![16 R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8
Fig. 1 – Initial chest x-ray demonstrates left-sided
diaphragmatic hernia secondary to diaphragmatic rupture.
psychosocial, respiratory, and skin complications [1]. We
reported a case with cough-related diaphragmatic rupture
which incidence is unknown since condition is rare and many
cases likely go undiagnosed.
Case history
A 72-year-old woman G3P3A0 with a medical history of mor-
bid obesity, hypertension, fibromyalgia, diabetes mellitus type
2, and controlled sleep apnea with no toxic habits.
She came to the emergency department with a chief com-
plaint of dry cough and progressive shortness of breath of
approximately 1 year of evolution. She mentioned multiple
visits to her primary physician as well as to the emergency
room without improvement of symptoms during that year.
Her treatment included nasal and inhaled steroids, proton
pump inhibitors, antibiotics, and expectorants. As she contin-
ued with a prolonged forceful cough not responsive to medical
management and developed upper chest pain and a tearing
abdominal pain radiated to the back. Chest ecchymosis was
present alongside with worsening dyspnea, early satiety upon
eating, and left breast pain. She denied fever, sputum produc-
tion, or recent trauma. Within that year, the patient never got
a chest x-ray. Initial chest x-ray (Fig. 1) taken 1 year after the
beginning of symptoms showed left-sided diaphragmatic her-
nia secondary to diaphragmatic and chest wall rupture. Sub-
sequent chest CT scan axial view (Fig. 2), coronal view (Fig. 3),
sagittal view (Fig. 4), and reconstruction (Figs. 5 and 6) demon-
strated evidence of rib fracture, chest wall, and diaphragmatic
rupture with a displacement of small and large bowel into
the left side thoracic cavity causing left pulmonary collapse.
Surgical findings consisted of a chronic large left anterior di-
aphragmatic hernia with bowel and omentum protruding to
the pleura cavity plus subcutaneous detachment of left sub-
costal cartilage from the sternum as the causative of lung col-
lapse. Afterward, thoracotomy was performed with repair of
bowel placement on the abdominal cavity, correction of di-
aphragmatic rupture, reinforcement with a proline mesh, and
chest tube placement for pneumothorax. A 1-week postsur-
gical follow-up with chest x-ray showing resolved herniation
(Fig. 7) and discharge without complications.
Fig. 2 – Chest CT with evidence of intra-abdominal content in the left hemithorax. (A) Lung window and (B) abdominal
window.](https://image.slidesharecdn.com/herniadiafragmatika-250309041223-f53e6cb7/85/HhhhhhHernia-diafragmatikaaaaaaaaaaaaa-pdf-2-320.jpg)
![R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8 17
Fig. 3 – Coronal view of intra-abdominal content in the left-sided hemithorax. (A) Lung window and (B) abdominal window.
Fig. 4 – Sagittal view with anterior diaphragmatic and chest
wall rupture with intra-abdominal content. (Abdominal
window.)
Discussion
Diaphragmatic rupture is most commonly cause by penetrat-
ing injury or blunt abdominal trauma in 63% and 37% of the
cases, respectively [2]. The diaphragm is a dome-shaped mus-
cle, which contracts during the inspiratory phase. Cough val-
salva maneuver causes lack of coordination of different mus-
cles of expiration, the muscle of the abdominal wall contract
Fig. 5 – Chest CT reconstruction with evidence of a
diaphragmatic hernia, rib fractures, and intra-abdominal
content of left breast.
pushing the diaphragm upward, whereas the ribs are pushed
inward and downward leading to a diaphragmatic rupture [3].
Herniation of bowel loops into the chest can be a consequence
of diaphragmatic rupture, which impairs ventilation and oxy-
gen delivery. The true incidence of abdominal organ herni-
ation due to diaphragmatic rupture is unknown since many
cases likely go undiagnosed or usually appear delayed.
Diaphragmatic injuries are usually diagnostic challenges.
Chest radiographs are the initial and most common imaging
study to evaluate the diaphragm. When the results are incon-
clusive, CT is the next study of choice since it can assess the](https://image.slidesharecdn.com/herniadiafragmatika-250309041223-f53e6cb7/85/HhhhhhHernia-diafragmatikaaaaaaaaaaaaa-pdf-3-320.jpg)
![18 R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8
Fig. 6 – Chest CT reconstruction of the lung, remarkable for
the left lower lobe collapse.
