CASE CONFERENCES

The Proceduralist
Section Editor: George Eapen, M.D.

Spontaneous Hemothorax
Christopher K. Morgan1, Lara Bashoura2, Diwakar Balachandran2, and Saadia A. Faiz2
1
Divisions of Pulmonary, Critical Care Medicine, and Sleep Medicine, The University of Texas Health Science Center at Houston,
Houston, Texas; and the 2Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
ORCID IDs: 0000-0002-7427-9388 (D.B.); 0000-0001-7284-3945 (S.A.F.).

In Brief
A 53-year-old woman with metastatic
sarcoma presented with increasing dyspnea
and a left pleural effusion. Subsequent
workup suggested a spontaneous
hemothorax and definitive outpatient
management was performed.
Case Vignette
A 53-year-old woman with recently
diagnosed metastatic malignant spindle-
cell sarcoma of the leg presented with
dyspnea and left-sided pleuritic chest
pain associated with a recurrent left pleural
effusion. Three days before presentation,
she underwent a thoracentesis at another
facility yielding 1.2 L of bloody fluid, but no
further fluid analysis was performed. The
patient was not on any anticoagulation or
chemotherapy, and hematologic parameters
were all within normal limits. Her
dyspnea improved significantly for a few
days; however, her symptoms gradually
recurred and she presented to our hospital.
She denied any other respiratory
symptoms and had no history of trauma.
Physical examination revealed tachypnea
and dullness to percussion of the posterior
left hemithorax. Chest radiograph showed
opacification of two-thirds of the left
hemithorax with contralateral shift of the
mediastinum along with bilateral
opacities consistent with her known
metastases (Figure 1A).
Repeat thoracentesis evacuated 1.3 L of
bloody fluid with a pleural fluid/serum
hematocrit ratio of 0.5, suggestive of
a hemothorax (Figure 2). Pleural fluid
chemistries were consistent with an
exudate, and cytology was negative.
Computed tomography angiogram revealed
no acute thromboembolic disease, but
bilateral pleural effusions (left greater than
right), pulmonary nodules and masses, and
pleural-based nodularity were noted
(Figure 3). Six days later the effusion
recurred along with respiratory symptoms,
and an indwelling pleural catheter (IPC)
was placed. Thoracentesis from the
contralateral hemithorax at this time also
yielded 550 ml of bloody fluid with
a pleural fluid/serum hematocrit of 0.6,
consistent with a hemothorax. She
improved clinically and was discharged
with instructions to drain the pleural fluid
daily.
Output from the IPC was initially
500 ml of fluid daily, decreasing to 200 ml
daily within 2 weeks. Her symptoms of
chest pain and dyspnea improved
substantially and she planned to return to
her home country for further treatment
but was readmitted with increased
weakness before her flight back home. She
was found to be markedly anemic, with
a hemoglobin level of 4 g/dl, down from
8.5 g/dl before discharge. She was
transfused and instructed to only drain the
catheter if significant dyspnea recurred.
During her 72 hours in the hospital, the IPC
was drained twice with 400 ml and 200 ml of
bloody pleural fluid. After her initial blood
transfusion, her hemoglobin remained stable,
and she did not require any more blood
products. Although her chest radiograph
revealed moderately increased pleural
effusion in the contralateral right
hemithorax, she remained asymptomatic, so
no further pleural procedures were
performed (Figure 1B). Even after discharge,
her symptoms remained controlled with the
intermittent drainage, and she was able to
safely return to her home country soon
thereafter.
Discussion
Spontaneous hemothorax is defined as pleural
fluid hematocrit greater than 50% of the
peripheral blood hematocrit and the absence
of natural or iatrogenic trauma affecting the
lung or pleural space. Bloody effusions are
classically associated with malignancy, but
only rarely does cancer cause a true
hemothorax. Our patient likely had bilateral
spontaneous hemothoraces related to her
metastatic sarcoma. Traumatic hemothorax
from recent pleural intervention was believed
to be unlikely, because her initial drainage
was bloody and the contralateral effusion was
also found to be consistent with
a hemothorax. Other etiologies of
spontaneous hemothorax may include

