Primary spontaneous hemopneumothorax (PSHT) is a condition in which blood and air accumulate in the pleural space without history of trauma or any obvious cause [1]. The amount of blood used to define PSHT is controversial. Some studies regarded 400 cc as a minimal amount of blood to be present for a case of PSHT [2] [3].

La-ennec in 1828 was credited with 1st description of PSHT, which was diagnosed at post-mortem. Subsequently, successful treatment of PSHT by thoracocentesis was performed by Whitaker in 1872 [4].

It is a rare condition occurring in about 0.5–12% of spontaneous pneumothorax [5].

PSHT is different from spontaneous pneumothorax in which the patient may present with hypovolemic shock which needs urgent intervention [5]. The treatment goals include resuscitation, hemostasis and lung expansion [6].

The condition is treated initially by tube thoracostomy, however, surgical intervention is required in cases of hypovolemic shock or continuous bleeding [7].

The optimal management of SHP remains controversial. There are no definitive guidelines on patient selection for surgery and timing of intervention.

The conservative treatment indicated by some authors if bleeding persisted less than 24 hours provided that the patients is stable [8].

To our knowledge, recurrence of PSHT has never been reported in literature. The current paper presents a rare case of PSHT with recurrence.

A 22-year-old male, non-smoker, referred to emergency department for having sudden onset left side chest pain, radiated to the shoulder associated with cough, pallor and generalized body weakness for one day duration. He had history of weight loss and anorexia for one month duration. The patient was tall, thin, looking ill and pale. He was dyspneic, but nearly absent air entry on the left side.

Vitals: blood pressure 110/70 mmHg, pulse rate 110/minute, chest X-ray showed hydro pneumothorax in the left side (Figure 1). Left side tube thoracostomy inserted, 150 cc of blood drained with air. Within the next hour when the patient started physiotherapy, another 1350 cc blood drained. Resuscitation was done by blood (one unit) and fluid and the patient responded. Blood investigations were ordered which showed INR of 1.8 upon which two units of plasma has been given. The patient has been closely monitored, over the next 10 hours, only 200 cc blood drained.

Liver function tests, abdominal ultrasound and alpha one antitrypsin were all within the normal limits. Flexible bronchoscopy was done which was normal. Subsequent erect chest X-ray showed expanded lung with clearance of both costodiaphragmatic angle. The chest drain was clamped and removed the day after (Figure 2). The patient was sent home an sixth day. After one week, the patient presented with the same complaint (Figure 3), tube thoracostomy re-inserted, which drained 500 cc bloods. Computed tomography scan of the chest with IV contrast showed retained left side hemothorax with collapse consolidation of the left lower lobe, no bullae was found (Figure 4).

Thoracotomy done, clot evacuated, no source of bleeding was found. The patient was sent home three days later. After one month patient re-admitted with contralateral primary spontaneous pneumothorax (Figure 5) managed by posterolateral thoracotomy.

Primary spontaneous hemopneumothorax (PSHT) is a surgical emergency for which neither definition nor guideline for management has not been established well [5].

PSHT is different from PSP in dramatic deterioration of the patient due to continuous blood loss in spite of that both conditions present with nearly same clinical features and diagnosed by the same diagnostic tools.

The symptoms of chest pain, dyspnea and cough may be combined by signs and symptoms of hypovolemic shock and lethargy [6]. The amplitude of symptoms is affected by degree of blood loss rather than magnitude of lung collapse. The amount of blood that considered enough to diagnosis SHP is 400 cc and 1000 cc as massive one. Chest X-ray is the routine diagnostic tool for diagnosis although 10% of chest X-ray shows only pneumothorax initially [6] [9].

The usual causes of bleeding in case of PSHT which were seen intraoperatively are:

1. Torn of adhesions between the two layers of pleura.
2. Rupture of aberrant congenital vessels that usually not contract due to lack of muscular layer.
3. Rupture of vascularized bullae [5][6] [9].

