basal atelectasis. (b) CT with pulmonary embolism protocol evidencing a left-sided 35% pneumothorax, left basal atelectasis, and a left pleural effusion.

DISCUSSION

Patients with pneumothorax may experience various symptoms, including tachypnea, chest pain, and dyspnea. Dyspnea can have out-of-proportion severity compared with the size of pneumothorax; nonetheless, the most prevalent yet nonspecific finding is tachycardia.⁶ Initially, pneumothorax was missed because our patient also had hemodynamic repercussions and symptoms from the secondary anemia that resolved after the blood transfusion, along with hypoxemia.

Mechanical ventilation can also cause pneumothorax; however, it is usually diagnosed while the patient is still being ventilated and is rarely found in patients with normal lungs, making it an unlikely cause of our iatrogenic pneumothorax.⁶

Iatrogenic pneumothorax secondary to liposuction is rare. A single-center retrospective chart review reported an incidence of 0.0432%.⁷ Most incidence reports were based on case reports and case series; nevertheless, all the cases reported in the single-center study presented with oxygen saturation deterioration during the procedure,⁷ a phenomenon not observed in our case. A pleural lesion secondary to pectoralis major muscle dissection is a proposed cause of iatrogenic pneumothorax during breast augmentation.³ This likely caused our iatrogenic pneumothorax after ruling out less likely causes. Since our patient presented in acute respiratory distress and the iatrogenic pneumothorax size was significant, a chest tube was placed.

Clinical suspicion and chest x-rays remain the initial diagnostic tools for pneumothorax; nevertheless, chest ultrasound is faster to perform and has a higher pooled sensitivity than chest x-rays, 87% vs. 46%, respectively, making it an alternative in critical care and unstable patients. However, it has lower pooled specificity than the chest x-rays, at 99% vs. 100%, respectively.⁸ A chest ultrasound was not considered in our case since the pneumothorax presented as an incidental finding. Chest CT remains the gold standard for diagnosing pneumothorax. We consider it the initial diagnostic tool for complicated cases, because, as demonstrated, chest x-rays can miss pneumothorax, increasing associated morbidity and mortality. We believe that the atypical presentation of this iatrogenic pneumothorax makes our case unique and encourages other authors to report complications associated with cosmetic procedures.