Rare late-presentation congenital diaphragmatic hernia mimicking a tension pneumothorax

Tension pneumothorax from large bowel herniation and perforation as a late presentation of traumatic diaphragmatic hernia during pregnancy: a case report

BACKGROUND

Diaphragmatic hernias can be congenital or acquired, with trauma being the primary cause of the latter. Both types may have delayed presentations, with abdominal organs protruding into the thoracic cavity, causing symptoms of varying severity. Pregnancy can sometimes precipitate the condition. Tension pneumothorax resulting from bowel perforation into the thorax is exceptionally rare, with only a few cases reported. To the best of the authors knowledge, this is the third documented case of a late-presenting trauma-related diaphragmatic hernia during pregnancy, complicated by tension pneumothorax.

CASE PRESENTATION

A 30-year-old woman, 29 weeks pregnant, was referred to Semmelweis University emergency department with moderate dyspnea. Initial investigation revealed tension pneumothorax. Chest tube placement released air, pus, and feces. Computer tomography identified a diaphragmatic hernia with bowel incarceration and perforation as the underlying cause. The patient underwent a delayed cesarean section and surgical repair, with a good outcome. A history of thoracic trauma eight years prior was later revealed.

CONCLUSION

Evaluating pregnant patients with shortness of breath in the emergency department is challenging. Identifying a history of thoracic or abdominal trauma is crucial, as this can raise the suspicion of diaphragmatic hernia, which can present with a wide range of symptoms. Spontaneous tension pneumothorax in pregnant women is extremely rare and requires cautious management. A multidisciplinary approach is crucial for the successful treatment of maternal diaphragmatic hernia.

Nontraumatic right diaphragmatic hernia with malrotated left liver lobe incarceration: An unusual case report with literature review

Diaphragmatic hernia is an unusual finding, especially in emergency settings and in the absence of trauma. Imaging plays a crucial role, with various CT signs of diaphragmatic rupture having been described, including the "dangling diaphragm," "absent diaphragm," "collar sign," "hump sign," "fascia sign," and "dependent viscera sign". We report an unusual case of a 53-year-old woman who presented with exertional dyspnea and asthenia. A CT scan was performed, revealing a large right diaphragmatic hernia involving an abnormally rotated liver and several other organs. The association between a malrotated liver and diaphragmatic hernia is extremely rare, with only a few cases previously reported in the literature. Surgery remains the definitive treatment, and the surgical approach depends on the size of the defect and the presence of significant complications.

Clinical challenges and management of late presenting congenital diaphragmatic hernia mimicking tension pneumothorax in a child: a case report and review of literatures

BACKGROUND

Congenital diaphragmatic hernia(CDH) is a rare congenital anomaly characterized by herniation of abdominal contents into thoracic cavity through a defect in diaphragm. While commonly diagnosed prenatally or in neonatal period, late-presenting CDH can occur and may mimic other thoracic emergencies such as tension pneumothorax, complicating diagnosis and management.

CASE PRESENTATION

A two-year old male black child from Ethiopia presented to the emergency department with sudden onset of acute respiratory distress. Initial clinical assessment and chest radiography suggested a diagnosis of tension pneumothorax due to the presence of significant mediastinal shift and apparent pleural air. Despite insertion of chest tube, the child's condition did not improve, raising suspicion of alternative diagnosis. Careful observation of initial chest x-ray and subsequent chest ultrasound revealed a left sided congenital diaphragmatic hernia with herniation of stomach and intestine into thoracic cavity compressing the left lung and causing mediastinal shift. After the diagnosis of CDH was confirmed, the child was stabilized and emergent surgical repair performed. Postoperative recovery was uneventful, and the child was discharged with no significant long-term complications.

CONCLUSION

This case underscores the importance of considering CDH in the differential diagnosis of acute respiratory distress in a child. It highlights the diagnostic challenges and potential risks of emergency interventions based on initial misdiagnosis. Even if x -ray looks like typical of tension pneumothorax, it showed giant cystic air filled structure pushing the mediastinal structure to contralateral side with loss of left diaphragmatic outline which raised suspicion of congenital cystic lung mass or congenital diaphragmatic hernia. Advanced imaging and high index of suspicion are crucial for accurate diagnosis and timely management, ultimately improving patient outcomes. Consideration of alternative diagnosis when our initial intervention with insertion of chest tube fail to provide symptom improvement in suspected pneumothorax should raise suspicion of congenital diaphragmatic hernia like in our case.