The management of SHP includes resuscitation and volume replacement, initial drainage with tube thoracostomy and then intervention weather open or thoracoscopic method whenever indicated [7]. Blood transfusion is indicated in patient with clinical features of hypovolemia and shock [1]. The initial goals of treatment are hemostasis, lung re-expansion and drainage. Conservative treatment were used by some authors in patients whose bleeding lasted less than 24 hours, but restrictive types of lung pathology were seen during follow up which required surgery later on in some patients [1] [6] [7].

The indications for surgical intervention in literature included shock state, initial drainage of 1000 cc, continuous drainage of 200 ml for two successive hours, and inadequate lung expansion in spite of proper drainage system and massive hematoma noticed on CT scan [1] [6] (Table 1).

Video assisted thoracic surgery has acquired more acceptances since it provides less tissue damage with less postoperative pain with shorter mean of hospital stay. The indication of VATS is not different from that used for open technique. The intervention will provide direct control of bleeding point, sealing the air leak, evacuation of the retained hematoma, resection of bullae with pneumorraphy and effective drainage of pleural space [1][2] [6][7][9].

We present a case of recurrence PSHT in which in first attack the patient was treated conservatively. According to our knowledge, no recurrence of PSHT has been documented regardless of which surgical method had been used. This may be explained by the fact that blood acts as a biological agent for pleurodesis which induces dense adhesion and prevents recurrence [1] [3][5][6][7][8][10] [11][12].

Primary spontaneous hemopneumothorax (PSHT) is a surgical emergency, recurrence although very rare can occur early in follow-up, especially when the patient treated conservatively.

1. Tay CK, Yee YC, Asmat A. Spontaneous hemopneumothorax: our experience with surgical management. Asian Cardiovasc Thorac Ann 2015 Mar;23(3):308–10.   [CrossRef]   [Pubmed]    
2. Tatebe S, Kanazawa H, Yamazaki Y, Aoki E, Sakurai Y. Spontaneous hemopneumothorax. Ann Thorac Surg 1996 Oct;62(4):1011–5.   [CrossRef]   [Pubmed]    
3. Haciibrahimoglu G, Cansever L, Kocaturk CI, Aydogmus U, Bedirhan MA. Spontaneous hemopneumothorax: is conservative treatment enough? Thorac Cardiovasc Surg 2005 Aug;53(4):240–2.   [CrossRef]   [Pubmed]    
4. Issaivanan M, Baranwal P, Abrol S, Bajwa G, Baldauf M, Shukla M. Spontaneous hemopneumothorax in children: case report and review of literature. Pediatrics 2006 Oct;118(4):e1268–70.   [CrossRef]   [Pubmed]    
5. Kim ES, Kang JY, Pyo CH, Jeon EY, Lee WB. 12-year experience of spontaneous hemopneumothorax. Ann Thorac Cardiovasc Surg 2008 Jun;14(3):149–53.   [Pubmed]    
6. Tulay CM, Aygün M. Emergency surgery for spontaneous hemopneumothorax. J Coll Physicians Surg Pak 2014 Jun;24(6):435–347.   [CrossRef]   [Pubmed]    
7. Homma T, Sugiyama S, Kotoh K, Doki Y, Tsuda M, Misaki T. Early surgery for treatment of spontaneous hemopneumothorax. Scand J Surg 2009;98(3):160–3.   [Pubmed]    
8. Wu YC, Lu MS, Yeh CH, Liu YH, Hsieh MJ, Lu HI, Liu HP. Justifying video-assisted thoracic surgery for spontaneous hemopneumothorax. Chest 2002 Nov;122(5):1844–7.   [CrossRef]   [Pubmed]    
9. Hwong TM, Ng CS, Lee TW, et al. Video-assisted thoracic surgery for primary spontaneous hemopneumothorax. Eur J Cardiothorac Surg 2004 Nov;26(5):893–6.   [CrossRef]   [Pubmed]    
10. Hart SR, Willis C, Thorn A, Barfoot L. Spontaneous haemopneumothorax: are guidelines overdue? Emerg Med J 2002 May;19(3):273–4.   [CrossRef]   [Pubmed]    
11. Tulay CM, Aygün M. Emergency surgery for spontaneous hemopneumothorax. J Coll Physicians Surg Pak 2014 Jun;24(6):435–347.   [CrossRef]   [Pubmed]