Echocardiographic
Diagnosis
A 63-year-old recurrent
L. DcJo.seph, M.D.;O* Robert %V. Leverison, M.D.;#{176}#{176} C. Edward F. Zeus, M.D., I”.C.C.P4
The
literature
graphic
contains
findings
descriptions rare.
We
discuss
logically.
the
a large
confirmed
The
both
importance
ining the area left ventricle,
below where
of the and
clot;
thrombus left
and
the mitral valve near most of the thrombi
myxoma
left
the
the
and ventricular
here
are
the
a large graphic
Pennsylvania
S. Hershey a #{176}Assistant
Reprint Center.
clot,1
contains
in
pathoexam-
the apex of the are located, is
reports
Division State
Medical
Professor
Fellow.
of in
of Cardiology, University
Center,
School Hershey,
of
of Medicine, Pa.
and
murmurs
with
peripheral
findings
from
limits.
Milton 17033
S. Hershey
an
acute
palpitations,
paroxysmal
nocturnal
the
un(ler\vent
lated
left
thrombus
from
scending
Medical
was
venous coronary
essentially
mass.
the left bypass
artery.
The
The
and
were
studies
revealed
The
it
peetoris,
occlusion was
within
Because
angina
Total
ventriculotomy,
equal.
enzyme
artery
ventricular
was
full grossly
unstable
coronary
was
There
infarction.
performed.
was
left
had
patient
descending
radiolucent
Milton
and
myocardial
with-
abdomen
of organs. were
examination
of acute that
The
all pulses
and
electrocardiograms
catheterization
Medicine,
evident.
neurologie
aortocoronary
Physiology.
or
occasions.
denied
or enlargement
edema,
normal
believed
angio-
were
masses,
no evidence
of Medicine.
Dr. Dejoseph, Pennsylvania
No
anterior Department
He
orthopnea,
several
sustained
exaniination
Serial
Presented
in a patient thrombus, with
on
had
infarction.
exertion,
distention,
no
atrial
findings ‘
sleep
patient
distress.
present.
confirmation.
of Medicine
requests: Hershey,
such rare.
left
findings
ventricular
pathologic
reports
of
describing or tumor are
echocardiographic
left
numerous
findings
thrombus
apical and
#{176}Fromthe
+Cardiology Professor
literature
(‘chocardiographie
from
revealed an apprehensive man in no Blood pressure was 118/72 mm Hg, and the pulse rate was 76 l)eats per minute and regular. There was no jugular venous distention. The chest was clear to percussion and auscultation. Examination of the heart revealed no palpable or visible lifts or thrills. The point of maximal impulse was in the fifth intercostal space in the midclavieular line and ‘ ‘a s diffuse. On auscultation, an 53 and 54 gallop rhythm was
thrombus
angiographically
on
acute
out
Ithough
previously,
Physical
are
findings
of echocardiographically
past
him the
dyspnea.
however,
ventricular
the
in
had a one-month history of which at first occurred only two weeks had occurred at rest
pain,
myocardial
clyspnea
or tumor
man
awakened
years
REPORT
chest
I)Ut
had
also
Three
stressed.
A
exertion,
and
echocardio-
echocardiographic
apical
white
precordial
anteroseptal
myxoma
atrial
with
A. Sliirofl, M.D.;t Martin, M.D.; and
reports
ventricular
here
with
was
which
many
in left
of left
a patient
CASE
CIot*
Intraventricular Robert Leslie Robert
of
found, patient
of as
was
cardiac the
left
vell
as a
sul)sequently
with removal of a peduncuventricular apex, and a single graft
his
to
patient s
left
anterior
postoperative
decourse
uneventful.
Fmuiui 1. Echocardiograms taken prior to removal of clot. A. Echocardiogram taken with transduc-er angled to record position deep in left ventricular cavity. Distinct mass of echoes is seen ( between arrows ) , which lies bet veen the echoes of interventricular septum ( S ) and left yentricular posterior wall ( LV ) . B. Transducer is scanned upward from deeper position of left yentricle ( LV ) to area of mitral valve ( m ) . Note disappearance of echo-producing mass ( between arrows) scanning is same
operative
mitral valvular left to right from
echo comes area of mitral
as
area
scanned
tracing.