Diaphragmatic Hernia With Secondary Pneumothorax Due to Intestinal Perforation After Thoracoabdominal Aortic Aneurysm Operation: A Case Report

A male in his 70s with a history of artificial vessel replacement for a thoracoabdominal aneurysm had been treated non-operatively for adhesive bowel obstruction during the past two months. The initial symptom was nausea and the patient was transferred to our hospital because of diffuse abdominal pain. Computed tomography revealed pneumothorax, diaphragmatic hernia, and bowel perforation. A left thoracic drain was inserted and air and clear yellow fluid were drained. Secondary pneumothorax was presumably caused by intestinal perforation associated with diaphragmatic hernia. Although reported cases with secondary pneumothorax associated with diaphragmatic hernia and intestinal perforation are caused by trauma, this complication can occur postoperatively.

Congenital diaphragmatic hernia in patient with 1p36 deletion

Key Clinical Message

This case underscores the atypical presentation of late-onset congenital diaphragmatic hernia in a 9-old with 1p36 deletion syndrome. Recognition of respiratory distress and abdominal symptoms is crucial for intervention.

Abstract

Congenital Diaphragmatic Hernia (CDH) is a condition characterized by the protrusion of abdominal contents into the thoracic cavity due to a defect in the diaphragm. While typically observed in the neonatal period, CDH can present in later life. This case report describes the presentation, diagnosis, and management of a nine-year-old boy with 1p36 deletion syndrome who presented with respiratory distress, abdominal pain, vomiting, and anorexia. The initial diagnosis was tension pneumothorax, and thus the patient underwent chest tube placement. However, a high-resolution CT scan revealed a left hemidiaphragmatic hernia, and the patient eventually underwent an emergency laparotomy due to acute-onset respiratory distress. Intraoperatively, a diagnosis of Bochdalek hernia with gastric perforation was made, and the CDH and gastric perforations were resolved successfully. This case highlights the importance of considering late-presenting CDH as a possible diagnosis in pediatric patients with similar symptoms and the radiological findings suggestive of tension pneumothorax. Early recognition and prompt surgical intervention can lead to successful management of such cases.

Death by late presenting of diaphragmatic hernia in an infant: case report and review of the literature

Background

Congenital diaphragmatic hernia (CDH) is a congenital malformation of the diaphragm, resulting in the herniation of the abdominal organs into the thoracic cavity. If not properly diagnosed before or at birth, CDH represents a life-threatening pathology in infants and a major cause of death. We present a fatal case of congenital diaphragmatic hernia corresponding to Bochdalek hernia, discovered incidentally during a sudden death’s autopsy of an infant. To achieve a better view of the range of these anomalies, we also conducted a literature review on this subject describing the pathogenesis, manifestations, diagnosis, and autopsy contribution to addressing these CDH.

Case presentation

The case involved a 4-month-old female infant who presented sudden respiratory difficulties after breastfeeding. External examination found marked cyanosis with no evidence of trauma. Upon opening the chest cavity, the stomach, markedly distended, was occupying much of the left pleural cavity. The left lung was compressed and displaced superiorly, and the heart was also compressed and deviated to the right. This mediastinal deviation was due to an ascension of the stomach into the chest cavity through a 2 × 1.5 cm defect in the posterior left hemidiaphragm. Further examination remarked an ecchymotic appearance of the stomach portion entrapped in the hernia defect suggesting recent strangulation of the stomach. The lungs showed atelectasis with signs of pulmonary infection in the histology study.

Conclusions

CDH might be considered uncommon and not always mentioned in the list of sudden death in infant causes. Forensic pathologists should know of this malformation in order to apply the best autopsy techniques and thus allow positive feedback to pediatricians considering the possible legal implications.