Buffalo chest syndrome is a type of simultaneous bilateral pneumothorax. It can be fatal if not treated immediately. However, the occurrence of this anomaly is extremely rare. This article highlights the aetiology, incidence, and treatment for the same.

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Practice pearls

1. The interpleural communication can be compared to an anatomical entity found in the North American bison, hence the nomenclature, “Buffalo Chest”.
2. Simultaneous bilateral pneumothorax comprises approximately 1.6% of all spontaneous pneumothorax cases; it may be caused by interpleural communications most commonly due to invasive mediastinal surgery.
3. Clinical manifestations range from mild chest pain to life-threatening respiratory failure. The effect of rupture of bleb/bullae may be amplified because of bilateral pneumothorax. Chest tube drainage on one side can lead to its resolution.
4. Closure of the pleuro-pleural communication is essential to prevent fatal bilateral recurrence.

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The buffalo chest is a potentially life-threatening condition in which a simultaneous spontaneous bilateral pneumothorax (SSBP) occurs due to communication of both pleural cavities. This can be due to iatrogenic or idiopathic fenestrations of the mediastinum.

Schorlemmer et al. were the first authors who introduced the term buffalo chest in 1984. They reported a case of a simultaneous bilateral pneumothorax after a subclavian venous catheterization in a patient who had undergone a median sternotomy causing communication of both pleural cavities.

The interpleural communication could be compared to an anatomical entity found in the North American bison. This knowledge was used by Native Americans for hunting bison. They used to kill their prey with a single chest wound, by causing a bilateral pneumothorax which resulted in rapid death.

In humans, both the pleural cavities in the chest are two separate compartments. Although, rarely an idiopathic cause of interpleural communication can occur in humans.

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Aetiology

The pleural, peritoneal and pericardial cavities all derive from the intra-embryonic coelom. This primitive body cavity develops in the primitive mesodermal layer of the embryo. Closure of the pericardial-peritoneal canals start during Carnegie stage 12 (26 - 30 days) and is completed in stage 18 (44 - 48 days). Between these stages, the mesenchymal ridge grows bilaterally into the pericardial-peritoneal canals until they end up as two separate cavities: the pericardial and pleural cavities.

Apoptosis has been observed in all stages of lung development. Although its role and regulation are not well understood, apoptosis probably is the key player in fetal lung development. This could also be a plausible explanation for a congenital buffalo chest.

Jacobi et al. hypothesised that disruption of the mediastinal pleura from lung metastasis is another possible explanation for developing an interpleural communication. It is estimated that SSBP comprises approximately 1.6% of all spontaneous pneumothorax cases. SSBP may be caused by interpleural communications most commonly due to invasive mediastinal surgery.

Reported sites of congenital pleuro-pleural communication were:

1. Anterior mediastinum
2. Lower middle mediastinum
   1. Pleural windows located between the aorta and oesophagus
   2. A defect of the middle mediastinal septum, from the tracheal carina to the diaphragm (history of surgical treatment for Tetralogy of Fallot).
   3. A wide defect in the middle mediastinal septum in patients with horseshoe lung (a rare anomaly characterised by fusion of the posterobasal portions of both lungs, behind the pericardial reflection, or sometimes behind the oesophagus)
3. Lower middle mediastinal communication

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Occurrence and treatment

Even though only a few cases of a buffalo chest in humans have been described, it can be presumed that the incidence of interpleural communication in humans is underestimated as it can only be diagnosed if a pneumothorax occurs, or during autopsy if the pathologist pays specific attention to the thorax anatomy regarding this condition. Therefore, it is important to always pay attention to the contralateral chest when a patient presents with a pneumothorax.

The presence of an interpleural communication can translate into an advantage. At least, in theory, bilateral pneumothorax or effusions in the presence of an interpleural communication could be treated with just one chest tube, thereby avoiding the need for and risks of an additional chest tube on the contralateral side.

However, the presence of an interpleural communication also comes with a potential disadvantage. In case of a pneumothorax, there is a realistic risk of contralateral tension pneumothorax at the undrained side, when the interpleural communication functions as a one-way valve. It is important to be aware of this potential risk and to always consider this if a patient that received a chest tube, further deteriorates.

The clinical manifestations of SSBP can be varied ranging from mild chest pain to life-threatening respiratory failure. The effect of rupture of bleb/bullae may be amplified because of bilateral pneumothorax. Intercostal tube drainage (ICD) on one side can lead to the resolution of bilateral pneumothoraces.

Closure of the pleuro-pleural communication is essential to prevent the recurrence of bilateral pneumothorax. Closure can be performed by covering or direct sutures. Parietal pleurectomy has been reported to obliterate the anterior mediastinal window.

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Incidence

SSBP due to suspected pleuro-pleural communications has been described in a total of 9 patients, and among them confirmed pleuro-pleural communication has been demonstrated in 4 patients, highlighting the rarity of this case. Although not confirmed by surgery, congenital pleuro-pleural communication was suspected in three patients who suffered bilateral pneumothorax after unilateral thoracic puncture due to insertion of a central venous catheter.

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Buffalo chest syndrome is a rare occurrence but can be fatal in conditions of simultaneous spontaneous pneumothorax. A congenital pleuro-pleural communication should be considered in such cases. Radiologic examination and chest CT before and after insertion of a single chest tube on one side may yield diagnostic clues. In addition, the anterior and lower-middle mediastinum should be carefully inspected. Closure of the pleuro-pleural communication is essential to prevent a fatal bilateral recurrence. Additionally, there is a requirement of further research into the incidence of this condition, its early diagnosis as well as treatment options.

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Click to see references

[1] Hata, Y., Suzuki, T., Yokoi, M., Yoshida, S., Takeyama, T., Nakazaki, H., Goto, H., Sato, F., Takagi, K. and Otsuka, H., 2022. Simultaneous bilateral spontaneous pneumothorax with congenital pleuro-pleural communication. [online] Jtd.amegroups.com. Available at: <https://jtd.amegroups.com/article/view/846> [Accessed 12 January 2022]

[2] Ray A, Gupta M. Iatrogenic buffalo-chest syndrome. Indian J Radiol Imaging. 2017 Apr-Jun;27(2):254-255. doi: 10.4103/0971-3026.209202. PMID: 28744089; PMCID: PMC5510326.

[3] Blacha, M., Smesseim, I., van der Lee, I., van den Aardweg, J., Schultz, M., Kik, M., van Sonsbeek, L., de Bakker, B. and Light, R., 2021. The Legend of the Buffalo Chest. Chest, 160(6), pp.2275-2282.

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