CHEST, 71: 3, MARCH, 1977
in
Figure
S, Septum.
B.
Note
into view. 5, Septum. valve ( m ) to deeper absence
of
mass
of
ECHOCARDIOGRAPHIC
portion
echocardiogram of left ventricle ( LV ) . This
echoes
which
C.
Postoperative
were
DIAGNOSIS OF
present
in
pre-
INTRAVENTRICULAR CLOT
411
METHODS
Echocardiograms were recorded with the patient lying quietly in the supine position. A 2.25-MHz transducer onehalf inch in diameter ( Aerotech ) with a 7.5-em internal focus was used with an ultrasonic scope ( Unirad 100 Diagnostic Echoscope ) . Permanent recordings were made on black and white film ( Polaroid type 107 ) using a camera ( HewlettPackard 197A ) attached to the oseilloscopie screen of the diagnosie eehocardiographie scope. Serial pictures were taken as the transducer was angled from aorta to cardiac apex in an inferolateral direction. Right and left cardiac catheterization and left ventricular angiographic studies were performed in the usual manner. Coronary artenographie studies were done using Sones’ technique. RESULTS
The
echocardiogram
in the the
apical
area
mitral
echo
septum
mass
was
separate and
and
with
to the
apex
was
surgery,
a large
diameter
was
mass
the was
area
of
a distinct
found
of the
left
radiolucent the
apex
3 to
aneurysm
the
3 to
apex
being
4 cm
(Fig
thrombus
from
mi-
enlarged
entire
mass
pedunculated
an
the
ventricle.
the
occupying
in
from
a moderately
with
removed
scanning
transducer
revealed
A large
diameter
This
.
upon
the
chamber
aneurysmal.
below
1B)
repeatedly
catheterization
ventricular
ventricle
from the echoes of the intervenleft ventricular posterior wall. The
direction area
an echo-producing
left 1A
identified
inferolateral tral valve Cardiac left
( Fig
valve
clearly
tricular
revealed of the
of the
2)
.
in At
4 cm
left
in
ventri-
cle. Postoperative echocardiograms of a distinct echo-producing mass
revealed (Fig 1).
no evidence
the
findings
in
Farooki
et al
myoma
in infants,
described
Both
ventricle.
were to the
tively,
of the
ventricular
echoes
presumably
cavity
also
septal
during
one
the
In
the
tumors
echoes. mitral
valve
The
echoes
et al8
and
intervendue
to a
ventricle.
The findings in our case were limited to the area of the left ventricle below the mitral valve. These correlated well with both the findings at angiographic study and at surgery,
where
points
in
movable. Mural percent914 approximately
418
the
the apex
thrombi
thrombus of
the
of the
of hearts at 5 percent
DEJOSEPH ET AL
was ventricle
heart
attached and
are
postmortem of patients
found
at was
not
in 21
examination undergoing
of left
nary occur
artenographie as a
that
the
the
left
area
be
tricular
studies.’ of
result
Since detected
emboli
are
most is
important that
mitral
valve
emboli are some
that
well
of these it is im-
one
deep
found in
in the
apex
of
performing
examine
within
the
carefully
the
the
left
yen-
cavity. REFERENCES
1 Popp atrial 2 Wolfe
RL, Harrison DC : Ultrasound for the diagnosis of tumor. Ann Intern Med 71 :785-787, 1969 SB, Popp RL, Feigenbaum HO: Diagnosis of atrial tumors by ultrasound. Circulation 39:615-622, 1969 3 Finnegan RE, Harrison DC: Diagnosis of left atrial myoxma by echocardiograph. N Engl J Med 282: 10221023, 1970
freely
to 67
5 Srivastava TN, atrial myxoma.
and in coro-
systemic thrombi
searched for on routine Also, because it seems
commonly
it
4 Nasser WK, Davis 2. Phonocardiographie, and angiographic 83:810-82,4, 1972
several
taken in right anterior defect ( arrows) in
it appears that echocardiographically,
study
the
The these
be diligently examination.