Fig. 7 – Chest x-ray postanterior diaphragmatic hernia and
chest wall abnormality repair.
extent and anatomical sites of coexisting thoracoabdominal
injuries [4].
The rate of missed diaphragmatic rupture on chest radio-
graphs ranges from 12% to 66% with the potential risk of a late
visceral herniation through the diaphragmatic defect [5]. The
sum of physician unawareness about the diagnosis, and the
subtle and nonspecific findings of chest radiography along-
side the technical limitations such as supine positioning, use
of portable radiography, and limited patient cooperation make
the diagnosis difficult through chest radiography alone. How-
ever, it remains a valuable imaging option in the acute phase
for the detection of diaphragmatic rupture and when CT is not
available or cannot be performed [6,7].
Diaphragmatic rupture has an overall mortality rate of
25% as reported by the National Trauma Data Bank. Due to
an increased rate of herniation and strangulation of abdom-
inal organs secondary to diaphragmatic rupture, which can
be life threatening, early diagnosis and repair are desirable
[8–10]. Therefore, physicians should be aware of this uncom-
mon complication of cough.
R E F E R E N C E S
[1] Roberge RJ, Morgenstern MJ, Osborn H. Cough fracture of the
ribs. Am J Emerg Med 1984;2:513–17.
doi:10.1016/0735-6757(84)90077-9.
[2] Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current
status of traumatic diaphragmatic injury: lessons learned
from 105 patients over 13 years. Ann Thorac Surg
2008;85(3):1044–8.
[3] Hillenbrand A, Henne-Bruns D. Cough induced rib fracture,
rupture of the diaphragm and abdominal herniation. World J
Emerg Surg 2006;1:34. doi:10.1186/1749-7922-1-34.
[4] Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging
of diaphragmatic injuries. J Thorac Imaging 2000;15:104–11
PMID: 10798629.
[5] Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG,
Buchler MW. Missed diaphragmatic injuries and their
long-term sequelae. J Trauma 1998;44:183–8.
doi:10.1097/00005373-199801000-00026.
[6] Desir A, Ghaye B. CT of blunt diaphragmatic rupture.
RadioGraphics 2012;32:477–98. doi:10.1148/rg.322115082.
[7] Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG.
Imaging of diaphragmatic injury: a diagnostic challenge?
RadioGraphics 2002;22:103–18.
doi:10.1148/radiographics.22.suppl_1.g02oc14s103.
[8] Wynn-Williams N, Young RD. Cough fracture of the ribs
including one complicated by pneumothorax. Tubercle
1959;40:47–9. doi:10.1016/S0041-3879(59)80019-2.
[9] George L, Rehman SU, Khan FA. Diaphragmatic rupture: a
complication of violent cough. Chest 2000;117:1200–1.
doi:10.1378/chest.117.4.1200.
