INTRODUCTION

Secondary contralateral lung resection is a high-risk procedure due to potential complications, particularly in emergency settings [1]. A second thoracic procedure in elective cases should focus on the patient’s recovery potential and functional status [2]. While acceptable outcomes have been reported in elective oncologic cases, the feasibility of this intervention in unstable trauma patients remains unclear [3].

Thrombocytopenia is a condition in which a person’s platelet count is abnormally low, diagnosed by complete blood count. In general, the normal human platelet count ranges from 150,000 to 450,000 platelets/μL of blood [4]. In posttraumatic patients, thrombocytopenia is often difficult to manage because its causes are diverse [5]. To our knowledge, cases in which a patient who previously underwent lobectomy for lung cancer survives contralateral pulmonary resection due to trauma are extremely rare. Instances involving concurrent thrombocytopenia are even more uncommon; therefore, we present this case.

CASE REPORT

A 78-year-old man was referred to our trauma center with left hemothorax after a cultivator accident. The patient had undergone right upper lobectomy for lung adenocarcinoma at another hospital 4 years earlier. On arrival, his arterial blood pressure and heart rate were 110/60 mmHg and 78 beats per minute, respectively. Chest computed tomography (CT) revealed multiple rib fractures, pneumothorax, and lung injury with contrast extravasation in the left lower lobe (Fig. 1A), as well as mediastinal shift attributable to the prior lobectomy (Fig. 1B). After CT, the patient’s blood pressure fell to 70/40 mmHg, and his hemoglobin level was 6.5 g/dL. His lactate level was 5.13 mmol/L. A 24F chest tube was inserted, and 1,500 mL of blood was drained over 1 hour. Emergency left thoracotomy was performed because the disruption of the chest wall prevented securing a surgical field for video-assisted thoracic surgery. Ten rib fractures were identified, and the lung injury appeared to have caused a deep laceration in the left lower lobe. Wedge resection was performed, and the fragmented rib fractures were treated with open reduction. The early postoperative course was uneventful until postoperative day 10, when the patient developed respiratory distress with high fever. Chest radiography showed haziness in the right lung, and pneumonia was suspected (Fig. 2). The next day, tonic–clonic seizures occurred. Piperacillin/tazobactam was started on postoperative day 10 to treat the pulmonary infection, and valproate with lamotrigine was initiated on postoperative day 11 to control the seizures. The initial platelet count on admission was 256,000 platelets/μL and gradually decreased. On postoperative day 19, the platelet count fell from 89,000 to 1,000 platelets/μL despite platelet transfusion (Fig. 3). Subsequently, the patient developed spontaneous epistaxis and oral bleeding. An evaluation was performed to determine the cause of thrombocytopenia. First, after consultation with neurology, valproate and lamotrigine were discontinued on postoperative day 20 because the seizures had occurred only once. Second, piperacillin/tazobactam was changed to meropenem on postoperative day 21. Additional evaluation included chest and abdominal CT scans to assess for additional delayed organ bleeding. We were unable to wean the patient from ventilator support, and a tracheostomy was performed on postoperative day 14. By postoperative day 27, the platelet count had risen to 121,000 platelets/μL, and the pneumonia showed signs of improvement. Rehabilitation was provided in the intensive care unit (ICU), and the patient was discharged after 58 days of postoperative hospitalization (Fig. 4).

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from the patient’s guardian.

DISCUSSION

Contralateral thoracic surgery for lung cancer or benign disease is under active investigation. The indications for this procedure have been described in various studies [1,2]. Limited resection, adequate pulmonary function, and feasible localization of the surgical site are considered suitable conditions for this highly selective operation [1–3]. Recent research has indicated that contralateral anatomic surgical resection can be performed safely in selected patients with multiple lung cancers, with acceptable morbidity and mortality rates [6]. Before the operation in this case, the posterior segment of the left lower lobe was predicted to be the damaged area, and localization was considered possible. Postoperatively, respiratory morbidities, including pneumonia and atelectasis, have been reported to occur frequently [2]. A major postoperative consideration is whether the patient can overcome the challenge of depressed lung function without complications. In eligible, stable patients, multiple factors should be weighed when determining surgical treatment. However, this option is not applicable to unstable trauma patients.