ventricle,15
below
filling
large
ventricle.
di.ffi-
ventricular
were
apex
angiogram
showing
the
were
left
of
respecease
ventricular
echocardiographie
right
Levisman the
the
left
each
position,
portant that they echocardiographic
rhabdo-
sides,
echo.
within
of the
in
cluster
right
systole.
thrombus
tumor.7’8
an abnormal
by
of echoes between
septum
peduneulated
the
and
to the
septal
from
a cluster and
and
or
of ventricular
left by
left
produced
to separate
tricular
cases
in the
identified
adjacent
described
thrombus
two
one
echoes
cult
features of left atrial myxoma throughout the literature;’6 paucity of reports concerning
interventricular
2. Left
documented.1619 emboli can
DIScuSSIoN
The echocardiographie are described profusely however, there is a distinct
Ficuas oblique
RH,
Dillon JC, et al: Atrial myoxma: eehoeardiographie, hemodynamic features in nine eases. Am Heart
Fletcher E : The echocardiogram Am J Med 54:136-139, 1973
6 Kostis JB, Moghadam of left atrial myxoma.
AN : Echocardiographie Chest 58:550-552, 1970
and
J left
diagnosis
CHEST, 71: 3, MARCH,
1977
7 Farooki
ZQ,
Henry
JG,
of ventricular
pattern
Arciiegas
E, et al: Ultrasonic in two infants. Am
rhabdomyoma
J
Cardiol 34:842-844, 1974 8 Levisman JA, MacAlpin RN, Abbasi AS, et al: Echocardiographic diagnosis of a mobile, pedunculated tumor in the left 1975
ventricular
cavity.
J Cardiol
Am
36:957-959,
9 Garvin CF: Mural thrombi in the heart. Am Heart J 21:713-720, 1941 10 Jordan BA, Miller RD, Edwards JE, et al: Thrombal embohsm in acute and healed myocardial infarction: 1. Intracardiac mural thrombuses. Circulation 6:1-6, 1952 11 Yater WM, Welsh PP, Stapleton JE, et al: Comparison of clinical and pathological aspects of coronary artery disease in men of various age groups: A study of 950 autopsy cases from the Armed Forces Institute of Pathology. Ann Intern Med 34:352-392, 1951 12 Bean WB: Infarction of the heart: 3. CliniCal course and morphological findings. Ann Intern Med 12:71-94, 1938 13 Phares WS, Edwards BE, Burchell HB: Cardiac aneusysms: Clinical pathologic studies. Proc Staff Meetings Mayo Clin 28:264-271, 1953 14 Schlichter J, Hellerstein HK, Katz LN: Aneurysm of the heart: A correlative study of 102 proved cases. Medicine 33:43-78, 1954 15 Hamby RI, Wisoff BC, Davison ET, et al: Comnary artery disease and left ventricular mural thrombi: Clinical, hemodynamic and #{225}ngiocardiographic aspects. Chest 66:488494, 1974 16 Young JR, Humphres AW, DeWolfe DC, et al: Peripheral arterialembolism. JAMA 165:621-627,1963 17 Thompson JE, Weston AS, Sigler L, et al: Arterial embolectomy after acute myocardial infarction: Study of 31 patients. Ann Surg 171 :979-986, 1970 18 Darlene RC, Austen WG, Linton RR: Arterial embolism. Surg Gynecol Obstet 124:106-114, 1967 19 Miller RD. Jordan BA, Parker RL, et al: Thrombal embolism in acute and healed myocardial infarction: 2. Systemic and pulmonary arterial occlusion. Circulation 6:7-15, 1952
Idiopathic
Spontaneous *
a
Pneumotnorax Elecfron Edward
E. Tueller, and
Ph.D.;
A lung ond rax
Mkroscopic
of
the
R. Cnse; Jr.,
from
of idiopathic by electron
in septal
increase
Nancy
F. McLaughlin,
obtained
occurrence was studied
lion
M.D.;
Richard
biopsy
Sfudy
mass
was
interstitium
a patient
a notable due
and
elastic
fibers.
of type
1 and
type
2 epithelial
In
following A
remarkable
finding.
