a 70-year - old man was admitted to the emergency department with a 1-month history of coughing and dyspnea .
he developed a productive cough with purulent sputum , left chest wall pain , and 3 days prior to arrival ecchymosis developed on the left upper quadrant of the abdomen .
he did not have a recent history of thoracic or abdominal trauma , and it was unknown if he had a history of thoracic surgery .
the initial chest x - ray showed a hyperdensity in the left lower lung , an obliterated diaphragmatic border with an atelectasis , and a decreased lung volume .
the scan film showed a protrusion of the lung through the left 7th intercostal space ( fig .
therefore , he was diagnosed with a lung herniation , and a medical conservative treatment was performed . on hospital day 10 , after experiencing uncontrolled coughing , the patient complained of aggravated dyspnea and left chest wall pain .
the subsequent chest x - ray showed increased hyperdensity with a gas - filled area above the left dome of the diaphragm .
he also showed dullness to percussion and chest wall tenderness . on hospital day 12 , a ct scan with contrast of the chest revealed herniation of the bowl and omental fat in the anterior portion of the left hemithorax ( fig .
, the patient was transferred to the department of thoracic surgery and underwent an emergency operation due to the incarceration of the bowl and a parapneumonic effusion due to passive atelectasis .
the operation revealed a partial agenesis of intercostal muscle , costal cartilage around the 7th anterolateral intercostal space due to the lack of developed intercostal muscle ( fig .
2a ) , an 8 cm defect of the diaphragm , and a herniation of the small bowel located in the anterior portion of the left thoracic cavity ( fig .
the primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined .
a lung herniation is defined as a protrusion of the lung beyond the normal confines of the thoracic cavity through an abnormal opening in the chest wall . a condition associated with increased intra - thoracic pressure or that weakens
the thoracic wall may cause a lung herniation . according to a report by goverde et al .
, lung herniation is such a rare disease , that only about 300 patients have been reported with the disease in the world literature , and most were single case reports .
congenital lung hernias are especially rare and consist of approximately 18% of all reported lung hernias .
most congenital lung hernias are found in the supraclavicular area , whereas a lung herniation in the intercostal area is rare .
a morgagni 's hernia is caused by a failure of fusion between the fibrotendinous portions of the sternal and the costal parts of the diaphragm .
a morgagni 's hernia is also a rare disease . in a report by berman et al .
, only 15 infants and children with morgagni 's hernia were admitted over a 20 year period at the hospital for sick children in toronto .
the majority of patients present with a morgagni 's hernia in the neonatal period , but the hernia may remain undiscovered until later in life .
morgagni 's hernia is secondary to an incomplete development of the diaphragm in contributing to the increase of abdominal pressure ; other contributing factors include trauma , severe exertion , and obesity .
we located the agenesis of the intercostal muscle and the costal cartilage , and the congenital morgagni 's hernia was located near the intercostal herniation .
the discoveries serve as evidence that this case involved a congenital disorder . in conclusion , we believe that the cause of the intercostal hernia combined with the morgagni 's hernia might have been due to incomplete development of the chest wall and diaphragm . the increased abdominal pressure due to recurrent cough is what aggravated the symptoms .
 a 70-year - old male visited urgent care due to coughing for 1 month and left chest pain . 
 he had no history of trauma . 
 the initial chest computed tomography ( ct ) showed the 7th left intercostal lung herniation . 
 a follow - up ct showed an intercostal lung herniation combined with a bowl herniation , which had developed due to a morgagni 's hernia . 
 an emergency operation was performed due to the incarceration of the bowl and lung . 
 the primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined . 
 we concluded that the defect of the diaphragm and the intercostal muscle was a congenital lesion , and the recurrent coughing was the aggravating factor of herniation . 