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Spontaneous Pneumothorax in Young Subjects a Clinical and Pathological Study

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Spontaneous Pneumothorax in Young Subjects a Clinical and Pathological Study Thorax: first published as 10.1136/thx.26.4.409 on 1 July 1971. Downloaded from Thorax (1971), 26, 409. Spontaneous pneumothorax in young subjects A clinical and pathological study I. LICHTER and J. F. GWYNNE Departments of Thoracic Surgery and Pathology, University of Otago Medical School, Dunedin, New Zealand Spontaneous pneumothorax may complicate lung disease which is clinically or radiologically apparent in patients suffering from chronic bronchitis, asthma, tuberculosis, bronchiectasis, and, less commonly, bronchial cancer, silicosis, pulmonary infarction, and other more rare disorders. These patients are usually in the older age group, and the commonest predisposing factor is chronic bronchitis. Pneumothorax occurring in these diseases is well recognized and needs no further elaboration. Spontaneous pneumothorax may also occur in apparently healthy people with no demonstrable pulmonary lesion. The subjects are often young, usually male, and have been in good health prior to their first episode. They are often athletic and tend to be of tall, thin physique. A group of 20 cases which falls into this latter category forms the basis of this study. They were all treated by wedge resection of apical lung disease. The clinical and histological findings are presented and the literature is briefly reviewed. Approximately 120 patients were admitted to the Predilection for the male sex is noted, only three http://thorax.bmj.com/ Thoracic Surgical Unit of the Wakari Hospital of the patients being females. Sixteen were between with spontaneous pneumothorax between the years the age of 16 and 30 (range 16 to 47). Two of 1962 and 1968. Most of these patients had clinical the older patients were females. and radiological evidence of established bilateral Measurements of body stature were not pulmonary disease such as bronchitis and emphy- recorded but most of the patients tended to be sema, bronchiectasis or tuberculosis and have not tall and thin. A history of athletic activity was been included in this study. frequent. Fifty of the patients stimulated particular interest because they gave no antecedent history OPERATIVE FINDINGS on September 25, 2021 by guest. Protected copyright. of chest disease and they form the basis of this At operation the characteristic findings were as study. More than half of this group responded follows: to therapy by intercostal tube drainage. In six At the apex of the lung there was a small area the air leak persisted despite drainage; 14 patients of fibrosis, usually no larger than 3 x 2 cm, sur- were readmitted because of recurrent pneumo- mounted by a thin-walled bullous cyst or cysts. thorax. These 20 patients, two of whom suffered Commonly there were several cysts, and these bilateral pneumothoraces, were subjected to measured from about 0-2 cm in diameter to 1 cm or thoracotomy and wedge resection. The clinical more (Fig. 1). Only occasionally was a small pinhole and pathological data from this group have been leak apparent at the apex of the cyst. In the case reviewed. of leaks that failed to seal within 48 hours of drainage, a tear was sometimes found in a large cyst that had been responsible for considerable air leak and failure CLINICAL DATA to heal. The remainder of the lung appeared normal. Relevant clinical findings are summarized in the Adhesions were uncommon. Table. The indication for resection was recurrence in PATHOLOGY 14 patients and persistent leak in six. The pneumo- The histological material from the specimens in the thorax was bilateral in two patients. Each lung series has been reviewed and a similar pattern of was affected with approximately equal frequency. abnormalities was observed throughout. 409 Thorax: first published as 10.1136/thx.26.4.409 on 1 July 1971. Downloaded from 410 1. Lichter and J. F. Gwynne TABLE SUMMARY OF CLINICAL FEATURES Case Age/Sex revious Clinical Presentation pisodes Histological Findings Follo"-up 1 18 M I One previous episode of spontaneous Extensive fibrosis and pneumothorax. Recurred 10 mth later. inflammation with linear Wedge resection for recurrence lymphocytic infiltration Prominent emphysema with large cysts, some with surrounding chronic in- flammation. Numerous intra-alveolar LeI macrophages. Mesothelial and alveolar cell proliferation. Dilated bronchi filled with mucus. Vessels showed endarter- itis 2 25 M Left 3 Three of spontaneous Widespread fibrosis previous episodes Yr pneumothorax. Wedge resection for chronic inflammation. re.ur-ence further recurrence with fibrous-walled subpleural Abundant pigmented macrophages.cysts. Distended bronchi containing mucus. Marked endarteritis obliterans 3 27 M Left Previous pneumothorax 