Prolifera-
to
an
abundance seen.
#{149}From the Peninsula Hospital, Burlingame, ler and McLaughlin), and California State ward ( Dr. Belton and Ms. Crise).
Calif
by
in
a contribution
memory
of
part
Martin
Reprint requests: Dr. fornia State University,
by the California Lung from R. F. McLaughlin, M. Kohn, M.D. Belton,
Hayward
CHEST, 71: 3, MARCH, 1977
Department
94542
of
a proliferation
was
Supported
a see-
pneumotho-
addition, cells
C. Belton,
F.C.C.P.
spontaneous microscopy.
was
collagen
John
M.D.,
pontaneous
pneumothorax, of air into
introduction
the
which results from the pleural spaces of the
thorax, has been observed in patients as a symptom of pulmonary diseases. Symptomatic spontaneous pneumothorax has been associated with a variety of pathologic conditions, including emphysema, bronchial asthma, chronic bronchitis, and Marfan’s syndrome.l 2 By contrast, idiopathic spontaneous pneumothorax appears to occur in the absence of consistently demonstrable pulmonary pathologic findings.3 The idiopathic condition has a marked tendency to recur and is most frequently seen in young men in the age range of 20 to 40 years old.1’4’5 It has been proposed that air escapes into the pleural space from a ruptured bleb in the visceral pleura. Such blebs are attributed to a dissection of air into the pleural tissue from a defect in the wall of a subpleural alveolus. ’ The cause of such a defect has never been established.
One
author
postulates
a chance
congenital
defect in the elastica of the alveolar wall.6 Another explanation involves a remote infection resulting in a check-valve obstruction of a small airway, distal distenlion, and subsequent rupture and dissection.’ A lung biopsy obtained from a patient undergoing treatment for a second occurrence of idiopathic spontaneous pneumothorax was examined with the light and electron microscopes. CASE
REPORT
On Jan 17, 1975, a 22-year-old man who was 180.3 cm (5 ft 11 in) tall and weighed 61 kg ( 135 lb) was admitted to the hospital with a right apical pneumothorax. He had smoked one pack of cigarettes per day for the past eight years. A chest tube was inserted, and the lung was expanded. On Jan 24, 1975, the patient was discharged from the hospital. Chest x-ray films taken at this time showed almost complete reexpansion of the right lung and otherwise normal pulmonary parenchyma. On the evening of March 24, 1975, the patient had a few coughs and developed what he thought was a muscular cramp in the right posterior portion of his chest. When he awoke the next morning, he smoked a cigarette and developed shortness of breath and difficulty in breathing with pain again in the right side of the chest. The patient entered the emergency room, and chest x-ray films taken at that time
showed
a medium-sized
4.0
of
pneumothorax, with approximately the visceral pleura and the chest wall in the superior portion of the right hemithorax. The size of the pneumothorax was estimated to be 10 to 15 percent. No other chest abnormalities or masses were seen. The patient was admitted to the hospital, at which time he stated that he had had no serious ChildhOod or adult illnesses cm
with
the
separation
exception
between
of the
first
collapsed
lung.
His
mother
died at the age of 40 years from lung cancer. His father and sister are in good health and have no history of pulmonary disease.
(Drs.
University, Association Jr.,
of
S
Biology,
TuelHay-
M.D.,
and in Cdi-
On the second
and
day
of hospitalization,
a right
thoracotomy
pleural abrasions were performed. At the time of surgery, fibrinous adhesions were seen medially in the upper right lobe, which suggested that this was the area of rupture of a bleb causing the pneumothorax. A lung biopsy was taken from an area adjacent to the area of suspected rupture. A portion of the tissue was fixed for routine pathologic examina-
IDIOPATHIC SPONTANEOUS PNEUMOTHORAX
419
Diagnosis
A 63-year-old recurrent
L. DcJo.seph, M.D.;O* Robert %V. Leverison, M.D.;#{176}#{176} C. Edward F. Zeus, M.D., I”.C.C.P4
The
literature
graphic
contains
findings
descriptions rare.
