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Competing Interests: Competing interests: None declared.

Synovial sarcoma is a rare malignancy that commonly metastasises to the lungs, lymph nodes and more infrequently to the heart. It is associated with an elevated risk of pneumothorax. In this case, we report a case of dual pathology in a metastatic synovial sarcoma patient. The patient not only presented with a pericardial effusion but also with a secondary pneumothorax. A bedside echocardiogram was performed quickly, and the pericardial effusion was diagnosed early. Diagnosing the pneumothorax was delayed as the chest X-ray was not expedited but the patient was treated with an intercostal catheter before complications ensued. In the context of chest pain in patients with metastatic synovial sarcoma, we argue that conducting an early bedside echocardiogram and chest X-ray is paramount to avoid potential life-threatening complications. Concurrent lung disease and recent chemotherapy administration should also raise the clinician's suspicion of pneumothorax in such cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

As the SARS-CoV-2 virus continues to infect millions of people worldwide, the medical profession is seeing a wide range of short-term and long-term complications of COVID-19. One lesser-known complication is that of pneumomediastinum. This is a rare, but significant, complication defined by the presence of air in the mediastinum with an incidence of 1.2 per 100 000. Described mortality rate is 30%, increasing to 60% in patients with concomitant pneumothoraces. Management of pneumomediastinum is typically conservative, but in cases of extensive subcutaneous emphysema, cardiac or airway compression, life-saving surgical decompression is necessary. We report a case of pneumomediastinum secondary to COVID-19, requiring a surgical approach not described in pneumomediastinum secondary to COVID-19. The case demonstrates the importance of prompt diagnosis and management, as well as the potential for good clinical outcome in selected patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

The COVID-19 pandemic has had a significant impact on the structure and operation of healthcare services worldwide. We highlight a case of a 64-year-old man who presented to the emergency department with acute dyspnoea on a background of a 2-week history of fever, dry cough and shortness of breath. On initial assessment the patient was hypoxic (arterial oxygen saturation (SaO 2 ) of 86% on room air), requiring 10 L/min of oxygen to maintain 98% SaO 2 Examination demonstrated left-sided tracheal deviation and absent breath sounds in the right lung field on auscultation. A chest radiograph revealed a large right-sided tension pneumothorax which was treated with needle thoracocentesis and a definitive chest drain. A CT pulmonary angiogram demonstrated segmental left lower lobe acute pulmonary emboli, significant generalised COVID-19 parenchymal features, surgical emphysema and an iatrogenic pneumatocoele. This case emphasises the importance of considering coexisting alternative diagnoses in patients who present with suspected COVID-19., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

A 25-year-old man with a history of Marfan syndrome, asthma and smoking presented with worsening dyspnoea and right-sided chest pain worsened with deep breathing after a fall 2 days prior. Diagnostic imaging revealed a spontaneous right-sided pneumothorax due to ruptured subpleural bullae in the apex of the right lung. Smaller subpleural bullae were also noted in the apex of the left lung. A chest tube was placed to reduce the right pneumothorax successfully., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Pneumothorax and pulmonary embolism (PE) are two life-threatening causes of shortness of breath in patients presenting to the emergency department. A rare but more serious presentation is that of simultaneous PE and pneumothorax. We present the case of a young patient, with no known comorbidities, who presented with simultaneous submassive PE and pneumothorax. We will review how these two diagnoses may be related, consider the implications of having this dual diagnosis on the patient's management and review the current evidence surrounding thrombolysis in submassive PE., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Takotsubo cardiomyopathy (TCM) is a unique type of cardiomyopathy characterised by left ventricular systolic dysfunction in association with stressful conditions. Patients with this condition usually present with chest pain and dyspnoea, and the presentation can mimic acute coronary syndrome. We present a case of a woman aged 58 years who presented with progressive dyspnoea and cough. Her initial evaluation was suggestive of acute myocardial infarction with elevated serum troponin T and ST segment elevation. Her chest radiograph showed a large right-sided pneumothorax, which was treated with chest tube insertion. Coronary angiography and echocardiogram did not show any evidence of obstructive coronary artery disease but did show a large area of akinesis consistent with TCM. The patient was managed medically with supportive care. Her pneumothorax resolved, and her follow-up echocardiogram also showed improvement. The association between pneumothorax and TCM is rare, and only four other cases have been reported so far in the English literature., (2017 BMJ Publishing Group Ltd.)

A 79-year-old man was referred to the emergency room following a sudden episode of 'spitting blood', with a blood pressure of 128 (systolic) and 75 mm Hg (diastolic) and a heart rate of 60 bpm. His medical history included the treatment of gastric cancer and untreated hypertension. At that time, his symptoms were limited without any chest, back or abdominal pain. After a presentation of haemoptysis was confirmed, a chest radiograph revealed an air-fluid level (a 'niveau') that was continuous towards the enlarged thoracic aorta and the thoracic cavity. Contrast-enhanced CT was subsequently performed, and revealed an aortic dissection and a pneumothorax adjacent to the dissection, accompanied by blood pooling in the thoracic cavity. The patient died 40 min after the admission to the emergency room due to an additional haemoptysis. The autopsy confirmed the diagnosis of a ruptured aortic dissection with pneumothorax., (2015 BMJ Publishing Group Ltd.)