(Received in original form May 27, 2015; accepted in final form July 24, 2015 )
Correspondence and requests for reprints should be addressed to Saadia A. Faiz, M.D., Department of Pulmonary Medicine, Unit 1462, The University of Texas
MD Anderson Cancer Center, P.O. Box 301402, Houston, TX 77030-1402. E-mail: safaiz@mdanderson.org
Ann Am Thorac Soc Vol 12, No 10, pp 1578–1582, Oct 2015
Copyright © 2015 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201505-305CC
Internet address: www.atsjournals.org

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 CASE CONFERENCES

intrathoracic or intraabdominal vascular

events, pulmonary infarction from
pulmonary emboli or necrotizing lung
infection, hemopneumothorax, and those
associated with coagulopathy. Our patient did
not have any evidence of these alternative
etiologies. Management of spontaneous
hemothorax encompasses conservative and
surgical approaches, with attention to
etiology-specific treatments.
Bone and soft tissue, schwannoma,
thymic growths, vascular tumors, germ
cell tumors, hepatocellular tumors, lung
cancer, mesothelioma, primitive
neuroectodermal tumor, and malignancies
resulting in extramedullary hematopoiesis
have all been described to result in
spontaneous hemothorax. Spindle cell
sarcoma may present as a primary
pleural tumor or it may be metastatic to the
pulmonary system. Pleuropneumonectomy
has been reported in some cases of
pleural sarcoma, but the usefulness of this
procedure remains unclear. Typical
options such as large-bore chest tube
placement or other surgical interventions may
also be limited in patients with advanced
malignancies due to poor functional status or
other social factors, and minimally invasive
symptom palliation may be preferable.
Although aspiration of bloody fluid
typically prompts the placement of
a chest tube in a patient with suspected
traumatic hemothorax, we believe that
this case highlights the differences
from standard therapy in patients with
spontaneous hemothoraces, particularly those
with malignancy. Traumatic hemothorax
often displays spontaneous echo contrast on
ultrasound, but among patients with
malignancy-associated hemothoraces, this
feature may be less pronounced because blood
loss is often slower, leading to clotting factor
Figure 1. Chest radiograph (A) before pleural procedure (demonstrating bilateral pleural effusions
with bilateral nodular opacities), and (B) at the time of admission with anemia (decreased left pleural
depletion and more hypoechoic fluid
effusion with loculated hydropneumothorax with indwelling pleural catheter in place and increased appearance on ultrasound (Figure 4). Bloody
right pleural effusion). effusions are common among patients with
malignancy, but they rarely meet the formal
criteria for hemothorax, and, as such, at our
institution, unless an effusion is very likely to
be a traumatic hemothorax, we do not place
a chest tube on the basis of pleural fluid
appearance at thoracentesis alone. If such
a patient has radiographic evidence of
pleural metastases and is clinically stable,
our standard practice is to complete
a symptom-limited thoracentesis and
await both fluid reaccumulation and the
results of formal pleural fluid analysis
Figure 2. Pleural effusion during intervention with sanguineous fluid. before committing the patient to additional

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Figure 3. Computed tomography of the chest demonstrates bilateral pleural effusion (left greater than right), pulmonary masses, and pleural-based
nodularity. (A) Lung windows. (B) Mediastinal windows.

invasive procedures. This particular
patient improved symptomatically after
the thoracentesis, and when the fluid
reaccumulated, a discussion with the patient
was held regarding the management options,
including chest tube placement and
pleurodesis. Because we did not believe this
was a traumatic hemothorax, there was
radiographic evidence of disseminated
pleural disease, and the patient did not wish
to stay in the hospital any longer, we chose
to manage her immediate symptoms with
the IPC.
The IPC is well accepted as an effective
option for the palliation of recurrent
malignant pleural effusions, but the role
in the management of hemothorax is
less clear. Traditionally, traumatic
hemothoraces are managed with large-bore
chest tubes, ostensibly to assure complete
evacuation of the pleural space and limit the
subsequent development of fibrothorax.
Although there are no clear-cut
predictors of fibrothorax in the setting of
nontraumatic hemothorax, it has been
our experience that slow diffuse oozing
from pleural-based metastatic disease
may be less likely to cause fibrothorax.
Particularly in the setting of advanced
disease with the associated lifespan

