Traumatic pulmonary pseudocyst is a rare complication of chest trauma that has been poorly documented and usually resolves without specific treatment. Here, we present a case of pulmonary pseudocyst in a child with chest trauma without obvious symptoms. It is important to consider this diagnosis in patients with chest trauma to avoid unnecessary invasive procedures

Ahmadi, Mitra

Askarzadeh, Mohammad Hossein

Ghafourian, Nasim

Jalili, Fatemeh

Mahdizadeh, Fatemeh

Zavareh, Mina

English

Nasim Ghafourian

Fatemeh Mahdizadeh

Mina Zavareh

Mitra Ahmadi

Mohammad Hossein Askarzadeh

Fatemeh Jalili

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Emergency. 2018; 6 (1): e29CASE REPORTPost-Traumatic Pulmonary Pseudocyst following BluntChest Trauma; a Case ReportNasim Ghafourian1, Fatemeh Mahdizadeh1∗, Mina Zavareh2, Mitra Ahmadi2, Mohammad HosseinAskarzadeh3, Fatemeh Jalili41. Department of Emergency Medicine, Imam Khomeini Hospital, Ilam University of Medical Sciences, Ilam, Iran.2. Department of Emergency Medicine, Pastornou Hospital, Tehran, Iran.3. Department of Emergency Medicine, Afshar Educational Hospital, Yazd University of Medical Sciences, Yazd, Iran.4. Department of Emergency Medicine, Hasheminejad Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.Received: April 2018; Accepted: May 2018; Published online: 1 May 2018Abstract: Traumatic pulmonary pseudocyst is a rare complication of chest trauma that has been poorly documented andusually resolves without specific treatment. Here, we present a case of pulmonary pseudocyst in a child withchest trauma without obvious symptoms. It is important to consider this diagnosis in patients with chest traumato avoid unnecessary invasive procedures.Keywords: Thoracic injuries; contusions; wounds, nonpenetrating; Chest trauma; pulmonary pseudocyst; pulmonary con-tusion© Copyright (2018) Shahid Beheshti University of Medical SciencesCite this article as: Ghafourian N, Mahdizadeh F, Zavareh M, Ahmadi M, Askarzadeh M, Jalili F. Post-Traumatic Pulmonary Pseudocyst fol-lowing Blunt Chest Trauma; a Case Report. Emergency. 2018; 6 (1): e29.1. IntroductionTraumatic pulmonary pseudocyst (TPP) is a rare complica-tion of chest trauma that has been poorly documented andrarely talked about (1, 2). It can occur at any age, but is moreoften seen in children and young adults (3-5). These patientsmay be asymptomatic with unremarkable examination find-ings (5, 6). This report presents a case of pulmonary pseudo-cyst in a child with chest trauma without obvious symptoms.2. Case reportA 16 month boy was brought to the emergency departmentwho was run over by a car. His mother explained that thechild’s chest was trapped under the rear of a reversing car.On arrival, he was uncomfortable and during examinationwas irritable. On physical examination, he was hemodynam-ically stable and well perfused but oxygen saturation was %85in room air. The physical examination was unremarkable.∗Corresponding Author: Fatemeh Mahdizadeh; Department of EmergencyMedicine, Imam Khomeini Hospital, Ilam, Iran. Tel: +989125497734 Email:mahdizadeh_fatemeh@yahoo.comThere wasn’t significant respiratory distress or any bruisingor laceration on chest wall. Chest was clear to ausculta-tion. No other abnormalities were noted in the remainderof the physical examination. The patient was in usual stateof health prior to the accident. His past history and familyhistory were normal and he was not on any medication. Hisgrowth and development were also normal.No evidence of free fluid was found in focused assessmentsonography of trauma that was performed by an emergencymedicine specialist. A chest X-ray was done in supine posi-tion in the emergency department, which was subsequentlyfollowed by computed tomography (CT) scan of the chest(figure 1). Chest radiography showed bilateral homogenousopacity. CT scan of the chest revealed bilateral parenchy-mal contusion, low-percentage pneumothorax, a rib fracture,and an oval cavity lesion with an air-fluid level in the basalsegment in lower lobe of the right lung. This sub-pleuralcavity measured 28 mm (height) and 14 mm (width) in size.There weren’t any pathologic findings in spiral brain CT scan.Total leukocyte counts were mildly raised (12900 per mm3with %64 polymorphonuclear leukocytes). No biochemicalabnormalities were revealed. There was no weight loss, lym-phadenopathy or clubbing of fingers. He had no known ex-posure to tuberculosis and no known pulmonary disease.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comN. Ghafourian et al. 2Figure 1: Anterior posterior chest radiograph (left) and axial chest computed tomography (right) at the time of admission.Figure 2: Anterior posterior chest radiograph on day 3.There was no associated cough, fever, expectoration, hemop-tysis or breathlessness, which clinically ruled out an infectiveprocess. With no evidence of underlying infection and giventhe clinical scenario, the diagnosis of TPP was made.Pulse oximetry of the patient was monitored continuously.He was treated with oxygen via inhalation (3 liters perminute) and a general surgeon was consulted. Oxygen sat-uration was %97 while receiving oxygen.The patient was moved to the intensive care unit. He was ob-served. He was comfortable with no new problem. On thethird hospital day the chest radiograph showed appreciablereduction in contusion without pneumothorax or significantcavity (figure 2). The patient remained asymptomatic dur-ing the hospital stay so he was discharged from the hospitalon the next day without any antibiotics, emergency interven-tion, and additional surgical processes, thus confirmed ourdiagnosis of TPP. Surgeon advised his mother to follow up inclinic. There was no problem after one month.3. DiscussionThe incidence of TPP has been reported