Video-Assisted Thorascopic Removal of

Migratory Acupuncture Needle Causing

Pneumothorax*
Wesley B. von Riedenauer, Mark K. Baker and Robert J. Brewer

Chest 2007;131;899-901
DOI 10.1378/chest.06-1443
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services can be found online on the World Wide Web at:
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fibrosis and PAH undergoing right-heart catheterization,
treatment with a single dose of oral sildenafil (50 mg)
lowered the mean PA pressure, improved ventilation/
perfusion matching, and improved gas exchange.7 A re-
port12 of three patients with IPF and PAH treated with 8
weeks of sildenafil therapy showed a significant increase in
mean 6MWD (80 to 120 m; p ⫽ 0.03). Data published in
abstract form only reported the effects of sildenafil in 10
patients with IPF and PAH.13 Right heart catheterization
during the initial dose of sildenafil showed a reduction in
pulmonary vascular resistance of 28%; during a median
follow-up time of 8.4 months, significant improvements in
dyspnea, gas exchange, and quality of life were reported.
The 6MWD is a relevant outcome measure in patients
with IPF and PAH.14,15 Recently, a retrospective review16
of 454 patients with IPF who had undergone formal 6-min
walk testing at the time of referral for lung transplantation
found that a lower 6MWD was associated with an in-
creased risk of death (adjusted rate ratio, 4.7; p ⬍ 0.0001).
In contrast to traditional therapies in IPF patients, silde-
nafil appears to be generally well-tolerated.7,12 Only one
patient in our protocol had a serious adverse event
(transient hypotension) that was attributable to sildenafil.
Based on the results of this study, we believe sildenafil is
a promising therapy for patients with IPF and PAH. The
results of this study should be confirmed in a large,
randomized, placebo-controlled trial.
References
1 Bjoraker JA, Ryu JH, Edwin MK, et al. Prognostic signifi-
cance of histopathologic subsets in idiopathic pulmonary
fibrosis. Am J Respir Crit Care Med 1998; 157:199 –203
2 Nicholson AG, Colby TV, Dubois RM, et al. The prognostic
significance of the histologic pattern of interstitial pneumonia in
patients presenting with the clinical entity of cryptogenic fibro-
sing alveolitis. Am J Respir Crit Care Med 2000; 162:2213–2217
3 Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardiographic
assessment of pulmonary hypertension in patients with advanced
lung disease. Am J Respir Crit Care Med 2003; 167:735–740
4 Lettieri CJ, Nathan SD, Barnett SD, et al. Prevalence and
outcomes of pulmonary arterial hypertension in advanced
idiopathic pulmonary fibrosis. Chest 2006; 129:746 –752
5 Nadrous HF, Pellikka PA, Krowka MJ, et al. The impact of
pulmonary hypertension on survival in patients with idio-
pathic pulmonary fibrosis. Chest 2005; 128(suppl):616S– 617S
6 Leuchte HH, Baumgartner RA, Nounou ME, et al. Brain
natriuretic peptide is a prognostic parameter in chronic lung
disease. Am J Respir Crit Care Med 2006; 173:744 –750
7 Ghofrani HA, Wiedemann R, Rose F, et al. Sildenafil for
treatment of lung fibrosis and pulmonary hypertension: a
randomised controlled trial. Lancet 2002; 360:895–900
8 American Thoracic Society. Idiopathic pulmonary fibrosis: diag-
nosis and treatment: international consensus statement; Ameri-
can Thoracic Society (ATS), and the European Respiratory
Society (ERS). Am J Respir Crit Care Med 2000; 161:646 – 664
9 American Thoracic Society. ATS statement: guidelines for the
six-minute walk test. Am J Respir Crit Care Med 2002;
166:111–117
10 Efron B, Tibshirani R. An introduction to the bootstrap.
Norwell, MA: Kluwer Academic Publishers, 1994
11 Weitzenblum E, Ehrhart M, Rasaholinjanahary J, et al.
Pulmonary hemodynamics in idiopathic pulmonary fibrosis
