Spontaneous intercostal bulge
RodneyJ Folz, Claude A Piantadosi, Emily K Folz
Carolina 27710, USA
R J Folz
C A Piantadosi,
E K Folz
Correspondence to Rodney J
Folz, MD, PhD, Box
2620/Room 339, Medical
Science Research Building,
Durham, NC 27710, USA
Accepted 23 July 1997
A 48-year-old man had been diagnosed with severe chronic obstructive pulmonary disease and
referred to our pulmonary clinic. His medical history revealed a 60-80 pack year smoking history
and long-standing heavy alcohol consumption. He worked as an upholsterer, with exposure to
glues and paints for 20 years. Tuberculin skin testing was negative with a positive Candida con-
trol. Sputum Gram-stain revealed many polymorphonuclear leukocytes and was AFB-stain posi-
tive. Culture growth indicated mycobacterium other than tuberculosis identified as Runyoun's
Group III. Drug sensitivity testing demonstrated 0% resistance to the combination of isoniazid,
rifampin, and ethionamide.
His clinical condition gradually deteriorated despite antimicrobial therapy. Pulmonary function
testing in 1994 demonstrated severe obstructive lung disease with a DLCO of29% predicted (8.5
ml/min/mmHg). One month later, he developed acute bronchitis and during a severe coughing
spell he noticed the acute onset of bulging of his left anterior chest wall. The bulge rapidly
expanded during manoeuvres which increased intrathoracic pressure and rapidly reduced with
cessation of these manoeuvres. In addition to the expansion and contraction of this chest wall
bulge, physical examination was remarkable for sonorous breath sounds and the sound of
'gurgling' fluid within the bulge. A chest X-ray is shown in figure 1. A chest computed tomogra-
phy (CT) scan (figure 2) was obtained in the semi-prone position during a Valsalva manoeuvre.
Figure 1Chest X-ray
during a Valsalva manoeuvre
Chest CT scan in the semi-prone position
1 Identify the pertinent findings in the chest X-ray (figure 1) and CT scan (figure 2).
2 What is the clinical diagnosis?
3 How might one classify these lesions?
4 List three sites of relative anatomic weakness in the chest wall.
The chest X-ray demonstrated hyperinflation,
severe bullous emphysema, and cavities con-
taining air-fluid levels. The chest CT scan in
the semi-prone position during a Valsalva
change in the left lung and a small cavity in the
right lung. The arrow indicates herniation of a
large bulla through the left anterior second and
third rib interspace.
The diagnosis is spontaneous intercostal her-
niation of a lung bulla.
The original classification ofextrathoracic lung
herniation by Morel-Lavallee
comprehensive and often
literature. The classification describes lung
herniation according to location - cervical,
thoracic, or diaphragmatic - and according to
aetiology - congenital or acquired. Acquired
lung hernias are further divided into traumatic,
consecutive, spontaneous, and pathological.
Only one case of diaphragmatic lung hernia-
tion has been described.'
The term consecutive hernia is confusing; it
was used to define those hernias developing
some time after a focal chest wall injury. These
cases should be categorised
Pathological hernias develop secondary
neoplasm or infection involving the chest wall.
still cited in the
The thorax has three sites of relative anatomic
weakness, and these are the most common sites
ofcongenital and spontaneous lung herniation.
In the cervical region, there is a relatively
unsupported region between the sternocleido-
mastoid and the anterior scalene muscles. In
the intercostal spaces, there are two areas of
anatomic weakness created by the absence of
musculature. The external intercostal muscles
extend from the rib tubercles posteriorly to the
beginnings of the costal cartilages anteriorly.
From there, they continue along the costal car-
tilage as the anterior intercostal membranes.
The internal intercostal muscles extend from
the sternum to the angles of the ribs, from
which they continue as the posterior intercostal
membranes to the vertebral column. It is at
these sites created by the absence of the exter-
nal intercostal muscles anteriorly, and the
absence of the internal intercostal muscles
posteriorly, that most spontaneous thoracic
lung herniations occur.
Approximately 264 cases of lung herniation
have been reported in the literature.2 3Ofthese,
an estimated 52% were post-traumatic, 18%
were congenital, and 29% were spontaneous.24
Of 11 spontaneous hernias reported by Hiscoe
and Digman, eight were cervical and three
thoracic.4 They contrasted their findings to
Classification oflung hernias
According to location
According to aetiology
* acquired: traumatic, consecutive, spontaneous,
spontaneous hernias were cervical and 18
thoracic.4 These reports suggest that approxi-
mately half of the cases of spontaneous lung
herniations are intercostal.
