Case of delayed hemothorax caused by bleeding after blunt chest trauma
A 24 yr old man visited the emergency department with chest pain after being struck by his friend's fist over the anterior chest wall 3 days before. On arrival, his vital signs were table with negative signs of hypotension and dysrhythmia. No complaints of dyspnea or referred pain.
Physical examination showed local tenderness over the right 5th and 6th rib area. The chest X-ray showed a suspicious bulky mass over the right mediastinum.
Electrocardiography revealed normal sinus rhythm without ischemic change.
Patient was discharged with oral analgesics in stable condition, but the patient returned after 10hrs with new onset of symptoms of dyspnea, tachycardia and impending shock. The chest X-ray was again repeated which revealed right pleural effusion that was not seen in the earlier chest X-ray, a tubal thoracotomy was performed, and about 1L of fresh blood was drained. The thoracotomy was done in emergency under the impression of massive hemothorax.
The finding was a ruptured thymus with massive bleeding and thus a total thymectomy was performed, and pathological finding of the thymus showed langerhans cell histiocytosis, the patient was discharged after a week with the prognosis of a good recovery.
Further findings and investigations revealed patients pathological change of thymus that had predisposed to the traumatic bleeding. The langerhans histiocytosis was is neoplasticism proliferation of the Langerhans cell that occurs in nodal and extra nodal sites, rarely seen in isolated lesions of thymus. Thus adult patients presenting with blunt chest trauma accompanied by mediastinum widening on the X-ray, then thymus bleeding should be considered as one of the differential diagnosis.