Fatal bilateral pneumothoraces

Inspired by Yamaguchi et al 2021.[1]

PMCT – postmortem computed tomography
EA – electroacupuncture
CPR – cardiopulmonary resuscitation
CXR – chest x ray film
BMI – body mass index

key to acronyms
Photo by Robina on Unsplash.

This case report comes from Tokyo and involves PMCT. The last reported case was from Shanghai, and I highlighted it on this blog in November 2018. It was the first time I had come across the use of PMCT, as well as the technique of identifying tension pneumothorax postmortem.

This case report is more comprehensive than usual in terms of the detail of the acupuncture treatment applied, and it is the first time that the use of EA has been implicated as a potential factor in the case.

The patient was a man in his 60s who was receiving acupuncture every 2 days for chronic back pain and stiff shoulders. On the day of his death, he had 22 needles inserted to a relatively shallow depth – 0.5cm in the shoulder region and 1cm in the lower back. The needles were relatively long (6.8cm), although this is consistent with the Japanese traditional style that I have seen demonstrated. EA was applied at low frequency for 20 minutes.

The patient complained of an inability to exhale immediately after treatment, but managed to walk out onto the street, where he became dyspnoeic again and collapsed. CPR was performed by an acupuncturist, and the patient was transported to hospital in cardiopulmonary arrest.

On arrival at hospital a CXR showed bilateral pneumothoraces but resuscitation including insertion of a chest drain on the right was unsuccessful and the patient was pronounced dead approximately 1 hour after the onset of symptoms.

Autopsy was performed 40 hours after death. The deceased patient had a BMI of just over 27. PMCT demonstrated bilateral pneumothoraces and bilateral subcutaneous emphysema. Numerous gold threads of about 10mm long were also found embedded subcutaneously in the back and legs, but there was no indication that any of these had migrated to the lungs or cardiovascular system.

umekomihariokibari – embedded needle acupuncture

umekomi – embedded

hari – needle

okibari – acupuncture

using Google translate

Whilst no bruising was seen on the skin surface, there were more than 10 noted in the subcutaneous tissue of the back and some haemorrhages in the paravertebral muscles. Most relevant was bruising found in 2 places on the right parietal pleura – the 6th interspace 7cm from the spine and near the 12th rib 2cm from the spine. The depth of the lower of these two lesions was 5cm from the skin surface.

Formalin was injected into the main bronchi, and a pinhole-like injury was seen on the dorsal aspect of the right lower lobe as formalin was squeezed out of it. The left lung showed poor distension and no hole was found. The left lung weighed only 230g compared with 659g for the right. Histology showed emphysema and lung fibrosis, particularly on the left.

So, it seems clear that at least one of the acupuncture needles found its way into the right lung. The needles were certainly long enough, but apparently they were only inserted 1cm in this region. The authors of the case report suggest that the needles may have been drawn in by muscle contraction stimulated by the low frequency EA, and I was surprised to find they justified this assertion by citing my paper on safety aspects of EA from 2011.[2]

I suspect the more likely explanation is that they were inserted deeper in the first place, since muscle contraction in the region concerned would be much or likely to result in the needle being extruded. Still, the main lesson I would take from this case is to only use the shortest possible needles to reach your target. Lots of long needles flopping around in a patient’s back may look more dramatic, but is it really worth the risk?

The authors also listed the other autopsy case reports of pneumothoraces after acupuncture,[3–7] and to my surprise there were a couple I had missed, bringing the total to 7, of which 6 were bilateral. All but the first report came from the Far East, and I was intrigued to see that this first report came from one of the two large teaching hospitals in Leeds where I trained, and was published in my second year of medicine, by one of our professors of forensic medicine. I did not know Professor David John Gee at the time, but his obituary in the Irish Times from 20 years ago makes interesting reading.

References

1          Yamaguchi R, Makino Y, Torimitsu S, et al. Fatal bilateral pneumothoraces after electroacupuncture treatment: A case report and literature review. J Forensic Sci Published Online First: 26 August 2021. doi:10.1111/1556-4029.14874

2          Cummings M. Safety aspects of electroacupuncture. Acupunct Med 2011;29:83–5. doi:10.1136/acupmed-2011-010035

3          Gee D. Fatal pneumothorax due to acupuncture. BMJ 1984;288:114.

4          Iwadate K, Ito H, Katsumura S, et al. An autopsy case of bilateral tension pneumothorax after acupuncture. Leg Med Tokyo Jpn 2003;5:170–4. doi:10.1016/S1344-6223(03)00052-X

5          Kasuda, Shogo, Morimura, Yoshifumi, Kudo, Risa, et al. A case of sudden death due to bilateral tension pneumothorax after acupuncture. J Nara Med Assoc 2004;55:331–5.

6          Lee B, Kim Y, Park S, et al. Bilateral tension pneumothorax due to acupuncture: Two autopsy cases: Acupuncture resulting in pneumothorax. Basic Appl Pathol 2010;3:67–9. doi:10.1111/j.1755-9294.2010.01075.x

7          Jian J, Shao Y, Wan L, et al. Autopsy diagnosis of acupuncture-induced bilateral tension pneumothorax using whole-body postmortem computed tomography: A case report. Medicine (Baltimore) 2018;97:e13059. doi:10.1097/MD.0000000000013059


Declaration of interests MC