[10] Ayers DE, LeFeuver A, Barker P. Surgical repair of intercostal
pulmonary hernia secondary to cough induced rib fracture. J
R Nav Med Serv 2002;88:55–6 PMID: 12500483.](https://image.slidesharecdn.com/herniadiafragmatika-250309041223-f53e6cb7/85/HhhhhhHernia-diafragmatikaaaaaaaaaaaaa-pdf-4-320.jpg)
HhhhhhHernia diafragmatikaaaaaaaaaaaaa.pdf
- 1. R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/radcr Case Report Chronic cough causing unexpected diaphragmatic hernia and chest wall rupture Marlene Farinacci-Vilaró, MDa,∗ , Luis Gerena-Montano, MDb , Hector Nieves-Figueroa, MDd , Juan Garcia-Puebla, MDa , Ricardo Fernández, MDa , Ricardo Hernández, MDa , Rosangela Fernández, MDa , Modesto González, MDc , Cid Quintana, MDc a Pulmonary and Critical Care Medicine Department, San Juan City Hospital, San Juan, Puerto Rico b Internal Medicine Department, San Juan City Hospital, San Juan, Puerto Rico c Cardiovascular Hospital, San Juan, Puerto Rico d Ponce Health Science University, Ponce, Puerto Rico a r t i c l e i n f o Article history: Received 5 August 2019 Revised 5 October 2019 Accepted 6 October 2019 Available online 8 November 2019 Keywords: Cough Diaphragmatic rupture a b s t r a c t Cough is a defense mechanism for airway protection and is associated with multiple sys- temic complications such as ribs fracture. Diaphragmatic rupture is commonly caused by blunt or penetrating trauma. We presented a case of a 72-year-old female with a 1-year his- tory of chronic cough, not responding to medical management. Imaging showing abdomi- nal herniation into the thoracic cavity and rib fracture due to diaphragmatic and chest wall rupture. Abdominal herniation and diaphragmatic rupture were repaired through surgery allowing resolution of symptoms. This is a life-threatening condition with a high-mortality rate in which early diagnosis and repair are desirable. Therefore, awareness of this uncom- mon complication of cough should be acknowledged. © 2019 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Cough is a physiologic defense mechanism to protect airways from foreign material and secretions. It is one of the most common symptoms responsible for outpatient clinic eval- Financial support: This case report did not receive any specific grant form any funding agency in the public, commercial, or not-profit sectors. Competing Interests: None. ∗ Corresponding author. E-mail address: [email protected] (M. Farinacci-Vilaró). uation with approximately 30 million visits annually in the United States. It is classified according to the duration as acute (less than 3 weeks), subacute (3-8 weeks), and chronic (more than 8 weeks). Sustained cough can be associated with multi- ple complications including cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurologic, ophthalmologic, https://doi.org/10.1016/j.radcr.2019.10.010 1930-0433/© 2019 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)
- 2. 16 R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8 Fig. 1 – Initial chest x-ray demonstrates left-sided diaphragmatic hernia secondary to diaphragmatic rupture. psychosocial, respiratory, and skin complications [1]. We reported a case with cough-related diaphragmatic rupture which incidence is unknown since condition is rare and many cases likely go undiagnosed. Case history A 72-year-old woman G3P3A0 with a medical history of mor- bid obesity, hypertension, fibromyalgia, diabetes mellitus type 2, and controlled sleep apnea with no toxic habits. She came to the emergency department with a chief com- plaint of dry cough and progressive shortness of breath of approximately 1 year of evolution. She mentioned multiple visits to her primary physician as well as to the emergency room without improvement of symptoms during that year. Her treatment included nasal and inhaled steroids, proton pump inhibitors, antibiotics, and expectorants. As she contin- ued with a prolonged forceful cough not responsive to medical management and developed upper chest pain and a tearing abdominal pain radiated to the back. Chest ecchymosis was present alongside with worsening dyspnea, early satiety upon eating, and left breast pain. She denied fever, sputum produc- tion, or recent trauma. Within that year, the patient never got a chest x-ray. Initial chest x-ray (Fig. 1) taken 1 year after the beginning of symptoms showed left-sided diaphragmatic her- nia secondary to diaphragmatic and chest wall rupture. Sub- sequent chest CT scan axial view (Fig. 2), coronal view (Fig. 3), sagittal view (Fig. 4), and reconstruction (Figs. 5 and 6) demon- strated evidence of rib fracture, chest wall, and diaphragmatic rupture with a displacement of small and large bowel into the left side thoracic cavity causing left pulmonary collapse. Surgical findings consisted of a chronic large left anterior di- aphragmatic hernia with bowel and omentum protruding to the pleura cavity plus subcutaneous detachment of left sub- costal cartilage from the sternum as the causative of lung col- lapse. Afterward, thoracotomy was performed with repair of bowel placement on the abdominal cavity, correction of di- aphragmatic rupture, reinforcement with a proline mesh, and chest tube placement for pneumothorax. A 1-week postsur- gical follow-up with chest x-ray showing resolved herniation (Fig. 7) and discharge without complications. Fig. 2 – Chest CT with evidence of intra-abdominal content in the left hemithorax. (A) Lung window and (B) abdominal window.