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Figure 4. Ultrasound image of pleural effusion reveals hypoechoic pleural fluid (*) with diaphragm (D) and irregular lung parenchyma (arrow).
limitations, we have rarely encountered the
development of significant fibrothorax after
minimally invasive management of
spontaneous hemothorax. Small-bore chest
drains are also believed to be more prone
to clogging, given the viscosity
of blood, but malignancy-associated
hemothoraces may not share all
the characteristics of traumatic
hemothoraces. For instance, the slow
ooze from pleural metastatic disease may
result in greater clotting factor depletion and
lower viscosity. Furthermore, the pleura
is likely to be markedly abnormal in these
patients, and often incomplete lung
reexpansion is encountered due to pleural
infiltrative disease and adhesions. Even with a
large-bore chest tube, complete evacuation
may require decortication, which can be
a significantly morbid procedure in
debilitated patients. The IPC is therefore
an attractive minimally invasive option that
may result in definitive symptom
palliation, provided the risk of catheter
clotting, ongoing blood loss, and
possible fibrothorax are carefully considered.
In patients with IPCs placed for
malignant pleural effusions, we typically
recommend daily symptom-limited drainage
in an effort to achieve maximal symptom
relief, maximal lung expansion, and maximal
pleurodesis rates. Similar to the mechanism of
action of a standard chest tube, adequate fluid
evacuation should result in pleural apposition
that tamponades the bleeding and
promotes pleural symphysis. However, in
patients who have poorly expandable lung
due to pleural metastatic involvement,
pleural apposition may not take place
Case Conferences: The Proceduralist
despite adequate fluid evacuation,
and continued drainage may only
exacerbate the blood loss. In our patient,
Figure 1B shows a chest radiograph taken
at the time of admission for the anemia
that demonstrates a left-sided
hydropneumothorax that is suggestive of
poorly expandable lung at this location. This
likely contributed to chronic blood loss from
this location and her subsequent readmission
despite an overall decrease in the volume of
fluid drained. Given these findings, we
believed that the best course of action was to
modify the drainage schedule to achieve
symptom relief while minimizing the
amount of chronic blood loss. The
exact mechanism by which her anemia
subsequently stabilized after the modification
of the drainage schedule is unclear.
Spontaneous cessation of pleural bleeding is
unlikely, because she had progressive disease
and was not on any systemic treatment. We
hypothesize that drainage of the pleural fluid
and subsequent partial pleural apposition
provided tamponade effects at least in the
areas of pleural apposition. However,
suction-assisted drainage of the pleural
catheter itself may cause local irritation, and
daily drainage of the catheter likely led to
continued blood loss from the areas of
poor lung expansion. Her underlying
untreated malignancy also likely contributed
to her anemia. Regardless, because she
presented with profound anemia after the
catheter had been drained daily for
several days, we modified our drainage
recommendations to symptom-directed
drainage only. Given her advanced disease
and trapped lung physiology, surgical
intervention with pleurodesis was not
an option, although it could be considered
to achieve hemostasis in other patients. Our
objective was to provide acceptable symptom
relief without provoking any additional
bleeding. We believe that partial pleurodesis
can still occur in this setting, as evidenced by
the fact that the catheter output continued to
decrease over the next several days, although
the contralateral effusion continued to
increase.
The complexities outlined in this
case serve to highlight the need for
a thoughtful, reasoned, and multidisciplinary
approach to the care of these patients. Careful
integration of clinical and radiographic
information along with patients’ preferences
is essential to the development of
a personalized treatment plan. Careful
coordination with the oncologist as well as
other support services is critical in selecting
the optimal management option in such
patients.
Follow-Up
After her blood transfusion and
modified drainage, the patient was
observed in the hospital for 72 hours.
She remained free of respiratory
symptoms, including dyspnea and chest
pain. She was subsequently discharged
and was able to safely travel to her
home country to undergo additional
chemotherapy. n
Author disclosures are available with the text
of this article at www.atsjournals.org.
1581

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Spontaneous hemothorax: report of 6 cases and review
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AnnalsATS Volume 12 Number 10 | October 2015