Case
A 35-year-old male presented to the emergency room (ER) with acute dyspnoea (SpO2 98%), pain and absent breathing sounds over the left hemithorax and hypotension (reported pre-hospital blood pressure 63/37 mmHg). He had no relevant medical history, except smoking of marihuana. Supposedly he felt a little snap in the left lung while running in an effort to catch the train, earlier that day.

Physical examination in the ER revealed an SpO2 of 100% with 4 l/min of oxygen via a nasal cannula, a respiratory rate of 20/min with absent breathing sounds over the left lung, sinus tachycardia 120 beats/min, blood pressure of 101/70 mmHg after administration of 1000 ml of Ringer’s lactate and cool extremities. The electrocardiogram showed sinus tachycardia without other irregularities. When the haemodynamics seemed stabilised, ER staff took the opportunity to perform an X-ray, which showed a left pneumothorax with rightward shift of the mediastinum and trachea (figure 1). Lung ultrasound was not performed. After receiving 50 μg of fentanyl, a pleural catheter was inserted by the pulmonologist, after which blood flowed from the pleural cavity indicative of a haemothorax. The patient was admitted to the intensive care unit (ICU) for haemodynamic monitoring and stabilisation. Because of
increasing haemodynamic instability, we decided to reduce the mediastinum shift by draining 500 ml of blood from the pleural cavity. After stabilisation, the patient went for thoracic computed tomography angiography. It showed multiple bullae in both lungs and a snapped bulla in the apex of the left lung. Moreover, it showed laceration of a branch of the left subclavian artery (thyreocervicalis branch) with signs of active blood loss (figure 2). The patient successfully underwent coiling of the lacerated branch but episodes of dyspnoea and hypotension persisted. He underwent bullectomy via video-assisted thoracoscopic surgery the next day. A small oozing adhesion with active blood loss was sealed. The patient remained in the ICU for two days postoperatively and was discharged from hospital soon after.

Discussion
Spontaneous haemopneumothorax is a rare complication of spontaneous pneumothorax. One third of patients present with symptoms of hypovolaemic shock.[1] However, our patient’s X-ray also showed a rightward mediastinum shift, possibly causing obstructive shock. This case therefore presented a particular challenge in managing the hypotension. Drainage of blood from the pleural cavity could reduce the obstructive component and improve haemodynamics, but also exaggerate the haemorrhagic component by reducing tamponade of possible bleeding vessels. We therefore decided to drain a limited amount of blood (500 ml), with positive effects on blood pressure.

Spontaneous haemopneumothorax occurs in 3% of patients with spontaneous pneumothorax.[1] It typically occurs in young males with primary spontaneous pneumothorax (incidence 5-10 per 100,000 [2]). Pathogenesis of primary spontaneous pneumothorax is suggested to be rupture of apical, subpleural blebs or bullae, which are particularly associated with smoking of tobacco and/or cannabis.[3,4] This can result in blood loss from torn adhesions between parietal and visceral pleurae, rupture of vascularised bullae or torn aberrant vessels, leading to spontaneous haemopneumothorax. Currently there are no specific national guidelines for the management of spontaneous haemopneumothorax. The literature suggests conservative treatment via tube thoracostomy in haemodynamically stable patients without persisting air leak or blood loss, and surgical intervention in case of hypovolaemic shock, continuous blood loss (>100 ml/h) or persisting air leak.[5] Interestingly, a review of case series shows no recurrence in 201 patients after spontaneous haemopneumothorax.[1]