Hemothorax causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

Haemothorax may be caused by trauma or can be spontaneous and iatrogenic. Causes of traumatic haemothorax include blunt force injuries, penetrating thoracic injuries, and thoracoabdominal injuries. Causes of spontaneous haemothorax include vascular disorders, malignancies, connective tissue disorders, gynecological disorders, hematological disorders, and miscellaneous pathological entities. Haemothorax can also be a complication of various iatrogenically–related procedures. In addition, the cause of haemothorax can remain unknown even after exploratory thoracotomy.^{[1][2][3][4][5][6][7][8][9][10][11][12]}

Common causes of hemothorax include.^{[1][2][3][4][5][6][7][8][9][10][11][12]}

Chest trauma is of three types:

• Blunt force injury cases such as those that occur in vehicular collisions and following falls or jumps from heights
• Penetrating thoracic injuries produced by a stab or gunshot wounds
• Thoracoabdominal injuries

Spontaneous haemothorax is a rare clinical condition in the absence of trauma or iatrogenic causes. Bilateral spontaneous haemothorax is a very rare entity and the main cause of it is primary or metastatic pleural angiosarcoma. Causes of spontaneous haemothorax include:

• Vascular disorders causing spontaneous hemothroax include aortic aneurysm rupture, rupture of thoracic aortic dissection – dissection is due to arterial hypertension followed by atherosclerosis -, rupture of a saccular aortic aneurysm and traumatic rupture of the pericardial sac during cardiopulmonary resuscitation in individuals with hemopericardium, fatal spontaneous dissection of supra-aortic vessels without any evidence of aortic disease during pregnancy and early puerperium, bronchial artery aneurysm rupture, aneurysmatic internal thoracic artery, intercostal vessels, internal thoracic artery aneurysm, or pulmonary congenital aberrant vessels, ruptured mycotic aneurysms, innominate truncal dissection, using neck veins for mainlining and rupture of a subclavian artery aneurysm, pulmonary arteriovenous malformations (AVMs), fatal and non-fatal AVM-associated massive hemothorax is often linked to Osler–Weber–Rendu disease, associated with congenital heart disease such as rupture of a patent ductus arteriosus, Eisenmenger syndrome, aortic coarctation and bicuspid aortic valve disease.

• Malignancies causing spontaneous hemothroax include lymphangiosarcoma and vascular mediastinal schwannoma, schwanommas of von Recklinghausen disease, lymphangioma, mediastinal teratoma, metastatic choriocarcinoma, metastatic renal carcinoma, Abrikossoff tumor, pulmonary angiosarcoma, osteochondroma, Kaposiform endodermal sinus tumour, hemangioendothelioma, hemangioma, hemangiopericytoma fibrous tumor of the pleura, hepatocellular carcinoma, periosteal chondroma, chondroblastoma of the rib, synovial sarcoma, osteosarcoma, Ewing sarcoma, neurofibrosarcoma, thymoma, mediastinal meningioma, thoracic neuroblastoma, pleural mesothelioma, chronic myeloid leukaemia, neurofibromatosis type I (Morbus von Recklinghause), chondrosarcomas, ectopic meningioma and germ cells tumors.

• Connective tissue disorders causing spontaneous hemothorax include Vascular Ehlers–Danlos syndrome (Ehlers–Danlos type IV, EDS IV), Marfan syndrome, Loeys–Dietz syndrome, familial thoracic aortic aneurysm syndrome, Shprintzen–Goldberg syndrome and Type I neurofibromatosis (NF-1) or Von Recklinghausen’s disease (VRD).

• Pleural disorders causing spontaneous hemothorax include spontaneous pneumothorax, spontaneous pneumohemothorax (the accumulation of >400 mL of blood in the pleural cavity in association with spontaneous pneumothorax) and pleural metastasis.

• Coastal exostoses or osteochondroma occurs either sporadically or as a manifestation of a genetic disorder known as hereditary multiple exostoses (HME). Lesions mainly occur in infants and children and their complications include haemothorax, pneumothorax, diaphragmatic or pericardial lacerations and visceral pleural injury.

• Gynecological disorders causing spontaneous hemothorax include Intrathoracic implantation of ectopic endometrial tissue occurs as a result of the migration of endometrial tissue through the thoracic diaphragm. Spontaneous haemothorax may be a response to cyclical hormonal changes in menstruating women.

• Hematological disorders causing spontaneous hemothroax include hemophilia, immune-mediated platelet destruction due to Many drugs such as sedatives, tranquilizers, anticonvulsants, and heparin, anticoagulant-associated hemothorax, specifically, as a result of thromboembolic disease treatment, hematology-related hemothorax include Glanzmann’s thrombasthenia, thrombotic thrombocytopenic purpura, and intrathoracic extramedullary hematopoiesis, intrathoracic intramedullary hematopoiesis due to a secondary process, such as myeloproliferative disorders, hemolytic anemia, hereditary spherocytosis, chronic asthma, and Gaucher disease, beta thalassemia, rupture of extramedullary hematopoietic pulmonary nodules, haemothorax has been also reported in the setting of plasminogen activator user for venous thrombosis in patient with pneumonia.

• Miscellaneous causing spontaneous hemothroax include tuberculosis, necrotizing lung infection, uremia, spontaneous hemothorax secondary to a ruptured parasitic hydatid (Echinococcal) cyst of pulmonary parenchyma, Malaria is another rare parasitic etiology for spontaneous hemothorax, amyloidosis-induced spontaneous mediastinal hemorrhage with hemothorax due to perivascular and vascular wall involvement, systemic diseases like systemic lupus erythematosus (SLE) and Henoch-Schönlein purpura, pulmonary emboli, ectopic pregnancy, Extralobar pulmonary sequestration (EPS).
• In some patients the cause can remain unknown even after exploratory thoracotomy.

Iatrogenous haemothorax may be caused by either intrathoracic vessel cannulation, chest drain insertion, needle thoracocentesis, pleural or lung biopsies, closed-chest cardiopulmonary resuscitation, placement of subclavian- or jugular-catheters, endoscopic thoracic interventions, cardiopulmonary surgery, sclerotherapy of oesophageal varices, rupture of pulmonary arteries after placement of Schwann–Ganz catheters, thoracic sympathectomy or translumbar aortography. surgical procedures such as releasing the pleurae from the vertebrae, or the removal and curettage of intervertebral discs and cartilage end plates.

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