We
discuss
logically.
the
a large
confirmed
The
both
importance
ining the area left ventricle,
below where
of the and
clot;
thrombus left
and
the mitral valve near most of the thrombi
myxoma
left
the
the
and ventricular
here
are
the
a large graphic
Pennsylvania
S. Hershey a #{176}Assistant
Reprint Center.
clot,1
contains
in
pathoexam-
the apex of the are located, is
reports
Division State
Medical
Professor
Fellow.
of in
of Cardiology, University
Center,
School Hershey,
of
of Medicine, Pa.
and
murmurs
with
peripheral
findings
from
limits.
Milton 17033
S. Hershey
an
acute
palpitations,
paroxysmal
nocturnal
the
un(ler\vent
lated
left
thrombus
from
scending
Medical
was
venous coronary
essentially
mass.
the left bypass
artery.
The
The
and
were
studies
revealed
The
it
peetoris,
occlusion was
within
Because
angina
Total
ventriculotomy,
equal.
enzyme
artery
ventricular
was
full grossly
unstable
coronary
was
There
infarction.
performed.
was
left
had
patient
descending
radiolucent
Milton
and
myocardial
with-
abdomen
of organs. were
examination
of acute that
The
all pulses
and
electrocardiograms
catheterization
Medicine,
evident.
neurologie
aortocoronary
Physiology.
or
occasions.
denied
or enlargement
edema,
normal
believed
angio-
were
masses,
no evidence
of Medicine.
Dr. Dejoseph, Pennsylvania
No
anterior Department
He
orthopnea,
several
sustained
exaniination
Serial
Presented
in a patient thrombus, with
on
had
infarction.
exertion,
distention,
no
atrial
findings ‘
sleep
patient
distress.
present.
confirmation.
of Medicine
requests: Hershey,
such rare.
left
findings
ventricular
pathologic
reports
of
describing or tumor are
echocardiographic
left
numerous
findings
thrombus
apical and
#{176}Fromthe
+Cardiology Professor
literature
(‘chocardiographie
from
revealed an apprehensive man in no Blood pressure was 118/72 mm Hg, and the pulse rate was 76 l)eats per minute and regular. There was no jugular venous distention. The chest was clear to percussion and auscultation. Examination of the heart revealed no palpable or visible lifts or thrills. The point of maximal impulse was in the fifth intercostal space in the midclavieular line and ‘ ‘a s diffuse. On auscultation, an 53 and 54 gallop rhythm was
thrombus
angiographically
on
acute
out
Ithough
previously,
Physical
are
findings
of echocardiographically
past
him the
dyspnea.
however,
ventricular
the
in
had a one-month history of which at first occurred only two weeks had occurred at rest
pain,
myocardial
clyspnea
or tumor
man
awakened
years
REPORT
chest
I)Ut
had
also
Three
stressed.
A
exertion,
and
echocardio-
echocardiographic
apical
white
precordial
anteroseptal
myxoma
atrial
with
A. Sliirofl, M.D.;t Martin, M.D.; and
reports
ventricular
here
with
was
which
many
in left
of left
a patient
CASE
CIot*
Intraventricular Robert Leslie Robert
of
found, patient
of as
was
cardiac the
left
vell
as a
sul)sequently
with removal of a peduncuventricular apex, and a single graft
his
to
patient s
left
anterior
postoperative
decourse
uneventful.
Fmuiui 1. Echocardiograms taken prior to removal of clot. A. Echocardiogram taken with transduc-er angled to record position deep in left ventricular cavity. Distinct mass of echoes is seen ( between arrows ) , which lies bet veen the echoes of interventricular septum ( S ) and left yentricular posterior wall ( LV ) . B. Transducer is scanned upward from deeper position of left yentricle ( LV ) to area of mitral valve ( m ) . Note disappearance of echo-producing mass ( between arrows) scanning is same
operative
mitral valvular left to right from
echo comes area of mitral
as
area
scanned
tracing.
