A 46-year-old. Hispanic male with a past medical history significant for recurrent pneumothoraces, cannabis smoking, minimal tobacco smoking, heart failure with mildly reduced ejection fraction (45–50%), history of pericardial effusion, and cardiac tamponade status post-pericardial window presented to a major trauma with complaints of sudden onset chest pain and hemoptysis.

The patient had been experiencing fevers, chills, and worsening shortness of breath for the past 2 weeks. He had a remote history of prior left-sided tension pneumothorax in 2001 due to a stab wound that required a chest tube placement. Two years later, the patient had a right-sided spontaneous pneumothorax that required chest tube placement that was thought to be secondary to marijuana use. The patient has been smoking 7.5 g of marijuana per day since his early teenage years (for over 20 years). He also smoked half a cigarette per day for the past 6.75 years. He denied any history of asthma or Chronic Obstructive Pulmonary Disease and was not taking any medications at home with no history of any prescribed medication use. The patient also reported to have a history of a large ventral hernia. In 2018, the patient presented to another community hospital with acute onset shortness and abdominal pain. He was found to have a left diaphragmatic hernia (possibly secondary to previous trauma) for which he underwent operative repair. He had a complicated postoperative course to include midline wound dehiscence, for which pt reports a “skin substitute” was placed. He reported occasionally wearing an abdominal binder to keep the hernia in place; stated that he had “twinges” of right-sided pain when the binder was removed, but he was still passing gas and having regular bowel movements.

The patient’s symptoms began after bearing down in the restroom. He developed hemoptysis along with a sensation of an “air bubble” in his chest which felt similar to his prior pneumothoraces. The patient drove to the emergency department for evaluation. On admission, the patient reported right-sided, non-radiating chest pain that he rated a 10/10. The patient was afebrile at 36.4 °C with a heart rate of 74/min, blood pressure of 132/88 mmHg, respirations of 18 breaths/min, and SpO₂ of 98% on room air. He had a BMI 21.03 kg/m². Electrocardiogram showed normal sinus rhythm without any QTc prolongation. Physical examination was significant for decreased breath sounds on the right and a large, reducible ventral hernia.

Admission laboratories were largely unremarkable with renal function panel showing elevated blood glucose of 111 mg/dl. The Complete Blood Count showed normal white blood cell count of 6.84 K/ul , haemoglobin of 12.1 g/dl, and platelets of 492 K/ul. Respiratory Biofire for viral etiologies was negative. Troponins were unremarkable at 4 ng/l. Due to the history of recurrent pneumothorax, alpha 1-antitrypsin was measured and found to be within normal limits at 197 mg/dl.

The admission chest X-ray (CXR) revealed a moderate right-sided pneumothorax without mediastinal shift [Figure 1, A]. A 12 French Pigtail chest tube was placed with immediate symptomatic relief by the pulmonary critical care fellow following the case. The follow-up CXR showed significant improvement of right-sided pneumothorax with only a tiny residual pneumothorax remaining. Cardiothoracic surgery was consulted in the emergency department, but found that the patient did not meet any criteria for cardiothoracic intervention at this time. A computed tomography (CT) scan of the chest demonstrated diffuse emphysematous and bullous changes of the lateral aspect of both upper lobes (greater on the left), nonspecific mild ground glass infiltrates in the posterior aspect of the right lower lobe with adjacent bullous changes, and resolution of the pneumothorax. Incidentally, a thick-walled cavitary lesion was also observed in the posterior right lower lung field [Figure 2]. After 48 h, the patient’s chest tube was placed to water seal, clamped, then removed without any significant issues. In addition, he was placed on non rebreather mask 100% oxygen to augment complete resolution for 12 h. His follow-up CXR did not show any evidence of pneumothorax. [Figure 1, b]. A barium swallow was performed to rule out possible aspiration or oesophageal aetiology for his thick-walled lesion. The barium swallow did not show any evidence of aspiration or oesophageal perforation.

The patient made a significant clinical recovery and was subsequently discharged on room air. A follow-up with the pulmonology department was planned with an interval scan and a discussion for consideration of lung pleurodesis, given his high risk of recurrence. Patient declined pleurodesis during this hospitalization. Patient felt at this time pleurodesis was unnecessary and future pneumothoraces could be prevented with adequate lifestyle modifications (i.e. marijuana smoking cessation). The patient was discharged with 4 weeks of amoxicillin/clavulanate potassium 500 mg treatment for potential infectious aetiology given his cavitary lesion. Separately, general surgery elected not to operate on ventral hernia because there were no signs of incarceration and the patient was spontaneously passing gas and having a bowel movement. The surgery plan was to have the patient follow-up outpatient at a hernia repair centre for an elective repair.