Spontaneous hernias have resulted from a
variety of conditions associated with an exces-
sive increase in intrathoracic pressure. These
emphysema, pertussus, straining during la-
bour, heavy lifting, and blowing glass or musi-
cal instruments.5 6 The mechanism of sponta-
neous lung herniation in chronic bronchitis
and emphysema is thought to be related to lung
hyperinflation, refractory cough, and possibly
weakness.27 Spontaneous hernias have also
been described in patients with congenital
absence of chest wall musculature.6 Only one
other case of spontaneous herniation of a lung
bulla has been described. This occurred in the
cervical region of a 60-year-old woman with
presents clinically as the acute onset of a focal
bulge associated with pain. Less commonly, a
patient may present with progressive painless
enlargement of a lump in the neck or between
the ribs. Frequently there will be an increase in
the size of the lung hernia with Valsalva
manoeuvre. The hernial orifice is said to be
easy to palpate and one can reduce the hernia
by covering the orifice with the fingers.6 Diag-
nosis is usually evident clinically due to the
size of the spongy mass with
manoeuvres that change intrathoracic pres-
sure, as in the case ofour patient. Confirmation
ofthe diagnosis can be accomplished with plain
chest radiography utilising a tangential projec-
tion. Limited CT of the chest with Valsalva
hernia, but should be reserved for patients in
whom the clinical or plain radiographic fea-
tures are not conclusive.
Extrathoracic herniation of lung tissue is
usually non-life-threatening and does not typi-
cally require major therapeutic interventional
procedures. Out-patient management schemes
include strapping the hernia site with compres-
sive pads or by using a thoracic corset. Surgery
should be considered when the hernia is caus-
ing chronic chest pain,9 '° incarcerates the pul-
monary parenchyma,'" 12 results in recurrent
infection, or for cosmetic purposes. The use of
local tissues and/or synthetic materials to repair
described.3 910 11
Spontaneousintercostal herniation of alung
bulla in apatientwith severeemphysemaand
Keywords: lung bulla; herniation; mycobacterium;
cavitary lungdisease; bullousemphysema
1 Beale EC. On a case of hernia of the lung through
2 Munnell E. Herniation of the lung. Ann Thorac Surg
3 Scullion DA, Negus R, Al-Kutoubi A. Case report:
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4 Hiscoe DB, Digman GJ. Types and incidence of lung
5 Sloth-NielsenJ, JurikAG.Spontaneousintercostalpulmo-
6Montgomery JG, Lutz H. Hernia of the lung.Ann Surg
7 Prasad R, Mukerji PK, GuptaH. Herniation of thelung.
IndianJChest Dis Allied Sci 1990;32:129-32.
8 Victor S, Muthurajan S, Sekhar TG, et al. Giant cervical
herniation ofanapical pumonarybulla.JThorac Cardiovasc
9 DiMarcoAF,Oca0,RenstonJP. Lungherniation: a cause
of chronic chestpain following thoracotomy.Chest 1995;
10 CerniliaJ,LinJ,OttR,ScannellG,Waxman K. Atechnique
11 May AK, Chan B, Daniel TM, Young JS.Anteriorlung
herniation: another aspect of the seatbelt syndrome. J
12 Moncada R, Vade A, Gimenez C, et al. Congenital and
acquired lunghernias.JThoracImaging 1996;11:75-82.
Mycobacterialliver abscess in apatientwith AIDS
Cajal, Madrid, Spain
A33-year-old HIV-positiveman was admitted to ourhospitalwith a one-monthhistoryof low-
grade fever,malaise andweightloss.Eight yearsbefore he had beendiagnosedwith anasympto-
matic liverhydatid cyst,which had not been treated. Two months before admission his CD4
count was 15 cells/pl. Physicalexamination showed a cachecticpatient.Blood cultures taken on
the firstdayof admission werenegative,but asputumsmear revealed 10 acid-fast bacilli/100
fields on Ziehl-Neelsenstaining.Abdominalultrasonographyrevealed onelarge hypo-echoic
lesion in the liver(figure 1),afindingconfirmedby computed tomography (CT) (figure 2).
Treatment withisoniazid, rifampin,ethambutol andpyrazinamidewas started, but thepatient
remained febrile and showedprogressivedeterioration.
1 Which aetiologic agents should be considered?
2 How should the diagnosis be established?
3 What would be the best therapeutic approach ?