Cough and Chest Bulge: A Rare Case of Spontaneous Lung Herniation

Case Report: Spontaneous lung herniation is a rare but often under-diagnosed entity. History: 69 year old male with COPD, Gold Stage III presented with cough and shortness of breath for three weeks. He had an acute onset of right sided chest pain and swelling one week prior to admission after he felt "something give away" in his back. Physical Exam: Chest wall: 10 x 10 cm bulge below right scapula, prominent with cough. Ecchymoses seen in lower half of chest wall. Imaging: CT scans showed herniated lung through the right 8th intercostal space. Discussion: Less than 300 cases of lung herniation have been reported of which around a 100 are spontaneous thoracic (intercostal) hernias. Most result from an acute increase in intrathoracic pressure due to coughing, sneezing, blowing on a musical instrument or heavy lifting classically in (Figure Presented) male smokers with chronic pulmonary disease. The diagnosis is usually confirmed by means of chest radiography, fluoroscopy or computer tomography. It is sometimes missed on routine chest radiographs. Management: Complications (strangulation, incarceration) are rare. Conservative management is recommended. Spontaneous resolution seldom occurs. Compressive pads or corsets may be effective for pain. Surgery is curative and is indicated when there is pain, recurrent infection, hemoptysis, interference with daily activities, if complications arise or if the hernias are very large. Outcome: This patient was seen by thoracic surgery and managed conservatively. He denied symptoms during follow up in clinic.