Bilateral Pneumothoraces after Unilateral Lung Biopsy. A Case of 'Buffalo Chest'?

An 81-year-old man with a productive cough was found to have multiple bilateral pulmonary nodules and was referred for biopsy. Under computed tomography guidance, fine-needle aspiration of a right lower lobe nodule led to a diagnosis of lung adenocarcinoma (Figure 1). A small pneumothorax developed on the right and, despite the fact that the left lung and mediastinum were not manipulated during the procedure, extended into the left hemithorax. Both pneumothoraces resolved without intervention. “Buffalo chest” is a term derived from the animal’s peculiar anatomy in which there is only one contiguous pleural space containing both lungs. Previous reports in the literature (approximately 10–15 cases) are almost universally in patients with prior thoracic surgery causing disruption of the mediastinal barrier (i.e., esophagectomy [1], heart–lung transplant [2], pneumonectomy), with only a few existing “congenital pleuro-pleural communication” cases (3). Bilateral pneumothoraces have also been described after unilateral procedures in patients prone to spontaneous pneumothoraces (1, 4) and in patients with sarcoma metastases receiving chemotherapy (5). This patient had no prior surgical history or emphysematous/cystic lung disease, raising the possibility of a congenital condition, despite a seemingly intact mediastinum on computed tomography. Disruption of the mediastinal pleura from lung metastases is another etiology to consider, as has been previously hypothesized (5). n