The normal platelet count in humans is 100,000 to 300,000 platelets/μL of blood, and platelets have a normal lifespan of 8 to 10 days [4]. Thrombocytopenia is defined as a platelet count <100,000 platelets/μL of blood, and severe thrombocytopenia as <50,000 platelets/μL; if the platelet count is <10,000 platelets/μL, spontaneous bleeding, such as epistaxis and gastrointestinal bleeding, can occur [4]. Thrombocytopenia in critically ill patients is multifactorial and can be broadly classified into three main mechanisms: decreased production, increased consumption, and increased destruction of platelets [7]. In the ICU setting, common causes include sepsis-induced consumption, hemodilution from massive fluid resuscitation, trauma-related platelet consumption and sequestration, and drug-induced thrombocytopenia [4,8,9]. Trauma-induced thrombocytopenia typically occurs within the first 24 to 48 hours after injury because of massive bleeding, consumption coagulopathy, and dilutional effects from resuscitation [8,10]. Surgery-related thrombocytopenia is usually transient, occurring within the first few days postoperatively due to hemodilution, blood loss, and platelet activation [10].

Drug-induced thrombocytopenia represents a distinct mechanism involving immune-mediated platelet destruction. This condition typically manifests 5 to 10 days after initial drug exposure or within hours to days upon reexposure to the offending agent [5,11]. The main causes of thrombocytopenia in the ICU are sepsis and trauma; drug-induced thrombocytopenia is difficult to detect in a post-trauma state [4]. The precise mechanism of drug-induced thrombocytopenia has not been fully elucidated, with one hypothesis suggesting that autoantibodies may be involved [5]. Thrombocytopenia occurs in 12% to 18% of patients receiving valproate. The mechanism is believed to involve either direct bone marrow suppression or immune-mediated platelet destruction. Risk factors for valproate-associated drug-induced thrombocytopenia include older age, female sex, and high drug dose [12]. Piperacillin/tazobactam is often used in the ICU for pulmonary infections; although only rarely reported, thrombocytopenia induced by this combination typically presents as an immune-mediated reaction, with severe platelet depletion occurring 7 to 14 days after initiation [7]. Early-onset postoperative thrombocytopenia is considered physiologic and transient; however, when thrombocytopenia persists for more than 5 days, differential diagnosis is required to identify causes other than surgery or trauma [8,12]. To address this, drugs that can cause thrombocytopenia are often discontinued sequentially [12,13]. Thereafter, evaluation for bleeding at other sites should continue alongside laboratory monitoring. In trauma patients, hemodynamic monitoring and a high index of suspicion can help determine the cause of thrombocytopenia.

In our case, several factors support drug-induced thrombocytopenia as the most likely etiology. First, the temporal relationship was highly suggestive: the patient’s platelet count was normal on admission (256,000/μL) and remained stable until postoperative day 18, followed by a decline coinciding with the administration of valproate and piperacillin/tazobactam. Second, such severe thrombocytopenia (1,000/μL) with associated spontaneous bleeding is characteristic of the drug-induced condition. Third, recovery of the platelet count after drug discontinuation (from 1,000 to 121,000/μL) supports causality. Finally, the patient’s advanced age and higher drug doses represent known risk factors for thrombocytopenia. Based on the evaluation and clinical course, we believe that drug-induced thrombocytopenia, likely caused by valproate, with a contribution from piperacillin/tazobactam, was the most probable cause in this case.

Contralateral pulmonary resection for chest trauma in patients with prior anatomic lung resection can be successfully performed in life-threatening situations. Even in patients with drug-induced thrombocytopenia, a condition often encountered in the ICU yet not well understood, the cause of thrombocytopenia can be identified and treated. Early diagnosis and management of drug-induced thrombocytopenia are essential for recovery. Surgeons should maintain a high index of suspicion when thrombocytopenia develops beyond the expected post-trauma period, especially in patients receiving multiple medications known to cause this complication. Based on our review of the literature, this is the first case report of contralateral lung resection after previous lobectomy in a chest trauma patient with drug-induced thrombocytopenia.

ARTICLE INFORMATION

Author contributions

Conceptualization: DK, KSL, ISJ; Investigation: all authors; Methodology: all authors; Writing–original draft: DK, ISJ; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Computed tomography in the emergency department. (A) Contrast extravasation in the lung parenchyma (arrow). (B) Displaced rib fragment suspected of causing lung injury (arrow).

Fig. 2.

Postoperative chest radiograph. (A) Chest radiograph on postoperative day 1. (B) Chest radiograph on postoperative day 10 (pneumonia suspected in the right lung field).

Fig. 3.

Timeline showing platelet count. Platelet count declined from 89,000 platelets/μL to a nadir of 1,000 platelets/μL. Recovery to 121,000 platelets/μL occurred after drug discontinuation.

Fig. 4.

Radiograph on the day of discharge.

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References

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