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© 2007 American College of Chest Physicians
and other interstitial pulmonary diseases. Respiration 1983;
44:118 –127
12 Madden BP, Allenby M, Loke TK, et al. A potential role for
sildenafil in the management of pulmonary hypertension in
patients with parenchymal lung disease. Vascul Pharmacol
2006; 44:372–376
13 Wilkens H, Weingard B, Mack U, et al. Long-term treatment
with sildenafil for pulmonary hypertension in pulmonary
fibrosis [abstract]. Proc Am Thorac Soc 2005; 2:A195
14 Hallstrand TS, Boitano LJ, Johnson WC, et al. The timed
walk test as a measure of severity and survival in idiopathic
pulmonary fibrosis. Eur Respir J 2005; 25:96 –103
15 Lettieri CJ, Nathan SD, Browning RF, et al. The distance-
saturation product predicts mortality in idiopathic pulmonary
fibrosis. Respir Med 2006; 100:1734 –1741
16 Lederer DJ, Arcasoy SM, Wilt JS, et al. Six-minute walk
distance predicts waiting list survival in idiopathic pulmonary
fibrosis. Am J Respir Crit Care Med 2006; 174:659 – 664
Video-Assisted Thorascopic
Removal of Migratory
Acupuncture Needle Causing
Pneumothorax*
Wesley B. von Riedenauer, MD; Mark K. Baker, PA-C;
Robert J. Brewer, MD
We report the case of a 25-year-old African-Ameri-
can man presenting to the Henry Ford Hospital
emergency department with acute dyspnea second-
ary to a pneumothorax resulting from a migratory
acupuncture needle. The patient received acupunc-
ture treatment approximately 5 years prior to this
presentation for treatment of posttraumatic chronic
right shoulder pain. Chest radiography revealed
retained needles in his right shoulder girdle and a
needle overlying the thoracic cage with an attendant
pneumothorax. Catheter aspiration for simple pneu-
mothorax provided immediate symptomatic relief.
Video-assisted thoracoscopy was then used to re-
move the migratory acupuncture needle from the
chest wall. The patient recovered without complica-
tion and was discharged to home.
(CHEST 2007; 131:899 –901)
Key words: acupuncture; dyspnea; pneumothorax; video-as-
sisted thoracoscopy
Abbreviation: VATS ⫽ video-assisted thoracoscopy
*From the Department of Cardiothoracic Surgery, Henry Ford
Hospital, Detroit, MI.
The authors have no conflicts of interest to report.
Manuscript received June 15, 2006; revision accepted July 21,
2006.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Wesley B. von Riedenauer, MD, Department of
Cardiothoracic Surgery, Henry Ford Hospital, 2799 West Grand
Blvd, Detroit, MI 48202; e-mail: vonriedenauer@yahoo.com
DOI: 10.1378/chest.06-1443
CHEST / 131 / 3 / MARCH, 2007 899
A puncture
cupuncture dates to 8000 BC. Several forms of acu-
iatrogenia have been reported, including
pneumothorax, hemorrhage, hematoma formation, hepa-
titis, site infections, syncope, near syncope, abdominal
aortic disruption, HIV transmission, cardiac tamponade,
endocarditis, and death.1–5 Pneumothorax has been re-
ported as one of the most common serious side effect of
acupuncture by several studies.3–5 Reports of acupunc-
ture-associated pneumothorax cite patient presentation
during, or shortly after, acupuncture therapy. Death from
acupuncture-associated pneumothorax has also been re-
ported.2,5 Different styles of acupuncture lend to different
complications. Chinese-style acupuncture involves the
placement and withdrawal of needles into the deep tissues
of the body, while the Japanese style of acupuncture
involves the placement of needles into the subcutaneous
tissues. Some Japanese-style acupuncturists practice
needle embedding in which needles are placed into the
deep and subcutaneous tissues and broken off at the
skin.1,4,5 Migration of these embedded needles has been
reported to cause significant consequences.1,5 There are
no previously reported cases of pneumothorax associ-
ated with the migration of embedded acupuncture
needles.

