Abstract Introduction Lung herniation is a rare condition where lung tissue protrudes beyond the thoracic cavity through an abnormal defect in the chest wall, diaphragm, or mediastinum. Intercostal lung hernias are exceptionally uncommon and are usually linked to trauma, previous thoracic surgery, obesity, chronic obstructive pulmonary disease (COPD), or increased intrathoracic pressure from vigorous coughing. Spontaneous cases without any prior trauma are sporadic. Case Presentation A 73-year-old man with COPD presented with right-sided abdominal pain for several days, worsening in the last 24 hours, along with new-onset shortness of breath. He was tachycardic and tachypneic upon arrival. Lab tests showed hs-Troponin-I at 64 ng/L (decreasing trend) and B-type natriuretic peptide at 57 pg/mL; the Electrocardiogram showed sinus tachycardia without ischemic changes. On examination, a chest wall protrusion was noted when the patient was asked to cough. Chest X-ray showed a rounded lucency near the left second and third ribs. Computed tomography (CT) angiography ruled out pulmonary embolism but revealed herniation of the left upper lobe through the second and third intercostal spaces into the anterior chest wall (Figure). In comparison with a 2015 CT, the same finding was observed, indicating a chronic, stable herniation. He had no history of trauma, thoracic surgery, or excessive coughing. His COPD was well controlled with home oxygen and inhaler therapy. The patient was referred for outpatient cardiothoracic follow-up, as no urgent intervention was needed. Discussion Intercostal lung herniation is a rare clinical condition first described by Roland in 1845. Morel-Lavallée later classified lung hernias based on etiology and anatomy into congenital and acquired types; the latter includes traumatic, spontaneous, and pathological forms. The pathophysiology involves weakening of the chest wall combined with increased intrathoracic pressure. In patients with COPD, chronic inflammation and hyperinflation lead to thinning of intercostal muscles and loss of tissue elasticity, which predispose them to herniation. Sudden increases in intrathoracic pressure from coughing or straining can further stretch or tear the intercostal muscles, allowing lung tissue covered by pleura to protrude through the defect. Chest X-ray may show a localized lucency or bulge, but CT imaging remains the diagnostic gold standard. Management depends on symptoms—stable, asymptomatic cases may be observed, while enlarging or symptomatic hernias require surgical repair. This patient’s chronic, stable herniation supports conservative management. Importantly, any abnormal chest X-ray warrants thorough follow-up, as incidental findings may reveal rare but clinically significant conditions. This abstract is funded by: None
Umashankar et al. (Fri,) studied this question.