CHEST, 71: 3, MARCH, 1977
in
Figure
S, Septum.
B.
Note
into view. 5, Septum. valve ( m ) to deeper absence
of
mass
of
ECHOCARDIOGRAPHIC
portion
echocardiogram of left ventricle ( LV ) . This
echoes
which
C.
Postoperative
were
DIAGNOSIS OF
present
in
pre-
INTRAVENTRICULAR CLOT
411
METHODS
Echocardiograms were recorded with the patient lying quietly in the supine position. A 2.25-MHz transducer onehalf inch in diameter ( Aerotech ) with a 7.5-em internal focus was used with an ultrasonic scope ( Unirad 100 Diagnostic Echoscope ) . Permanent recordings were made on black and white film ( Polaroid type 107 ) using a camera ( HewlettPackard 197A ) attached to the oseilloscopie screen of the diagnosie eehocardiographie scope. Serial pictures were taken as the transducer was angled from aorta to cardiac apex in an inferolateral direction. Right and left cardiac catheterization and left ventricular angiographic studies were performed in the usual manner. Coronary artenographie studies were done using Sones’ technique. RESULTS
The
echocardiogram
in the the
apical
area
mitral
echo
septum
mass
was
separate and
and
with
to the
apex
was
surgery,
a large
diameter
was
mass
the was
area
of
a distinct
found
of the
left
radiolucent the
apex
3 to
aneurysm
the
3 to
apex
being
4 cm
(Fig
thrombus
from
mi-
enlarged
entire
mass
pedunculated
an
the
ventricle.
the
occupying
in
from
a moderately
with
removed
scanning
transducer
revealed
A large
diameter
This
.
upon
the
chamber
aneurysmal.
below
1B)
repeatedly
catheterization
ventricular
ventricle
from the echoes of the intervenleft ventricular posterior wall. The
direction area
an echo-producing
left 1A
identified
inferolateral tral valve Cardiac left
( Fig
valve
clearly
tricular
revealed of the
of the
2)
.
in At
4 cm
left
in
ventri-
cle. Postoperative echocardiograms of a distinct echo-producing mass
revealed (Fig 1).
no evidence
the
findings
in
Farooki
et al
myoma
in infants,
described
Both
ventricle.
were to the
tively,
of the
ventricular
echoes
presumably
cavity
also
septal
during
one
the
In
the
tumors
echoes. mitral
valve
The
echoes
et al8
and
intervendue
to a
ventricle.
The findings in our case were limited to the area of the left ventricle below the mitral valve. These correlated well with both the findings at angiographic study and at surgery,
where
points
in
movable. Mural percent914 approximately
418
the
the apex
thrombi
thrombus of
the
of the
of hearts at 5 percent
DEJOSEPH ET AL
was ventricle
heart
attached and
are
postmortem of patients
found
at was
not
in 21
examination undergoing
of left
nary occur
artenographie as a
that
the
the
left
area
be
tricular
studies.’ of
result
Since detected
emboli
are
most is
important that
mitral
valve
emboli are some
that
well
of these it is im-
one
deep
found in
in the
apex
of
performing
examine
within
the
carefully
the
the
left
yen-
cavity. REFERENCES
1 Popp atrial 2 Wolfe
RL, Harrison DC : Ultrasound for the diagnosis of tumor. Ann Intern Med 71 :785-787, 1969 SB, Popp RL, Feigenbaum HO: Diagnosis of atrial tumors by ultrasound. Circulation 39:615-622, 1969 3 Finnegan RE, Harrison DC: Diagnosis of left atrial myoxma by echocardiograph. N Engl J Med 282: 10221023, 1970
freely
to 67
5 Srivastava TN, atrial myxoma.
and in coro-
systemic thrombi
searched for on routine Also, because it seems
commonly
it
4 Nasser WK, Davis 2. Phonocardiographie, and angiographic 83:810-82,4, 1972
several
taken in right anterior defect ( arrows) in
it appears that echocardiographically,
study
the
The these
be diligently examination.
