July 2023

Bilateral pneumothoraces after unilateral lung biopsy – an unexpected epiphenomenon 

July 2023 

Dr Joanna Start, Dr Michael Darby, Dr Annette Johnstone 


Case history 

A 74 year old underwent percutaneous CT-guided biopsy of a 13mm semi-solid nodule in the peripheral left upper lobe, suspected to represent T1a N0 M0 lung cancer. 

Past medical history included colorectal adenocarcinoma with anterior resection, right femoral artery angioplasty, myocardial infarctions and coronary artery bypass grafting (CABG). 

Access was difficult given the location of the nodule at the level of the axilla. A long parenchymal approach was therefore used with the patient supine, rather than crossing the fissure posteriorly which would increase the risk of pneumothorax. The needle required repositioning several times given difficult access and one core was obtained. Immediate post-biopsy CT demonstrated perilesional haemorrhage but no pneumothorax. 

Whilst in the radiology recovery area awaiting routine post-procedural imaging, the patient complained of chest pain and shortness of breath. Repeat CT at that time demonstrated bilateral pneumothoraces, larger on the right (not biopsied) side. 

A 12 French chest drain was inserted into the right pleural space which resulted in immediate clinical improvement and improvement of both pneumothoraces. 

The patient was admitted to the respiratory ward overnight for observation and made a good recovery. The pneumothoraces were not appreciable on the radiograph the following day, so the chest drain was removed and the patient discharged. The histopathology was subsequently reported as well-differentiated adenocarcinoma of the lung. 



Fig 1: PET-CT demonstrated mild tracer activity associated with the left upper lobe semi-solid nodule 



Fig 2: CT-guided biopsy with perilesional haemorrhage but no pneumothorax 



Fig 3: Bilateral pneumothoraces on the post-biopsy CT 



Fig 4: Right-sided chest drain with improvement of both pneumothoraces 



There are several previously reported cases of bilateral pneumothoraces secondary to abnormal physical communication between the pleural spaces.(1-6) This abnormal communication is colloquially known as ‘buffalo chest’, so named as the buffalo has a single communicating pleural space containing both lungs.(7) In our case, the connection is presumed secondary to disruption of the anterior mediastinum at the anterior junctional line during previous CABG. 

Causes of communicating pleural spaces are predominantly iatrogenic, secondary to previous cardiac and mediastinal surgery or oesophagectomy.(1,2) Other causes include external chest trauma, emphysematous or cystic lung disease and rarely congenital communication.(4) 

Presentation may be more severe than unilateral pneumothorax, due to a larger amount of air in the communicating pleural spaces. This can cause a tension effect without the associated mediastinal shift.(8) 

When consenting for and performing percutaneous CT-guided biopsy, consider whether there is a history of previous cardiothoracic surgery which predisposes to pleuropleural communication and bilateral pneumothoraces. 



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  1. Jacobi A, Eber C, Weinberger A, et al. Bilateral pneumothoraces after unilateral lung biopsy. A case of “buffalo chest”? American Journal of Respiratory and Critical Care Medicine. 2016;193(8):36 

  1. Groarke J, Breen D, O’Connell F, et al. Bilateral pneumothorax resulting from diagnostic thoracocentesis. European Respiratory Journal. 2007;30:1018-1020 

  1. Dayan PS and Klein BL. Idiopathic, bilateral pneumothorax: Case report in a young child. The Journal of Emergency Medicine. 1994;13(4):505-508 

  1. Sawalha L and Gibbons WJ. Iatrogenic “buffalo chest” bilateral pneumothoraces following unilateral transbronchial lung biopsies in a bilateral lung transplant recipient. Respiratory Medicine Case Reports. 2015;15:57-58 

  1. Lee YC, McGrath Gregory B, Chin Weng S, et al. Contralateral tension pneumothorax following unilateral chest tube drainage of bilateral pneumothoraces in a heart-lung transplant patient. Chest. 1999;116(4):1131-1133 

  1. Grathwohl KW and Derdak S. Buffalo chest. The New England Journal of Medicine. 2003;249:1829 

  1. Judson MA and Sahn SA. The pleural space and organ transplantation. American Journal of Respiratory and Critical Care Medicine. 1996;153:1153–1165