A 40-year-old heroin smoking man presented with acute onset severe shortness of breath. Radiological investigations revealed an unexpected loculated pneumothorax. Respiratory physicians inserted a chest drain which relieved his breathlessness. His exercise tolerance is much improved 6 months on. The side effects of smoking illicit substances are poorly understood. There is a growing trend for drug users to smoke rather than intravenously inject. It is therefore important for clinicians to be aware of the associated morbidity. The authors believe this is the first ever reported case of loculated pneumothorax associated with heroin smoking., (2015 BMJ Publishing Group Ltd.)

We report an extremely rare complication of a major ischaemic cerebral event caused by an air embolism due to spontaneous rupture of a giant pulmonary bulla that occurred during an airline flight. Shortly after take-off, the patient experienced sudden right-sided hemiplegia and dyspnoea. Following an emergency landing in Reykjavik, a CT scan of the brain showed minute air bubbles consistent with air emboli within the left-sided intracerebral arteries, and MRI showed signs of acute ischaemic cerebral infarction in the left hemisphere. The patient later underwent a pulmonary lobectomy and survived this life-threatening complication with relatively mild neurological sequelae., (2015 BMJ Publishing Group Ltd.)

Spontaneous pneumothoraces are relatively common; however, simultaneous bilateral spontaneous pneumothoraces (SBSP) have rarely been reported. This case report describes the presentation of SBSP in a 60-year-old man with occupational asthma. He was initially started on treatment for life-threatening asthma, but an early deterioration in symptoms prompted an urgent chest radiography that established the diagnosis of bilateral pneumothoraces. This was managed with bilateral needle thoracocentesis followed by stabilisation with intercostal chest drains. He was subsequently referred to the thoracic unit for minithoracotomy, bullectomy and talc pleurodesis. This case highlights the potential difficulties in diagnosing SBSP and advocates the necessity for prompt chest radiography when managing such presentations in the acute setting.

Foreign body aspiration can infrequently occur following trauma. Tooth aspiration after trauma is a rare clinical scenario. Here, we report a case in which tooth aspiration after trauma led to a presentation of acute respiratory failure with clinical findings mimicking tension pneumothorax. Successful removal of the aspirated tooth was accomplished by rigid bronchoscopy. Tooth aspiration must be considered in the list of differential diagnosis for any patient having signs or symptoms of respiratory distress following trauma especially maxillofacial trauma.

Bronchobiliary fistula is a rare and challenging condition that most commonly presents worldwide following infection with hydatid cystic disease of the liver but is increasingly seen in cases of trauma involving the right upper quadrant. The most common presenting complaint is biliptysis. Treatment is initially aimed at decompressing the biliary tree which allows a considered approach for closure of the fistulous tract. Options range from conservative management to endoscopic and percutaneous approaches. Traditionally definitive treatment would have been surgical and may ultimately have resulted in hepatic and/or pulmonary segmentectomy. Current management strategies of this potentially serious condition are variable. We describe a particularly challenging case in which interventional embolisation with microcoils was used in an attempt to treat persistent post-traumatic bronchobiliary fistula in a tertiary centre. We describe this technique and hope that it is may be of useful reference for those contemplating a similar approach.

A 51-year-old man was brought to the emergency room because of a sudden onset of severe dysponea. On presentation, his blood pressure was 94/55 mm Hg. Oxygen saturation was 86% while he was receiving 10 l/min oxygen through a non-rebreather mask. On physical examination, no jugular venous distention was noted, but breath sounds over the left lung were diminished. A bedside chest radiograph showed left tension pneumothorax, for which urgent needle decompression followed by chest thoracostomy was performed. Ventricular tachycardia developed, but a biphasic shock at 120 J immediately restored normal sinus rhythm. His vital signs, however, did not improve. A CT scan of the chest showed type A aortic dissection with bullae in the upper lobe of the left lung. He had an emergency operation for distal aortic arch displacement and was discharged on the 37th day of hospitalisation.

Tension pneumothorax complicating a pneumoperitoneum is a rare but known entity. However, all previously published articles report an air leak through defects in the diaphragm connecting the pneumoperitoneum and the pneumothorax. Here, the case of a 36-year-old man in whom the pneumoperitoneum acted like a tension pneumothorax because of a congenital eventration of the left diaphragm without penetration is presented. Emergency needle decompression of the abdomen was performed. A gastric ulcer that had passed through the diaphragm to the right lung was diagnosed intraoperatively. Unfortunately, the patient developed a ventricular fibrillation that remained resistant to all resuscitative efforts, and the patient died shortly afterwards.

Swyer-James-McLeod's syndrome (SJMS) occurs as a result of childhood recurrent respiratory infections. As this condition presents with few symptoms, if any, it may pass unnoticed until adulthood. The authors are presenting a case of a 17-year-old male admitted with spontaneous pneumothorax. Even though his lung expanded, his chest x-rays still mimicked a pneumothorax. Chest CT pulmonary angiogram was needed to confirm the diagnosis of unilateral SJMS. Diagnostic difficulty arose because both conditions were on the same side.