01 Mar

Massive Hemothorax Due to Intrathoracic Extramedullary Hematopoiesis in a Patient With Thalassemia Intermedia: Case Report

On the morning of admission she awoke with the sudden onset of left pleuritic chest pain radiating to her left shoulder, weakness, and rapidly increasing dyspnea. She later recalled that her husbands arm had struck her chest when he turned over in his sleep the night before. On admission the blood pressure was 90/60 mm Hg; pulse rate, 120 and regular; respirations, 28/min; and temperature 38.7°C rectally. Physical examination results showed signs of a massive left pleural effusion, which a chest roentgenogram showed to extend almost to the lung apex. The WBC count was 8,400/ cu mm, and platelets were 412,000/cu mm. The bleeding time, prothrombin time, and partial thromboplastin time were normal. Thoracocentesis yielded gross blood with a hematocrit reading of 20 percent which was equal to the venous hematocrit. Pleural fluid analysis was negative for malignant cells and for microorganisms on smears and cultures.

A chest tube was placed and drained 3,400 ml of bloody fluid over the next 48 hours. The patient’s condition improved with transfusions of packed RBCs. The chest roentgenogram showed a reduction in the hemothorax. A CAT scan showed the large left posterior mediastinal mass, surrounded by blood and clot in the left pleural cavity. A smaller mass was seen in the right paravertebral area, with a small right pleural effusion. Visualization of the masses was markedly enhanced following administration of IV contrast medium (Fig 2). Link
On the fourth hospital day, her condition deteriorated; her left effusion was found to have increased again, almost filling the left hemithorax. A second chest tube was placed but did not result in significant improvement. A left thoracotomy was performed. The chest was filled with approximately 3 L of clotted blood. There was an 8 x 6-cm mass in the left paravertebral area just above the diaphragm, and a 3 X 2-cm mass just lateral to it which had not been appreciated on CAT scan. The capsule of the larger mass had several oozing stellate lacerations and a larger, rapidly bleeding longitudinal tear. The smaller lacerations were readily closed with sutures. The larger laceration required packing with Gel-foam soaked in thrombin, and apposition of the edges with pledgetted mattress sutures to control the bleeding. The intraoperative blood loss was estimated to be 8 L. Biopsy of the mass revealed extramedullary hematopoiesis. Postoperatively, the left and later the right mediastinal masses were irradiated with 1,500 rads in divided doses. There has been no recurrence of bleeding.

Figure 2. CAT scans showing large hematopoietic mass with marked enhancement after giving IV contrast medium (large arrow) surrounded by left hemothorax. Smaller hematopoietic mass is seen on right side (small arrow), with a small pleural effusion. Left chest tube is in place (open arrow).

Figure 2. CAT scans showing large hematopoietic mass with marked enhancement after giving IV contrast medium (large arrow) surrounded by left hemothorax. Smaller hematopoietic mass is seen on right side (small arrow), with a small pleural effusion. Left chest tube is in place (open arrow).

Categories: Thalassemia Intermedia
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