Wednesday Image Review

What’s the Diagnosis? By Mona Moshet, MS4

A 29 year old male with no past medical history presents with sudden onset, pleuritic chest pain radiating to right flank while swimming yesterday. He notes associated dyspnea, particularly with deep inspiration. Social history is notable for smoking tobacco and marijuana. Vital signs are: Temp 98.7F, HR 54, BP 125/76, RR 16, SpO2 98% RA. Exam shows a thin appearing male in no acute distress with clear bilateral lung sounds. A CXR is obtained and shown below. What’s the diagnosis?

Answer: Spontaneous Pneumothorax (see pleural line at apex of right lung)

  • Is there an association between smoking marijuana and spontaneous pneumothorax (PTX)?
    • A brief literature review showed multiple cases but no studies proved causality.2, 3 However, one case control study had evidence that patients with spontaneous PTX and marijuana smoking history were at higher risk for poorer outcomes such as having larger pneumothoraces, prolonged post-op stays, and recurrence.1
  • Treatment: Depends on clinical status and size of PTX
    • Tension PTX = immediate needle decompression followed by thoracostomy
    • Supplemental O2
    • Observation for small primary spontaneous PTX (<2 cm between lung margin and and chest wall) with no significant dyspnea OR asymptomatic patient with large primary spontaneous PTX (>2 cm) with serial CXRs
    • Chest tube insertion site: within the “triangle of safety” (see figure below)


1. Stefani A, Aramini B, Baraldi C, Pellesi L, Della Casa G, Morandi U, Guerzoni S. Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study. PLoS One. 2020 Mar 30;15(3):e0230419. doi: 10.1371/journal.pone.0230419. PMID: 32226050; PMCID: PMC7105102.

2. Manasrah N, Al Sbihi AF, Al Qasem S, Naik R, Hettiarachchi M. Recurrent Spontaneous Pneumothorax Associated With Marijuana Abuse: Case Report and Literature Review. Cureus. 2021 Feb 7;13(2):e13205. doi: 10.7759/cureus.13205. PMID: 33717745; PMCID: PMC7943398.


4. Dynamed, AMBOSS

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