Case Presentation: A 74-year-old woman with a past medical history of mild asthma and a recent pneumonia presented to the hospital with left flank pain. She had no notable trauma or surgical history. She additionally endorsed left lateral chest wall pain exacerbated by coughing, with symptoms worsening over the preceding three days. Initial CT imaging was concerning for an empyema and possible bronchocutaneous fistulization. She did not undergo thoracentesis or chest tube placement early in her hospitalization as there was no adequate fluid pocket, and surgical intervention was deferred as the risks were thought to outweigh the potential benefits. The patient was therefore initially managed conservatively with a 14-day course of antibiotics and an aggressive pain control regimen. Her hospital course was later complicated by acute hypoxic respiratory failure requiring transfer to the intensive care unit. Repeat imaging at that time demonstrated a new 6th rib fracture and worsening pleural effusion. In the ICU, the patient underwent thoracentesis and subsequent chest tube placement, leading to clinical improvement. Following chest tube removal, she was continued on antibiotics for the remainder of her hospital course.
Discussion: This case illustrates a rare instance of lung herniation secondary to cough-induced rib fractures in the setting of empyema. Lung herniation is a protrusion of lung tissue beyond the thoracic cage, most commonly resulting from trauma or surgery, though it may also occur in neoplastic or inflammatory conditions. While surgical repair is often recommended to prevent progression, management must be individualized, as no standardized operative approach exists. [1] When procedural risks outweigh benefits, conservative measures should be considered, including analgesia, respiratory support, and infection control. This patient’s clinical course demonstrated the dynamic nature of chest wall defects complicated by infection. Despite initial stabilization, she developed respiratory failure and worsening pleural effusion, with repeat imaging revealing new rib fractures and disease progression. Transition from conservative therapy to thoracentesis and subsequent chest tube placement enabled adequate source control and clinical improvement. This underscores that while conservative management may be effective initially, timely escalation is essential when respiratory status declines or when imaging shows disease progression. Her ultimate recovery highlights the importance of individualized, staged management strategies. In select cases of spontaneous lung herniation with concurrent infection, a conservative approach may be reasonable initially, provided there is close monitoring, serial imaging, and readiness to intervene. This case adds to the limited literature on cough-induced rib fractures complicated by lung herniation and empyema, and reinforces the need for flexible, patient-specific management.
Conclusions: Timely recognition and individualized management of lung herniation and empyema are essential to prevent life-threatening complications. Our case highlights the value of a conservative approach including proper antibiotics, pain control, and pulmonary hygiene in this patient with an unconventional presentation.