Although the pleural cavities are anatomically separate in humans.

Although the pleural cavities are anatomically separate in humans, we describe bilateral pneumothoraces that occurr after percutaneous needle biopsy of the lung In one individuals, there may be communication between the pleural spaces; it is important for those performing interventional managements to be aware of this exceptional anatomic variant.

The pleural cavities in humans are usually anatomically separate.[1] Bilateral spontaneous synchronous pneumothoraces have been described in association with underlying pulmonary conditions so as bullous emphysema, cystic fibrosis, eosinophilic granuloma, Marfan's syndrome endometrosis, and Pneumocystis carinii pneumonia, as well as situations in which the two pleural cavities were violated from trauma or a single surgical or interventional procedure[2] lately communication between the pleural spaces was described in patients after sternotomy.[3] We report bilateral pneumothoraces after percutaneous lung biopsy in a patient without any of these predisposing factors. To our knowledge, this has not been previously described.

CASE REPORT

A 58-year-old woman with a lengthy smoking history presented to her local physician with left hemiparesis and ataxia. Cranial magnetic resonance imaging showed pair right hemispheric masses, and a chest radiograph demonstrated a 2-cm spiculated nodule in the anterior section of the right upper lobe. A transthoracic needle biopsy was scheduled to confirm the clinical impression of metastatic bronchogenic carcinoma.

Medical history was positive for rheumatoid arthritis and hypertension. Specimens from fresh bilateral breast biopsies were benign. There were no pulmonary symptoms.

Thoracic comput tomography (CT) confirmed the mien of the right upper lobe nodule situated peripherally near the anterior chest wall. There was mild bilateral upper lobe emphysema without bullae. No significant adenopathy or other parenchymal disease was instant The anterior junction line was in normal position.

Using CT guidance, a 19.5-gauge needle was inserted via an anterior parasternal approach, and the needle tip was positioned at the proxinal aspect of the mass. Three coaxial aspirations were performed using 22-gauge Chiba-style needle A repeated CT section at this time showed a moderate right pneumothorax, and although the patient remained asymptomatic, air was aspirated from the pleural space immediately with an 18-gauge angiocath inserted between the sides of the biopsy site. The Greene needle was remov and the action was terminated. The biopsy specimens were nondiagnostic.

The patient was placed in the declivous position. She experienced mild dyspnea, on the contrary had no other complaints. A chest radiograph 1 h later showed near undivided collapse of the right lung and a novel left pneumothorax as well, moderate in size (Fig 1) A 12-French thoracostomy tube was inserted at the biopsy incisional site and conjoined to a Heimlich valve. The patient's condition improved clinically and the couple lungs reexpanded.

Three hours later, a chest radiograph showed returning bilateral pneumothoraces, moderate in size. returning dyspnea improved when the thoracostomy tube was communicateed to 25 cm of negative urgency Both pneumothoraces gradually decreased in size across the next several days.

Four days after the lung biopsy, acute dyspnea and chest pain make knowned At the bedside, the chest tube was set up to be obstructed. No breath heartys were audible on the left side (contralateral to the original biopsy), and air was immediately aspirated from the left pleural space from one side a 16-gauge angiocath inserted from one side the second anterior interspace. The patient experienced immediate clinical improvement. Pigtail catheters were inserted into the two pleural spaces and connected to 20 cm of negative pressure

With the patient's condition finally stabilized and the pleural spaces evacuated, bronchoscopy with brushings of the right upper lobe bronchus was diagnostic for adenocarcinoma.

Nine days after the initial percutaneous biopsy attempt and pneumothorax, the pleural catheters were remov without incident. The patient turn backed home to commence radiation therapy, unless she died several months later from complications related to her cerebral metastases.

DISCUSSION

This case illustrates that in rare instances, the usually separate pleural cavities may communicate. Wittich and colleagues[3] not long ago described three patients with evidence of pleural cross-communication; however, all had had prior sternotomy. The authors postulated that the operative management disrupted normal anatomy, creating an artificial communication between right and left Jensen and his group[2] have described a case of bilateral pneumothoraces after lung biopsy in a patient whose contralateral lung was herniated across the midline at the time of the transaction such that both pleural cavities were violated on a single needle pass. In our case, no other than the right pleural space was troubleed as the anterior junction line was not near the biopsy site.

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