2k yr earlier Extensive linear fibrosis treated yr by intercostal tube drainage. incorporating distorted recurrence Wedge resection for recurrence Emphysema not seen. pig- mented macrophages. Superficial cysts 4 21 M ~ Left Previous episode of spontaneous Patchy fibrosis. pneu- mth mothorax 5 wk earlier. Further episode, polymorphs surrounded treated recurrence by intercostal tube drainage inflammation. Focal emphysema. Pig- with continuing air leak for 2 days. mented macrophages Wedge resection for persistent air leak relation to cholesterol. prominent cellular lining. Cysts lined by simple - 5 24 M Right First episode of pneumothorax. Treated Widespread vr by intercostal tube drainage. Air leak flammation. Patchy emphysema continued for No re..urrence 6 days, when wedge fibrous walled cysts. Pigmented macro- resection was done for persistent air phages. Collapsed distorted leak scars. Vessels show endarteritis http://thorax.bmj.com/ 6 M 19 2 Left side: Two previous episodes of left Severe focal fibrosis spontaneous Emphysema pneumothorax and one on chronic inflammation. recurrence right. Wedge resection on fur- many fibrous-walled cysts. left for Mesothelial. ther recurrence bronchiolar and alveolar cell ation. prolifera- Right side: One year later presented after 6 episodes of right-sided spon- Abundant pigmented yr pneumothorax, taneous 4 of which had bronchioles which Many recurrence within the past 2 mth. Wedge macrophages and pigment. Left resection for recurrence show endarteritis M 7 19 7 Seven previous episodes of spontaneous Focal fibrosis marked yr pneumothorax over previous 4 yr. chronic inflammation. Emphysema recurrence Wedge resection for recurrence fibrous-walled cysts. on September 25, 2021 by guest. Protected copyright. mented macrophages with focal choles-pig- terol deposition. Alveolar cell pro- liferation. Dilated bronchioles contain- Right ing macrophages 8 24 F Tension pneumothorax treated by inter- Large subpleural scar r tube Air 7s costal drainage. leak continued emphysema. Solitary fibrous-walled recurrence I for 6 days. Wedge resection for per- cyst with pigmented macrophages Left sistent air leak wall 9 16 M 2 of Two episodes spontaneous pneumo- Fibrosis involving almost speci- vr thorax over 7 men. not previous mth. Wedge Emphysema recurrence resection for further episode chronic inflammation Cysts only on surface 10 20 M Right 2 Two previous of Multifocal episodes spontaneous scarring 3 yr pneumothorax over and preceding 2 mth inflammation lipoid granulomata recurrence treated by intercostal tube drainage. On (history of camphor second occasion camphor oil was pleural cavity). Severe emphy- instilled into pleural cavity. Third sema. Fibrous-walled cysts. episode treated resection alveolar cell by wedge proliferation. Collapsed and bronchioles containing secretion. endarteritis of small 1 1 31 M Right One previous of and episode spontaneous Subpleural intrapulmonary fibro- 4 yr pneumothorax 5 mth On sis. Alveolar cell earlier. hyperplasia No recurrence second occasion treated intercostal areas. lined by Single cyst by tissue tube Continued air leak over with haemosiderin drainage. cholesterol 2-wk period. Wedge resection for per- deposition suggesting haemorrhage sistent air leak (cont.) Thorax: first published as 10.1136/thx.26.4.409 on 1 July 1971. Downloaded from Spontaneous pneumothorax in young subjects 411 Table continued of Case AgeiSex Side PreviousNo. Clinical Presentation Histological Findings Affetdece Episodes Follow-up 20 M Right 3 Two episodes of spontaneous pneumo- Widespread focal fibrosis with patchy 5 yr thorax over previous 2 mth. Third chronic inflammation. Emphysema No recurrence episode treated by wedge resection with fibrous-walled cysts, some lined by cellular layer. Alveolar walls lined by prominent cells. Dilated bronchi con- taining macrophages 13 47 M Right First episode of spontaneous pneumo- Extensive fibrosis with active chronic 7 yr thorax treated by intercostal tube drain- inflammation and lymphoid hyper- No recurrence age. Continued air leak for 3 days. plasia. Emphysema with cysts lined by Wedge resection for persistent air leak prominent cellular layer. Abundant pigmented macrophages. Alveolar cell hyperplasia in scars. Small thick-walled bronchi. Vessels show marked endar- teritis 14 21 M Left Second spontaneous pneumothorax Extensive focal fibrosis with a solitary 4 yr within 5 wk. Treated by wedge resection cavity surrounded by macrophages. No recurrence Widespread emphysema. Numerous pigmented macrophages. Alveolar cell proliferation. Severe endarteritis 15 37 F Right Spontaneous pneumothorax 5 yr earlier. Intrapulmonary fibrosis with intense 3 yr Second episode treated by wedge re- chronic inflammation. Emphysema No recurrence section with large fibrous-walled cysts. Abun- 3 mth later dant pigmented macrophages. Meso- pneumothorax thelial,
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