ventricle,15
below
filling
large
ventricle.
di.ffi-
ventricular
were
apex
angiogram
showing
the
were
left
of
respecease
ventricular
echocardiographie
right
Levisman the
the
left
each
position,
portant that they echocardiographic
rhabdo-
sides,
echo.
within
of the
in
cluster
right
systole.
thrombus
tumor.7’8
an abnormal
by
of echoes between
septum
peduneulated
the
and
to the
septal
from
a cluster and
and
or
of ventricular
left by
left
produced
to separate
tricular
cases
in the
identified
adjacent
described
thrombus
two
one
echoes
cult
features of left atrial myxoma throughout the literature;’6 paucity of reports concerning
interventricular
2. Left
documented.1619 emboli can
DIScuSSIoN
The echocardiographie are described profusely however, there is a distinct
Ficuas oblique
RH,
Dillon JC, et al: Atrial myoxma: eehoeardiographie, hemodynamic features in nine eases. Am Heart
Fletcher E : The echocardiogram Am J Med 54:136-139, 1973
6 Kostis JB, Moghadam of left atrial myxoma.
AN : Echocardiographie Chest 58:550-552, 1970
and
J left
diagnosis
CHEST, 71: 3, MARCH,
1977
7 Farooki
ZQ,
Henry
JG,
of ventricular
pattern
Arciiegas
E, et al: Ultrasonic in two infants. Am
rhabdomyoma
J
Cardiol 34:842-844, 1974 8 Levisman JA, MacAlpin RN, Abbasi AS, et al: Echocardiographic diagnosis of a mobile, pedunculated tumor in the left 1975
ventricular
cavity.
J Cardiol
Am
36:957-959,
9 Garvin CF: Mural thrombi in the heart. Am Heart J 21:713-720, 1941 10 Jordan BA, Miller RD, Edwards JE, et al: Thrombal embohsm in acute and healed myocardial infarction: 1. Intracardiac mural thrombuses. Circulation 6:1-6, 1952 11 Yater WM, Welsh PP, Stapleton JE, et al: Comparison of clinical and pathological aspects of coronary artery disease in men of various age groups: A study of 950 autopsy cases from the Armed Forces Institute of Pathology. Ann Intern Med 34:352-392, 1951 12 Bean WB: Infarction of the heart: 3. CliniCal course and morphological findings. Ann Intern Med 12:71-94, 1938 13 Phares WS, Edwards BE, Burchell HB: Cardiac aneusysms: Clinical pathologic studies. Proc Staff Meetings Mayo Clin 28:264-271, 1953 14 Schlichter J, Hellerstein HK, Katz LN: Aneurysm of the heart: A correlative study of 102 proved cases. Medicine 33:43-78, 1954 15 Hamby RI, Wisoff BC, Davison ET, et al: Comnary artery disease and left ventricular mural thrombi: Clinical, hemodynamic and #{225}ngiocardiographic aspects. Chest 66:488494, 1974 16 Young JR, Humphres AW, DeWolfe DC, et al: Peripheral arterialembolism. JAMA 165:621-627,1963 17 Thompson JE, Weston AS, Sigler L, et al: Arterial embolectomy after acute myocardial infarction: Study of 31 patients. Ann Surg 171 :979-986, 1970 18 Darlene RC, Austen WG, Linton RR: Arterial embolism. Surg Gynecol Obstet 124:106-114, 1967 19 Miller RD. Jordan BA, Parker RL, et al: Thrombal embolism in acute and healed myocardial infarction: 2. Systemic and pulmonary arterial occlusion. Circulation 6:7-15, 1952
Idiopathic
Spontaneous *
a
Pneumotnorax Elecfron Edward
E. Tueller, and
Ph.D.;
A lung ond rax
Mkroscopic
of
the
R. Cnse; Jr.,
from
of idiopathic by electron
in septal
increase
Nancy
F. McLaughlin,
obtained
occurrence was studied
lion
M.D.;
Richard
biopsy
Sfudy
mass
was
interstitium
a patient
a notable due
and
elastic
fibers.
of type
1 and
type
2 epithelial
In
following A
remarkable
finding.
