Spontaneous hemothorax is a very rare form of presentation of bronchogenic carcinoma. We present the case of a 73-year-old woman, non-smoker, with a history of hypertension, dyslipidaemia, diabetes mellitus, psoriasis and depressive disorder. The patient attended the emergency department with a one-week history of pleuritic chest pain and two-month history of weight loss and asthenia. Physical examination revealed absence of breath sounds in the base of the left hemithorax. The chest radiograph showed a radiopaque image in the left base consistent with pleural effusion and contralateral mediastinal shift. Computed tomography (CT) was performed, in which loculated pleural effusion, atelectasia of the lower lobe and lingula, and a solitary pulmonary nodule (maximum 2cm in diameter) were observed in the apical segment of the right lower lobe (Fig. 1). Thoracentesis was subsequently carried out, in which hemothorax was diagnosed and treated with chest drainage. The follow-up radiograph showed expansion, so the drain was removed on the sixth day. A new CT scan was then performed in which complete resolution of the hemothorax was observed, with persistence of the previously described nodule. The presence of malignant cells suggestive of adenocarcinoma was observed in 2 pleural fluid cytology specimens. Immunohistochemical analyses were positive for MOC-31, and a polymerase chain reaction (PCR) study showed a mutation in exon 19 of the EGFR gene. The patient was discharged with a diagnosis of EGFR-positive large cell carcinoma and treated with gefitinib.

Figure 1.

The chest CT scan shows loculated pleural effusion, atelectasia of the lower lobe and lingula, and a 2cm solitary pulmonary nodule in the apical segment of the left lower lobe.

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Spontaneous hemothorax is a rare entity and its causes include neoplasms, anticoagulant treatment or coagulation disorders, endometriosis, pulmonary infarction and pneumothorax with adhesions. Infectious causes have also been described.1 From a neoplastic perspective, metastases from gynaecological tumours, choriocarcinoma and sarcoma are the most common causes.2 The primary carcinoma most often associated with the development of spontaneous hemothorax is usually schwannoma of Von Recklinghausen disease and angiosarcoma.1 Spontaneous hemothorax as a form of presentation of a bronchogenic carcinoma is unusual in the literature,3 even in the context of pleural metastases.1 Compression and ischaemic necrosis of adjacent lung tissue due to subpleural growth of the tumour, or the invasion of pulmonary vessels with rupture and drainage into the pleural cavity, have been suggested as possible mechanisms.3 We performed a literature search in this respect. In databases such as PubMed (www.ncbi.nlm.nih.gov/PubMed), we found 576 studies using the key words “spontaneous hemothorax”. Of these, only 2 were related with bronchogenic carcinoma, one described by Chou et al.3 due to an adenocarcinoma with ipsilateral mediastinal node metastases, and another by Ausín et al.2 in 2005 due to a large cell carcinoma with liver and bone metastases. In our case, pathological, immunohistochemical and biological studies were carried out, so the patient was discharged with specific treatment to which she responded well.