A late presenting congenital diaphragmatic hernia misdiagnosed as spontaneous pneumothorax

Clinical challenges and management of late presenting congenital diaphragmatic hernia mimicking tension pneumothorax in a child: a case report and review of literatures

BACKGROUND

Congenital diaphragmatic hernia(CDH) is a rare congenital anomaly characterized by herniation of abdominal contents into thoracic cavity through a defect in diaphragm. While commonly diagnosed prenatally or in neonatal period, late-presenting CDH can occur and may mimic other thoracic emergencies such as tension pneumothorax, complicating diagnosis and management.

CASE PRESENTATION

A two-year old male black child from Ethiopia presented to the emergency department with sudden onset of acute respiratory distress. Initial clinical assessment and chest radiography suggested a diagnosis of tension pneumothorax due to the presence of significant mediastinal shift and apparent pleural air. Despite insertion of chest tube, the child's condition did not improve, raising suspicion of alternative diagnosis. Careful observation of initial chest x-ray and subsequent chest ultrasound revealed a left sided congenital diaphragmatic hernia with herniation of stomach and intestine into thoracic cavity compressing the left lung and causing mediastinal shift. After the diagnosis of CDH was confirmed, the child was stabilized and emergent surgical repair performed. Postoperative recovery was uneventful, and the child was discharged with no significant long-term complications.

CONCLUSION

This case underscores the importance of considering CDH in the differential diagnosis of acute respiratory distress in a child. It highlights the diagnostic challenges and potential risks of emergency interventions based on initial misdiagnosis. Even if x -ray looks like typical of tension pneumothorax, it showed giant cystic air filled structure pushing the mediastinal structure to contralateral side with loss of left diaphragmatic outline which raised suspicion of congenital cystic lung mass or congenital diaphragmatic hernia. Advanced imaging and high index of suspicion are crucial for accurate diagnosis and timely management, ultimately improving patient outcomes. Consideration of alternative diagnosis when our initial intervention with insertion of chest tube fail to provide symptom improvement in suspected pneumothorax should raise suspicion of congenital diaphragmatic hernia like in our case.

Congenital lung lesions: a radiographic pattern approach

Congenital lung malformations represent a spectrum of abnormalities that can overlap in imaging appearance and frequently coexist in the same child. Imaging diagnosis in the neonatal period can be challenging; however, the recognition of several archetypal radiographic patterns can aid in narrowing the differential diagnosis. Major radiographic archetypes include (1) hyperlucent lung, (2) pulmonary cysts, (3) focal opacity and (4) normal radiograph. Here we review the multimodality imaging appearances of the most commonly seen congenital lung malformations, categorized by their primary imaging archetypes. Along with the congenital lung malformations, we present several important imaging mimickers.

Difficulties in the hemodynamic assessment of the newborn with prenatally treated congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a malformation with a diverse clinical picture. Its severity can be assessed prenatally using the lung area to head circumference ratio (LHR). LHR lower than 1 as associated with high mortality is an indication for prenatal treatment involving occlusion of fetal trachea. Before such treatment other congenital malformations must be excluded. Assessment of circulatory system in these patients is difficult. Heart is compressed by viscera in the thorax that decreases blood return to the left atrium, and structures of the left heart may be smaller than in healthy fetuses. The echocardiographic picture may be similar to some congenital defects of the left heart. Differentiation between structural and functional cardiac abnormalities is difficult but essential for diagnostic and therapeutic decisions in the most severe type of CDH. The authors present problems with interpretation of hemodynamic disturbances in a neonate with prenatally diagnosed and treated severe CDH.