A 65-year-old man with severe chronic obstructive pulmonary disease (COPD) was admitted with a four-day history of chest pain and worsening shortness of breath. He explained the chest pain started suddenly when he tried to reach out for something on his computer table. It was located on the right anterior chest, sharp in nature, 7/10 in intensity, pleuritic, and worse with coughing and deep breathing. He had a past medical history of severe COPD with frequent exacerbations recently necessitating multiple antibiotics and steroid courses, coronary artery disease, gastroesophageal reflux disease (GERD), and hypertension. He had a 30-pack per year smoking history and quit about 10 years ago. He was a retired fireman living with his family.\nVitals signs in the emergency department (ED) were stable; he was breathing on ambient air. The physical examination demonstrated decreased breath sounds bilaterally without any wheezing or Ronchi. Moderate tenderness was present in the mid-axillary line in the fifth intercostal space, but no other abnormalities were noticed. Laboratory investigations were negative for any leukocytosis, troponin, or any other abnormalities. The electrocardiogram (EKG) showed a normal sinus rhythm. Computed tomography (CT) angiography was done to rule out pulmonary embolism (PE). The CT was negative for PE but showed mild peribronchial infiltrate in the right middle lobe and posterolateral lung herniation between the seventh and eighth ribs, with minimal subcutaneous emphysema along the right chest wall (Figure ).\nThe patient was admitted to the hospital and managed conservatively on broad-spectrum antibiotics, including vancomycin, levofloxacin, and 40 mg per day of prednisone. Two days later, his face swelled up suddenly with a change in the quality of his voice while he was eating dinner. An examination showed a swelling in the neck, diffuse crepitations on his body involving the face, all the way down to the buttocks. Repeat CT chest and neck showed extensive subcutaneous emphysema in the face, neck, chest, and mediastinum with a right-sided pneumothorax at the level of the previous lung herniation (Figures -).\nThe prevertebral and retropharyngeal air was demonstrated as compressing the oropharynx (Figure ). His oxygen requirement went up to 6 liters nasal cannula. A blowhole incision was made on the anterior chest wall, and he was observed in the medical intensive care unit (MICU). Surgery to close the defect was deferred due to his other comorbidities and the higher risk of post-operative complications. He improved gradually over the course of the next few days, completed the course of antibiotics with steroids, and was discharged to a rehabilitation center and did well post-discharge.
A 65 years old man presented to the emergency department with left-sided flank pain that started after a popping sound was heard following a cough spell. There was no history of trauma. He is an active smoker, and his past medical history includes congestive heart failure, hypertension, coronary artery disease, diabetes mellitus, chronic pain secondary to lumbar disc disease requiring multiple epidural injections and multiple orthopedic procedures including knee replacement and rotator cuff repair. He did not have any history of surgical procedures on his chest wall. His medications included hydrochlorothiazide, lisinopril, metoprolol, metformin, aspirin, clopidogrel and diclofenac. Examination was negative for any tenderness or deformity on the left flank. Electrocardiogram was unremarkable, and chest X-ray was negative for any acute pathology. He was discharged home on pain medications with a diagnosis of muscular spasm. A few days later, he represented with non-resolution of symptoms. This time on examination he was found to have a large hematoma of the left flank tracking inferiorly to the left gluteus. There was no fullness, tenderness or crepitus on palpation. Computed tomography (CT) thorax revealed a chest wall defect on the left side between eighth and ninth ribs with herniation of lung tissue (Fig. , red arrow) and a 5 cm × 3 cm hematoma but did not reveal any fractures. He was managed conservatively with pain medications as there was no evidence of vascular compromise to the lung tissue. A month later, he presented again with poorly controlled chest pain and shortness of breath. Chest X-Ray showed stable herniation of lung tissue with widening of eighth intercostal space (Fig. ). Subsequent CT thorax revealed progression of lung herniation (Fig. , red arrow) associated with left lower lobe atelectasis, alongside acute, displaced fractures of left eighth and ninth ribs (Fig. , green arrow). No surgical repair was performed based on a recent positive stress test and his elevated perioperative risk of cardiovascular events. He was discharged on opioid pain medications. At the follow-up visit, he still continues to have pain in the left lower chest, even though he is on a high dose of pain medications. We also tried intercostal nerve blocks, which seems to be ineffective in his case. There appears to be some respiratory compromise unsure whether secondary to chronic heart failure or ‘lung herniation fracture’.