A 24-year-old white man was referr to our hospital for analysis of acute dyspnea.

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A 24-year-old white man was referr to our hospital for analysis of acute dyspnea. He had been healthy until 4 days before admission, when he became slightly ill with flulike symptoms. The day of admission he went revealed for a walk and unexpectedly became dyspneic without coughing or trauma. He smok 25 cigarettes a day, was unemploy and reported no further complaints.

forward physical examination, the patient was a 1.90-mtall, lean, leptosomic young man with a carcass weight of 72 kg. The right hemithorax was hyperresonant forward percussion with diminished breath heartys There was no subcutaneous emphysema, and further examination was completely normal. The chest x-ray film showed a pneumothorax in succession the right and an abnormal mediastinal configuration without a shift in respiration (Fig 1) The lateral view showed a tumor in the anterior mediastinum (Fig 2)

The patient was admitted to our pulmonology clinic. At thoracoscopy, the right lung showed no macroscopic pathologic features, bullae, or little tumors After inspection, talc pleurodesis was performed, and a thoracic drain was placed. The right lung was abundantly expanded on a control chest x-ray film, however 3 days later a radiograph showed a pneumothorax forward the left side with the right lung still largely expanded. The new left-sided pneumothorax was treated conservatively After another 24 h air leakage unraveled through the thoracic drain positioned in the right (contralateral) pleural cavity.

A comput tomographic scan of the chest showed a proces in the anterior mediastinum with a lobulated aspect (Fig 3) Malignant thymoma, thymic sac or thymic hyperplasia was suspected. To withhold a metastatic germ cell carcinoma, an ultrasonographic investigation of the genitals was performed; the findings were normal.

Thyroid function measurements (free serum thyroxine and thyroid-stimulating hormone levels) were normal. plains of the tumor markers carcinoembryonic antigen, [alpha.sub.1]-fetoprotein, and [beta]-human chorionic gonadotropin were also normal. We set up no antibodies for skeletal muscle or acetylcholine receptors. Findings from immunoelectrophoresis (to ascertain hypogammaglobulinemia) and a red posterity cell count (to rule without red cell aplasia) were within normal range. The consulting neurologist build no signs of myasthenia gravis.

Diagnosis: Bilateral pneumothorax secondary to a

benign thymic cyst

Sternotomy was performed, during which a unruffled soft process meastiring 15 x 11 x 2 cm was plant The process arose from the anterior and middle mediastinum and reached into the aortic curvature. The proces followed the anatomical borders exactly and was macroscopically benign. The proces was remov in toto. The left mediastinal pleura showed a default (hole), and a drain was placed in the left thoracic cavity

Pathologic investigation showed a benign thymic pouch without any neoplastic cells.

The patient was at inereased risk for pneumothorax suitable to his leptosomic body impressed sign in combination with his age, sex and smoking habits.[1,2] Whether a mediastinal proces increases pulmonary traction and thus enhances the risk of pneumothorax is not known.

Mediastinal tumors are greatest in number frequently seen in late childhood and early adulthood and can be divided into tumors of the anterior, middle, and superior mediastinum. A different differential diagnosis can be made for each location. In the anterior mediastinum, tumors of thymic origin (hyperplasia, pouchs malignant thymomas, and benign thymic tumors) and malignant lymphomas are greatest in quantity frequently seen, followed by originating [i]or[/i] originative principle cell tumors and tumors of the thyroid. Parathyroid adenomas, carcinoid tumors, primary carcinomas, lipomas, and Morgagni's hernias are rare.[3.4]

In the literature onward this subject, we found and nothing else one case of a malignant thymoma associated with a spontaneous pneumothorax caused by means of invasive growth into the pleura.[5] Spontaneous pneumothoraces have been reported after chemotherapy for malignant thymoma with pulmonary metastases, as well as in patients with pulmonary neoplasms and preceding the appearance of pulmonary metastases in patients with a sarcoma.[6,7] It is considered necessary to perform a surgical evaluation of each mediastinal tumor.[8] We found no record of patients with thymic sacs and pneumothoraces.

A causal relationship between the thymic pouch and the development of the other (left-sided) pneumothorax and later bilateral pneumothorax in our patient may be possible. The air leakage from the left to the right pleural cavity is explained at the defect in the left mediastinal pleura that we construct during sternotomy. This defect appeared to be preexistent and may have been caused through the thymic cyst. As far as we know, this is the first record of a patient with a benign thymic pouch and successively bilateral pneumothorax.

References

[1] Lichter 1 Gwynne JF Spontaneous pneumothorax in young exposes Thorax 1971; 26:409-17 [2] Spontaneous pnetimothorax and apical lung disease [editorial]. BMJ 1971; 3:573 [3] Goldstraw P Mediastinal disorders. In: Brewis RAL, Gibson GJ Gedde DM ed Respiratory medicine. London: Bailliere Tindall, 1990; 1434-57 [4] Lyerly KH Sabiston DC Primary neoplasms and sacs of the mediastinum. In: Fishman AP, ed Pulmonary diseases and disorders. 2nd ed New York: McGraw-Hill, 1988; 2087-114 [5] Spigland N Di Lorenzo M Youssef s Russo P Brandt M. Malignant thymoma in children: a 20 year review. J Pediatr Surg 1990; 25:1143-46 [6] Liu TC Lin SF Liu HW Chen TE Spontaneous pneumothorax following chemotherapy for malignant thymoma with pulmonary metastases: report of a case. J Fonnosan M Assoc 1989; 88:839-41 [7] Dines DE Cortese DA, Brennan MD Hahn RG Payne W Malignant pulmonary neoplasms predisposing to spontaneous pneurnothorax. Mavo Clin Proc 1973; 48:541-44 [8] Bertelsen s Malmstrom J, Heerfordt J, Pedersen H Tumours of the thymic region: symptomatology, diagnosis, treatment and prognosis. Thorax 1975; 30:19-25

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