Acupuncture is an alternative medicine, actually it has had a greater acceptance in our continent being use for multiple therapeutic purposes. Although it is a minimally invasive procedure it is not exempt from complications, most common minor complications such as infections or local pain have been described, as well as less frequently but potentially fatal complications such as subarachnoid hemorrhage and tension pneumothorax. We report a case of pneumothorax secondary to acupuncture in a patient who was treated for carpal tunnel syndrome.

Acupuncture a type of alternative medicine is increasing in popularity in our country being often performed by non-medical professionals [1, 2]. According to a paper from the Colombian Ministry of Health in March 2018 there were in Colombia 752 authorized traditional Chinese medicine centers that perform these procedures with multiple therapeutic intentions [3]. Although it is a minimally invasive procedure, it is not exempt from complications, some of them minor such as local pain and infections, to potentially fatal complications such as subarachnoid hemorrhage, cardiac tamponade and tension pneumothorax [4].

We report the case of a man who came to our emergency department with dyspnea secondary to an acupuncture therapy

A 74-year-old male patient, with no previous known medical history, was admitted to the emergency department of our institution. His main symptoms were right pleuritic-type pain of a duration of approximately 2 hours associated with dyspnea starting after an acupuncture procedure.

This procedure was performed at the supraclavicular level, indicated for the management of right carpal tunnel syndrome. On admission, the patient is hemodynamically stable, with no evidence of frank signs of respiratory distress, with borderline oxygen saturation. On physical examination, decreased breath sounds on the right lung was evidenced and an increase in the anteroposterior diameter of the right hemithorax. An electrocardiogram was performed without signs suggesting acute ischemia. A Point of care lung ultrasound was performed with the absence of right pleural sliding in the B mode and “stratosphere” sign an M mode (See Figure 1). With these findings, it was decided to perform an AP and lateral chest X-ray where a right pneumothorax was confirmed. (Figure 2).

Figure 1

M-mode lung ultrasound (note the arrowed stratosphere sign)

Figure 2

a) AP chest X-ray and Image; b) Simple axial section chest tomography with pneumothorax (white arrow)

Pneumothorax is defined as the presence of air in the pleural space, and is classified as spontaneous and traumatic [5]. A traumatic pneumothorax can result from either a blunt force or a penetrating injury to the chest [6]. The most frequently associated injuries are assaults, traffic accidents or falls [7]. Some cases of traumatic pneumothorax secondary to acupuncture have been described in several countries [8, 9].

A systematic review carried out in China in 2010 reviewing 115 articles, with 479 reported cases of adverse events related to acupuncture procedures classifies them into 3 categories: infectious, traumatic and others. Pneumothorax being one of the most common complications reported 201 cases, of which 4 died, giving great importance to this adverse event [4].

The clinical presentation is similar to that of a pneumothorax due to any other etiology. The most frequent symptoms of presentation are pleuritic pain and dyspnea, taking into account the history of the previously performed procedure [10].

The diagnosis is based on clinical suspicion and imaging to confirm it [11]. Multiple studies have recently been conducted that suggest point-of-care ultrasound as a more sensitive alternative to chest X-ray for diagnosis, with a sensitivity ranging from 80-89% and a specificity of 89-95 %. Chest radiography has a sensitivity between 47-61% and a specificity of 90-98%, depending on the technical conditions in which it is performed [12, 13] Tomography is becoming more accessible and allows better quantification of the size of the pneumothorax and the identification of occult pneumothorax in certain circumstances [14].

Treatment is performed based on its characteristics [size, associated lesions, mechanical ventilation, etc.]. Is traditionally indicated in patients with tension pneumothorax, pneumothorax of more than 30% and pneumothorax in patients who will require mechanical ventilation [15]. Its management is performed by closed thoracostomy, however there is an increasing evidence about less invasive management using pig tail catheters [16].

It should be noted that minimally invasive procedures such as acupuncture are also at risk of potentially fatal adverse events such as tension pneumothorax. Timely recognition considering the clinical history and the recent performance of this procedure, should set warning signs for the medical staff at the emergency services. Diagnosis and treatment are the same as for pneumothorax of any other etiology.

Conflicts of Interest:

No conflicts of interest are declared.