Images in Clinical Medicine

Lung Herniation after Cough-Induced Rupture of Intercostal Muscle

Matthew O'Shea, M.R.C.P., and Morgan Cleasby, F.R.C.R.

N Engl J Med 2012; 366:74January 5, 2012

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Article

A 40-year-old woman with asthma presented with a 2-day history of pleuritic pain of acute onset in the right side of the chest. She had been coughing markedly for 2 weeks and was treated in the community with antibiotics for a lower respiratory tract infection. There was no history of trauma. Her medical history also included hypertension, depression, and osteoporosis. On presentation, physical examination revealed crepitus along the right midaxillary line. A posteroanterior chest radiograph showed subcutaneous emphysema over the right lateral thoracic wall (Panel A, arrows). Subsequent computed tomographic imaging (Panel B, coronal reformat; Panel C, axial reconstruction) showed subcutaneous emphysema (arrows) and a focal intercostal muscle defect in the ninth intercostal space (asterisks), with lung and pleural herniation. She underwent right posterolateral thoracotomy at the ninth intercostal space for repair of the intercostal hernia and an associated diaphragmatic tear. There was no evidence of recurrent hernia at her 3-month follow-up visit.

Matthew O'Shea, M.R.C.P.
Morgan Cleasby, F.R.C.R.
Good Hope Hospital, Birmingham, United Kingdom