Clinicoradiological Diagnosis of Cough-Induced Intercostal Hernia
A 66-year-old male presented to the clinic with an 11-month history of a painless enlarging mass on the left side of his chest wall. The patient noticed the mass after being discharged after a weeklong hospitalization for bilateral pneumonia. During that week the patient was continuously coughing and developed a pain in the left side of chest wall. Chest X-ray and computed tomography of the abdomen imaging showed no rib fracture or other type of injury to the chest wall, diaphragm, or abdominal wall. Discharge diagnosis included pneumonia and back pain. A few months later the patient found the mass on the left side of chest wall enlarging and decided to seek medical reevaluation by his primary care physician. He was later referred for another CT of his abdomen with intravenous contrast. This study report stated: “Patient developed a fracture with some displacement in the left posterior lateral eighth rib. The ribs more cephalad could be fractured as well. Associated with this finding there is some distortion of the ribs caudal to this left eighth rib fracture. Those ribs are displaced medially and there is bulging of the fat of the peritoneal cavity laterally without evidence of an actual hernia” []. The images were not conclusive for an intercostal hernia. A few more months past and the patient returned to the primary care physician with the same complaint of the chest wall mass. Additional CT of the abdomen was performed, and it showed the eighth rib fracture, the torn intercostal muscles, and no diaphragmatic defect [].\nPhysical examination revealed an obese patient who had a soft, nontender, reducible mass on the lateral aspect (midclavicular line to the midaxillary line) of the left-sided chest wall between eighth and 11th ribs. The mass measured 12 cm in diameter. Sensation over the mass was decreased slightly when compared to the right side.\nHis past medical history was significant for hyperlipidemia, hypertension, and benign prostatic hyperplasia. The patient had no history of any external trauma, no history of any rib fractures, and no lung disease other than the recent pneumonia. Patient denied any current tobacco use (quit 25 years earlier), patient occasionally used alcohol, and denied any illicit drug use.\nAfter reviewing the CT scans and examining the patient, a diagnosis of a chest wall hernia induced by severe coughing was established. The patient was referred to a cardiothoracic surgeon to repair the hernia.