Prolifera-
to
an
abundance seen.
#{149}From the Peninsula Hospital, Burlingame, ler and McLaughlin), and California State ward ( Dr. Belton and Ms. Crise).
Calif
by
in
a contribution
memory
of
part
Martin
Reprint requests: Dr. fornia State University,
by the California Lung from R. F. McLaughlin, M. Kohn, M.D. Belton,
Hayward
CHEST, 71: 3, MARCH, 1977
Department
94542
of
a proliferation
was
Supported
a see-
pneumotho-
addition, cells
C. Belton,
F.C.C.P.
spontaneous microscopy.
was
collagen
John
M.D.,
pontaneous
pneumothorax, of air into
introduction
the
which results from the pleural spaces of the
thorax, has been observed in patients as a symptom of pulmonary diseases. Symptomatic spontaneous pneumothorax has been associated with a variety of pathologic conditions, including emphysema, bronchial asthma, chronic bronchitis, and Marfan’s syndrome.l 2 By contrast, idiopathic spontaneous pneumothorax appears to occur in the absence of consistently demonstrable pulmonary pathologic findings.3 The idiopathic condition has a marked tendency to recur and is most frequently seen in young men in the age range of 20 to 40 years old.1’4’5 It has been proposed that air escapes into the pleural space from a ruptured bleb in the visceral pleura. Such blebs are attributed to a dissection of air into the pleural tissue from a defect in the wall of a subpleural alveolus. ’ The cause of such a defect has never been established.
One
author
postulates
a chance
congenital
defect in the elastica of the alveolar wall.6 Another explanation involves a remote infection resulting in a check-valve obstruction of a small airway, distal distenlion, and subsequent rupture and dissection.’ A lung biopsy obtained from a patient undergoing treatment for a second occurrence of idiopathic spontaneous pneumothorax was examined with the light and electron microscopes. CASE
REPORT
On Jan 17, 1975, a 22-year-old man who was 180.3 cm (5 ft 11 in) tall and weighed 61 kg ( 135 lb) was admitted to the hospital with a right apical pneumothorax. He had smoked one pack of cigarettes per day for the past eight years. A chest tube was inserted, and the lung was expanded. On Jan 24, 1975, the patient was discharged from the hospital. Chest x-ray films taken at this time showed almost complete reexpansion of the right lung and otherwise normal pulmonary parenchyma. On the evening of March 24, 1975, the patient had a few coughs and developed what he thought was a muscular cramp in the right posterior portion of his chest. When he awoke the next morning, he smoked a cigarette and developed shortness of breath and difficulty in breathing with pain again in the right side of the chest. The patient entered the emergency room, and chest x-ray films taken at that time
showed
a medium-sized
4.0
of
pneumothorax, with approximately the visceral pleura and the chest wall in the superior portion of the right hemithorax. The size of the pneumothorax was estimated to be 10 to 15 percent. No other chest abnormalities or masses were seen. The patient was admitted to the hospital, at which time he stated that he had had no serious ChildhOod or adult illnesses cm
with
the
separation
exception
between
of the
first
collapsed
lung.
His
mother
died at the age of 40 years from lung cancer. His father and sister are in good health and have no history of pulmonary disease.
(Drs.
University, Association Jr.,
of
S
Biology,
TuelHay-
M.D.,
and in Cdi-
On the second
and
day
of hospitalization,
a right
thoracotomy
pleural abrasions were performed. At the time of surgery, fibrinous adhesions were seen medially in the upper right lobe, which suggested that this was the area of rupture of a bleb causing the pneumothorax. A lung biopsy was taken from an area adjacent to the area of suspected rupture. A portion of the tissue was fixed for routine pathologic examina-
IDIOPATHIC SPONTANEOUS PNEUMOTHORAX
419
