Spontaneous hemothorax secondary to immature teratoma of the mediastinum

Avoidance of circulatory collapse by preoperative percutaneous drainage of tumor contents for a giant mediastinal mature cystic teratoma

Giant mediastinal tumors may cause fatal respiratory failure or circulatory collapse at the time of induction of general anesthesia and sometimes require extracorporeal life support. However, it is unclear whether preoperative percutaneous drainage of tumor contents for a giant mediastinal cystic teratoma reduces these risks. We report a case of a giant mediastinal cystic teratoma in which general anesthesia could be safely induced without extracorporeal life support by preoperative percutaneous drainage that reduced most of the tumor volume under local anesthesia. A 41-year-old woman diagnosed with a ruptured giant mediastinal teratoma required urgent surgery. To avoid circulatory collapse, preoperative percutaneous drainage of the tumor contents was performed, which successfully evacuated most of the tumor volume. General anesthesia was induced without any problem, and mediastinal tumorectomy was performed. We argue that it is worth attempting percutaneous drainage of tumor contents before cannulation of extracorporeal life support.

Non-traumatic and spontaneous hemothorax in the setting of forensic medical examination: a systematic literature survey

Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax.

A rare case of bilateral massive hemothorax from spontaneous rupture of a primary mediastinal mixed germ cell tumor

Spontaneous rupture of a mediastinal germ cell tumor, while rare, is always accompanied by bleeding. In this report, we describe a case of a primary mediastinal mixed germ cell tumor that presented with bilateral massive hemothorax and hemorrhagic shock. An urgent thoracotomy, which was performed to control bleeding, confirmed bilateral hemothorax secondary to a ruptured mediastinal tumor. Pathologic diagnosis revealed the mediastinal tumor to be mixed choriocarcinoma and immature teratoma, with lung metastatic choriocarcinoma. The patient recovered well from the operation and received salvage chemotherapy. Two years after diagnosis, the patient remains in remission with no evidence of disease.

A case of dermoid cyst ruptured into the lung

Ruptured cystic teratomas (dermoid cysts) are rare and always symptomatic, presenting as haemothorax, pleural effusion or pericardial effusion. We present an extremely rare case of a 45-year-old woman who, during a routine health assessment was noted to have a well-defined anterior mediastinal tumour with peripheral ground glass opacity on chest CT. The patient was asymptomatic. She underwent video-assisted thoracoscopic surgery and a ruptured dermoid cyst was observed and the contents had infiltrated into the right pulmonary parenchyma. There were no complications and no evidence of recurrence 10 months later. Despite most cystic teratomas being asymptomatic and benign, rupture into the pulmonary parenchyma may induce further damage, for which emergency surgical intervention is always necessary.

Massive Spontaneous Hemothorax Associated With Von Recklinghausen’s Disease

A 30-year-old woman with Von Recklinghausen's disease was admitted to our hospital because of sudden onset of dyspnea and syncope. A chest roentgenogram showed a massive right pleural effusion and insertion of an intercostal tube drained 1,600 cc of blood. A computed tomographic chest scan with contrast revealed a hyperdense mass in the right paravertebral area. At thoracotomy, retained clotted hemothorax and continued bleeding from tumor vessels was noted. The apex of the right hemithorax and the tumor location was packed. The pathologic diagnosis was ganglioneuroma and follow-up of the patient for 2 years after re-thoracotomy and removal of the packs revealed no complication and morbidity. We report this case to emphasize the importance of early recognition and prompt surgical intervention in spontaneous hemothorax associated with Von Recklinghausen's disease.

A Case of Thoracic Hemorrhage due to Ectopic Parathyroid Hyperplasia With Chronic Renal Failure

We report a case of secondary hyperparathyroidism in a 53-year-old man who had thoracic hemorrhage originating from an ectopic thymic parathyroid gland tumor. He was on long-term hemodialysis treatment and had persistent secondary hyperparathyroidism caused by 3 swollen parathyroid glands around the thyroid gland and a mediastinal ectopic parathyroid gland tumor. Parathyroidectomy and removal of the mediastinal tumor were planned. Preoperative chest x-ray and a computed tomographic scan obtained just before surgery showed left pleural effusion. Furthermore, diagnostic thoracentesis yielded hemorrhagic exudative fluid. Thoracoscopy confirmed the presence of a mediastinal tumor lesion that was bleeding into the thoracic cavity. The tumor was resected using thoracoscopic surgery, and ectopic thymic parathyroid gland hyperplasia associated with hemorrhage was pathologically diagnosed. A postoperative diagnostic chest computed tomographic scan and technetium 99m 2-methoxyisobutyl isonitrile scintigraphy showed successful removal of the ectopic parathyroid gland tumor. Subsequently, the secondary hyperparathyroidism could be clinically controlled by medical treatment, and total parathyroidectomy has been postponed indefinitely. We consider that hemorrhage from the ectopic parathyroid gland tumor resulted in thoracic bleeding. To our knowledge, this is the first case report of secondary hyperparathyroidism with thoracic hemorrhage originating from an ectopic mediastinal parathyroid gland.

Intrapleural rupture of a cystic thymoma

Although cystic degeneration of a thymoma is not uncommon, rupture of a cystic thymoma is rare. The authors report a patient with sudden chest pain and dyspnea due to rupture of a cystic thymoma into the right pleural space.