Abstract Introduction We present a rare case of spontaneous hemothorax in a young woman with metastatic malignant phyllodes tumor status post orthotopic heart transplantation. Malignant hemothorax is uncommon, typically arising from vascular erosion or tumor rupture, and is seldom reported in sarcomatous malignancies or the context of viral illness. To our knowledge, this is among the few reported cases of spontaneous hemothorax in a solid-organ transplant recipient with metastatic sarcoma and concurrent COVID-19 infection. Case Presentation A 28-year-old woman with metastatic malignant phyllodes tumor of the breast, end-stage renal disease on hemodialysis, and orthotopic heart transplant for cardiac metastasis presented with fever, leukocytosis, and left pleuritic chest pain. Her chronic immunosuppression included tacrolimus and prednisone, and she had recently tested positive for COVID-19. CT chest showed a moderate left pleural effusion with multiple enlarging pleural-based masses (3 cm and 7.6 cm). Initial thoracentesis yielded 600 mL of grossly bloody exudative fluid (RBC 102,000/μL, 76% neutrophils, protein 4.5 g/dL, LDH 860 U/L). A repeat tap one month later showed fewer red cells (6,000/μL) with persistent exudative features. Cytology from both specimens was negative for malignant cells. Coagulation parameters and platelet counts were normal, and no vascular injury or procedural complication was identified on imaging. Despite renal failure, there was no evidence of uremic bleeding or anticoagulant effect. She was treated for COVID-19 pneumonia and Streptococcus thermophilus bacteremia. Hemoglobin stabilized without transfusion, and no recurrent effusion appeared on follow-up imaging. Discussion Malignant hemothorax most often results from rupture of pleural-based metastases. Negative cytology occurs in up to 40-60% of malignant effusions and is even more frequent in sarcomas due to poor exfoliation and masking by blood-stained samples.1-4 The coexistence of pleural disease and recent viral infection suggests a multifactorial process. COVID-19 can cause diffuse endothelial inflammation and microvascular injury, predisposing to spontaneous bleeding in fragile tumor vasculature.4 Chronic immunosuppression may further impair vascular integrity. With procedural, coagulopathic, and uremic causes excluded, this case likely represents hemothorax from friable pleural metastases exacerbated by viral endothelial dysfunction and immunosuppression. Conclusion Spontaneous hemothorax in the setting of metastatic sarcoma, transplantation, and COVID-19 is exceedingly rare. This case highlights diagnostic limitations of pleural cytology and suggests COVID-19-related vascular injury may precipitate hemothorax in immunosuppressed hosts. This abstract is funded by: None
T Narra (Fri,) studied this question.