Figure 1. Chest radiograph demonstrating right pneumothorax

Case Reports and retained needles.
Our patient was a 25-year-old African-American man who
presented to the emergency department of Henry Ford Hospital
complaining of the acute onset of dyspnea associated with Discussion
diaphoresis and severe right-sided chest pain. Symptom onset
was abrupt and occurred while painting. He denied recent Iatrogenic pneumothorax from migratory embedded
trauma and any medical history of pneumothorax. Chronic right acupuncture needles is previously unreported. Our patient
shoulder pain following a traumatic sports-related clavicular presented approximately 5 years following his acupuncture
fracture in 1998 was reported. Acupuncture was enlisted for
symptomatic control of this chronic right shoulder pain in 2000.
Partial and transient pain relief was reported following acupunc-
ture therapy. The patient denied any knowledge of retained
needles. Tobacco consumption was reported at four to five
cigarettes per day.
Chest radiography revealed a right-sided 20% pneumothorax
associated with five needle-shaped metallic objects in the right
shoulder region. One metallic object was overlying the thoracic
cage (Fig 1). Catheter aspiration for simple pneumothorax
provided immediate symptomatic relief. CT imaging confirmed
retained needle penetration of the pleural space and attendant
pneumothorax (Fig 2). The patient consented to video-assisted
thoracoscopy (VATS) with removal of the retained foreign body.
The patient underwent VATS with clear visualization of the
migrated acupuncture needle penetrating through the parietal
pleura (Fig 3). The retained needle was removed under thora-
coscopic visualization using grasping forceps. Examination of the
right lung revealed no areas of disease. Chest tube drainage
continued until postoperative day 2. No further respiratory
symptoms developed, and there was no evidence of pneumotho-
rax on a follow-up chest radiograph. The patient was subse-
quently discharged to home with routine follow-up in 1 week.
The patient was evaluated in clinic following discharge and was
found to have remained symptom free and without recurrent
pneumothorax. Consultation was arranged with the Henry Ford
Hospital orthopedic service for removal of the other retained Figure 2. Chest CT demonstrating right-sided pneumothorax
acupuncture needles. and associated retained acupuncture needle.

900 Selected Reports

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© 2007 American College of Chest Physicians