as approximately 3%after blunt chest injuries and was higher in younger patientsand usually occurred following high speed motor vehicle ac-cidents or fall. It has also been reported after penetratingchest injury (6-10). In Iran, one case that presented with mul-tiple bilateral cysts has been reported (2).TPP manifestations with minor clinical and major radiolog-ical signs like the case of this study have been recorded inthe literature. Patients may be asymptomatic or associatedwith hemoptysis, cough, dyspnea, chest pain, fever and mildleukocytosis usually within the first 24 hours or up to four-teen days after injury (4-6). Physical examination findingsare unremarkable and are usually restricted to crackles on theaffected chest (5).TPPs are air-filled or fluid-filled cavities with no true epithe-lial lining and their size ranges from 2 to 14 cm in diameter (4,10). Most reported cases of TPPs have had concurrent lunginjuries such as pulmonary contusion, hematoma, hemop-neumothorax, and pneumothorax (5).Two mechanisms have been suggested for TPP formation:compression and decompression result in barotraumas andruptured parenchyma. Retraction of normal elastic lung tis-This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com3 Emergency. 2018; 6 (1): e29sue from contusion forms cavities filled with air and/or fluid.Also, air from a compressed part of the lung cannot escapefast enough due to closure of the glottis or an obstructedbronchus. Higher chest wall compliance and elasticity inchildren and young adults leads to increased transmission offorces and formation of TPP (9-11). Diagnosis is made basedon radiographic features and a history of chest trauma. TPPtypically follows a benign clinical course and is treated con-servatively (12). TPPs may be identifiable on chest radiogra-phy but CT is more valuable for early diagnosis (9). They maybe single or multiple and unilateral or bilateral. They may beseen on the site of injury or on the opposite side secondary tocounter coup effects, which are usually sub-pleural lesionscommonly found in the lower lobes. Unlike other cystic le-sions and cavities, the size, shape, and nature of wall of TPPschange relatively quickly (13-15). In this case, the cavity wasapproximately 3 cm and had an air-fluid level.Differential diagnoses include post pneumonia carcinoma,pneumatocele, tuberculosis, lung abscess, bronchogeniccysts and pulmonary sequestration. Most of these lesionsare self-limiting and benign lesions that don’t require spe-cific treatment, yet the clinical course might be complicateddue to infection and bleeding (10, 16). Surgical interventionis recommended only when complications such as infection,bleeding and rupture develop (12). TPPs mostly need con-servative management unless complications arise. The useof antibiotics is controversial and not routine (4, 6). Resolu-tion usually occurs within a few weeks to a few months. Ifthe cavity lesion does not decrease with time other etiologiesmust be considered.This patient was treated conservatively without antibiotictherapy. He was asymptomatic and was discharged on day 4of hospitalization without complications and thus confirmedour diagnosis of TPP.4. Conclusion:TPP is an uncommon complication of chest trauma. Oftenno specific treatment is needed. TPP should be considered inthe differential diagnosis of cystic or cavitary lung lesions fol-lowing significant blunt trauma, particularly in younger pa-tients, to prevent unnecessary and invasive procedures.5. Appendix5.1. AcknowledgementsThe authors would like to thank the emergency ward staff.5.2. Authors contributionAll authors passed four criteria for authorship contributionbased on recommendations of the International Committeeof Medical Journal Editors.5.3. Conflict of interestNone.5.4. FundingNone.References1. Cho HJ, Jeon YB, Ma DS, Lee JN, Chung M. Traumaticpulmonary pseudocysts after blunt chest trauma: Preva-lence, mechanisms of injury, and computed tomogra-phy findings. Journal of Trauma and Acute Care Surgery.2015;79(3):425-30.2. Rahimi-Rad M, Mohammadi A. Multiple bilateral trau-matic pulmonary pseuodocysts in a 53 year-old malediagnosed retrospectively. Pneumologia (Bucharest, Ro-mania). 2010;59(2):84-6.3. Das S, Cherian S, Bisen N, Hamarneh W, Lenox R. Pul-monary cystic lesions post motor vehicle accident: a rareoccurrence. QJM: An International Journal of Medicine.2012;106(6):581-2.4. Gupta N, George J, Gupta RC, Dixit R. Traumatic pul-monary pseudocyst. International journal of critical ill-ness and injury science. 2013;3(2):155.5. De Dios JAA, Paoletti L, Bandyopadhyay T. AN UNUSUALCYSTIC LUNG LESION. Chest. 2008;134(4):32C.6. Yazkan R, Ozpolat B, Åd̄ahinalp AS. Diagnosis and man-agement of post-traumatic pulmonary pseudocyst. Res-piratory care. 2009;54(4):538-41.7. 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Posttraumatic pulmonarypseudocyst: computed tomography findings and man-This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comN. Ghafourian et al. 4agement in 33 patients. Journal of Trauma and AcuteCare Surgery. 2012;73(5):1225-8.14. Weihua Z, Yanhong T, Hongwei L, Qiong L, Dihong W.Traumatic Pulmonary Cyst in 6 Cases of CT PerformanceAnalysis. Journal of Yangtze University (Natural ScienceEdition). 2012;11:011.15. DING C-q, SUN Y-y, DING A-l, ZHANG Y-n, WANG W-s, WANG C. CT Dynamic Analysis of Multiple TraumaticPulmonary Pseudo-cysts [J]. Computerized TomographyTheory and Applications. 2013;1:023.16. Ulutas H, Celik M, Ozgel M, Soysal O, Kuzucu A. Pul-monary pseudocyst secondary to blunt or penetratingchest trauma: clinical course and diagnostic issues.European Journal of Trauma and Emergency Surgery.2015;41(2):181-8.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com

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