Massive spontaneous hemothorax in a young ESRD patient

Pleural effusions are common problems for the emergency medicine physician and may require emergent therapeutic thoracentesis to prevent respiratory failure. Rarely, a pleural fluid collection may in fact be a spontaneous hemothorax. A 22-year-old man presented to the emergency department with chest pain. He had a history of end-stage renal disease (ESRD) as a result of minimal change disease. The patient was in visible respiratory distress with absent breath sounds in the right chest. A chest x-ray revealed a large pleural effusion with mediastinal shift. Emergent thoracentesis relieved the patient's symptoms, but the pleural fluid was grossly bloody. The patient's cell counts and PT/PTT were normal. His thromboelastography (TEG) was borderline abnormal. The patient required video-assisted thoracoscopic surgery (VATS) for debulking and removal of the hemothorax. Otherwise, he had an unremarkable recovery. There was no obvious cause of the hemothorax. Clinicians must be wary that in patients with ESRD on hemodialysis, a pleural effusion may be in fact a spontaneous hemothorax. Why should an emergency medicine physician be aware of this? Patients with ESRD may present with massive spontaneous hemothorax that requires emergent thoracostomy and operative management. Emergency medicine physicians should be knowledgeable about the causes and work-up of patients with spontaneous hemothorax.