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Sunday, 24 November 2013

Pleural disease – Pneumothorax – Misdiagnosis

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall. A. Pneumothorax is defined as a condition of collection of air within the pleural cavity, from either the outside or from the lung of which affect the lung breathing.
D.1. Misdiagnosis
According to the study by Medical Intensive Care Unit, Fitzsimons Army Medical Center, in the evaluation to identify risk factors predisposing to the misdiagnosis of pneumothorax in the ICU, showed that Nineteen (67.9%) patients with pneumothorax were diagnosed correctly on initial presentation of their pneumothorax. The remaining nine (32.1%) patients’ pneumothoraces were misdiagnosed at initial presentation. Certain medical ICU patients appear to be at higher risk for the initial misdiagnosis of pneumothorax. Familiarity with factors predisposing to this problem should allow for a higher index of suspicion for the diagnosis of pneumothorax in critically ill patients and possibly improve the early detection of pneumothorax(42).
1. Anaphylactic reaction of ruptured pulmonary hydatid cyst
There is a report of a 22-year-old male came to our emergency department in shock with symptoms of shortness of breath and altered mental status from the previous day. Radiograph showed a thin-walled circular translucent area in the right upper lung field, which was misdiagnosed as pneumothorax, and an intercostal chest tube was inserted. Anaphylactic reaction due to rupture of a hydatid cyst is rare, but hydatid disease should be suspected in patients from areas where Echinococcus is endemic, according to the Aligarh Muslim University(37).
2. MacLeod syndrome (Swyer-James syndrome)
There is a report of a 26-year-old man who had had a first left pneumothorax at the age of 21. He smokes tobacco. When he was 1-year-old he had experienced repeated episodes of acute bronchiolitis. At age 26, he suffered from a second left pneumothorax which was wrongly diagnosed as a recurrent drain-resistant pneumothorax. According to the study by Service de chirurgie infantile, hôpital Mère-Enfant, MacLeod syndrome is rare. It can be associated with pneumothorax which can be a source of misdiagnosis and error in the management of these patients(38).
3. Bronchogenic cysts
There is a report of a giant bronchogenic cyst in a 19-year-old woman presenting with pain and shortness of breath was mistaken for tension pneumothorax and initially treated with tube thoracostomy, according to Bursa Yuksek Ihtisas Hospital, Bursa(39).
4. Laparoscopic Nissen fundoplication
There is a report of a 13-year-old boy who, after exercise, had respiratory distress and left upper quadrant abdominal pain. Initially, a mistaken diagnosis of pneumothorax. And a nasogastric tube was then visualized on chest x-ray in the left hemithorax. He underwent a laparotomy and had herniation of spleen, stomach, and large and small bowel in the left pleural space passing through a traumatic defect in the hemidiaphragm but later felt to be conrtibuted by laparoscopic Nissen fundoplication 3 years prior(40).
5. Congenital diaphragmatic hernia
There is a report of two cases in which the initial diagnosis was tension pneumothorax and chest drains were inserted, but in both cases, the diagnosis turned out to be congenital diaphragmatic hernia(41).

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(37) http://www.ncbi.nlm.nih.gov/pubmed/21333077
(38) http://www.ncbi.nlm.nih.gov/pubmed/23200584
(39) http://www.ncbi.nlm.nih.gov/pubmed/20947603
(40) http://www.ncbi.nlm.nih.gov/pubmed/15793743
(41) http://www.ncbi.nlm.nih.gov/pubmed/9292904
(42) http://www.ncbi.nlm.nih.gov/pubmed/2055079