- 3. R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8 17 Fig. 3 – Coronal view of intra-abdominal content in the left-sided hemithorax. (A) Lung window and (B) abdominal window. Fig. 4 – Sagittal view with anterior diaphragmatic and chest wall rupture with intra-abdominal content. (Abdominal window.) Discussion Diaphragmatic rupture is most commonly cause by penetrat- ing injury or blunt abdominal trauma in 63% and 37% of the cases, respectively [2]. The diaphragm is a dome-shaped mus- cle, which contracts during the inspiratory phase. Cough val- salva maneuver causes lack of coordination of different mus- cles of expiration, the muscle of the abdominal wall contract Fig. 5 – Chest CT reconstruction with evidence of a diaphragmatic hernia, rib fractures, and intra-abdominal content of left breast. pushing the diaphragm upward, whereas the ribs are pushed inward and downward leading to a diaphragmatic rupture [3]. Herniation of bowel loops into the chest can be a consequence of diaphragmatic rupture, which impairs ventilation and oxy- gen delivery. The true incidence of abdominal organ herni- ation due to diaphragmatic rupture is unknown since many cases likely go undiagnosed or usually appear delayed. Diaphragmatic injuries are usually diagnostic challenges. Chest radiographs are the initial and most common imaging study to evaluate the diaphragm. When the results are incon- clusive, CT is the next study of choice since it can assess the
- 4. 18 R a d i o l o g y C a s e R e p o r t s 1 5 ( 2 0 2 0 ) 1 5 – 1 8 Fig. 6 – Chest CT reconstruction of the lung, remarkable for the left lower lobe collapse. Fig. 7 – Chest x-ray postanterior diaphragmatic hernia and chest wall abnormality repair. extent and anatomical sites of coexisting thoracoabdominal injuries [4]. The rate of missed diaphragmatic rupture on chest radio- graphs ranges from 12% to 66% with the potential risk of a late visceral herniation through the diaphragmatic defect [5]. The sum of physician unawareness about the diagnosis, and the subtle and nonspecific findings of chest radiography along- side the technical limitations such as supine positioning, use of portable radiography, and limited patient cooperation make the diagnosis difficult through chest radiography alone. How- ever, it remains a valuable imaging option in the acute phase for the detection of diaphragmatic rupture and when CT is not available or cannot be performed [6,7]. Diaphragmatic rupture has an overall mortality rate of 25% as reported by the National Trauma Data Bank. Due to an increased rate of herniation and strangulation of abdom- inal organs secondary to diaphragmatic rupture, which can be life threatening, early diagnosis and repair are desirable [8–10]. Therefore, physicians should be aware of this uncom- mon complication of cough. R E F E R E N C E S [1] Roberge RJ, Morgenstern MJ, Osborn H. Cough fracture of the ribs. Am J Emerg Med 1984;2:513–17. doi:10.1016/0735-6757(84)90077-9. [2] Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008;85(3):1044–8. [3] Hillenbrand A, Henne-Bruns D. Cough induced rib fracture, rupture of the diaphragm and abdominal herniation. World J Emerg Surg 2006;1:34. doi:10.1186/1749-7922-1-34. [4] Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging of diaphragmatic injuries. J Thorac Imaging 2000;15:104–11 PMID: 10798629. [5] Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Buchler MW. Missed diaphragmatic injuries and their long-term sequelae. J Trauma 1998;44:183–8. doi:10.1097/00005373-199801000-00026. [6] Desir A, Ghaye B. CT of blunt diaphragmatic rupture. RadioGraphics 2012;32:477–98. doi:10.1148/rg.322115082. [7] Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: a diagnostic challenge? RadioGraphics 2002;22:103–18. doi:10.1148/radiographics.22.suppl_1.g02oc14s103. [8] Wynn-Williams N, Young RD. Cough fracture of the ribs including one complicated by pneumothorax. Tubercle 1959;40:47–9. doi:10.1016/S0041-3879(59)80019-2. [9] George L, Rehman SU, Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000;117:1200–1. doi:10.1378/chest.117.4.1200. [10] Ayers DE, LeFeuver A, Barker P. Surgical repair of intercostal pulmonary hernia secondary to cough induced rib fracture. J R Nav Med Serv 2002;88:55–6 PMID: 12500483.