Figure 3. VATS visualization of retained acupuncture needle
penetrating the right hemithorax and parietal pleura.
therapy. Migration of embedded acupuncture needles is
associated with life-threatening consequences. The prac-
tice of embedding acupuncture needles is now considered
malpractice and is discouraged by professional acupunc-
ture associations. Removal of embedded needles from
locations of proven or suspected clinically significant
migration appears justifiable.
This case serves to remind readers that alternative, like
traditional, forms of medicine necessarily entail risks.
Scientific and clinical investigations, coupled with the
standardization of practice and training may lend to
increased efficacy, decreased iatrogenia, identification of
indications and contraindications, and a furtherance of
credibility.
References
1 Yokogushi K. Embedded needles in acupuncture: case report
and review of the literature. Med Acupunct 2004; 15:34 –35
2 Iwadate K, Ito H, Katsumura S, et al. An autopsy case of
bilateral tension pneumothorax after acupuncture. Leg Med
2003; 5:170 –174
3 Peuker E. Case report of tension pneumothorax related to
acupuncture. Acupunct Med 2004; 22:40 – 43
4 Ernst E, White A. Life-threatening adverse reactions after
acupuncture? A systematic review. Pain 1997; 71:123–126
5 Peuker E, White A, Ernst E, et al. Traumatic complications of
acupuncture. Arch Fam Med 1999; 8:553–558
Eosinophilic Pneumonia Due to
Duloxetine*
Vidal J. Espeleta, MD; William H. Moore, MD;
Philip B. Kane, MD; and Daniel Baram, MD, FCCP
A 32-year-old man presented with a 2-month history
of worsening fever, chills, and cough despite therapy
with oral antibiotics. Chest radiographs demon-
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© 2007 American College of Chest Physicians
strated migrating, peripheral upper lobe infiltrates.
A CBC count demonstrated significant eosinophilia.
At bronchoscopy, eosinophil-rich mucus was seen
impacted throughout his bronchi. A transbronchial
biopsy confirmed the diagnosis of eosinophilic pneu-
monia. Symptoms, eosinophilia, and radiographic
abnormalities were reversed with cessation of dulox-
etine. This case report briefly reviews the diagnosis
of drug-induced pulmonary infiltrates with eosino-
philia (PIEs) and eosinophilic pneumonia. To our
knowledge, this is the first reported case of PIEs due
to duloxetine. (CHEST 2007; 131:901–903)
Key words: antidepressant; drug-induced lung disease; eosino-
philic lung disease
Abbreviations: PIE ⫽ pulmonary infiltrate with eosinophilia
P sinophilic
ulmonary infiltrates with eosinophilia (PIEs) and eo-
pneumonia represent a classic diagnostic
differential in pulmonary medicine. In the developing
world, PIEs usually represent parasitic infection; in the
United States, it more commonly represents drug-in-
duced, connective tissue disease or idiopathic disease. A
careful history and physical examination are required in
the evaluation of eosinophilic lung disease. The clinician
must have a high index of suspicion for medications being
the etiology, even for those not yet reported in the
literature to be a causative agent.
A 32-year-old man had presented 1 month earlier with
a dry cough. He was treated with oral amoxicillin/clavu-
lanic acid (Augmentin; Glaxo-SmithKline; Research Tri-
angle Park, NC) for community-acquired pneumonia, as
his chest radiograph demonstrated a right upper lobe
consolidation (Fig 1, top, A). His symptoms waxed and
waned with episodic fever and chills. He was referred for
pulmonary evaluation when rapidly worsening dyspnea
developed.
His medical history was significant for attention deficit
hyperactivity disorder for many years; he denied asthma,
smoking, or illicit drug use. Medications he was using at
presentation were multivitamins, atomoxetine (Strattera;
Eli Lilly; Indianapolis, IN) for 2 years and duloxetine
(Cymbalta; Eli Lilly) for 4 months. He is a schoolteacher.
He denied any recent travel, had never been outside the
United States, and did not camp outdoors. Family history
*From the Division of Pulmonary/Critical Care Medicine (Drs.
Espeleta and Baram), and the Departments of Radiology (Dr.
Moore) and Pathology (Dr. Kane), Stony Brook University, Stony
Brook, NY.
The authors have reported to the ACCP that no significant
conflicts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Manuscript received July 3, 2006; revision accepted July 28,
2006.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Daniel Baram, MD, FCCP, Stony Brook
University, Division of Pulmonary/Critical Care Medicine, De-
partment of Medicine, T-17 040 HSC, Stony Brook, NY 11794-
8172; e-mail: daniel.baram@stonybrook.edu
DOI: 10.1378/chest.06-1659
CHEST / 131 / 3 / MARCH, 2007 901
Video-Assisted Thorascopic Removal of Migratory Acupuncture Needle
Causing Pneumothorax *
Wesley B. von Riedenauer, Mark K. Baker and Robert J. Brewer
Chest 2007;131; 899-901
DOI 10.1378/chest.06-1443
This information is current as of October 7, 2011
Updated Information & Services
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References
This article cites 3 articles, 1 of which can be accessed free at:
http://chestjournal.chestpubs.org/content/131/3/899.full.html#ref-list-1
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