DescriptionA 40-year-old male patient presented to the emergency department with complaints of shortness of breath associated with bilateral pleuritic chest pain. He denied any history of trauma and had smoked 40 cigarettes daily for the past 22 years.On examination, the patient appeared breathless with a respiratory rate of 25 breaths/min and peripheral capillary oxygen saturation (SpO 2 ) of 92% on room air. Neck examination showed no tracheal deviation and chest examination identified decreased bilateral chest expansion with no intercostal retractions. On chest palpation, there was a slightly diminished tactile fremitus on both sides. Chest percussion revealed a hyper-resonant note heard over the right and left upper and mid zones. On auscultation, there were no audible breath sounds and whispered voice sounds were abolished over the right and left upper and mid zones.The gasometric evaluation revealed the presence of hypoxaemia and hypocapnia. A posteroanterior chest radiograph showed a large bilateral pneumothorax (figure 1). The thoracic CT scan revealed focal areas of emphysema and apical subpleural blebs, which were located predominantly in the peripheral regions of the apex (figure 2).Supplemental high-flow oxygen was given to the patient. After confirmation with needle aspiration, small-bore chest drains were placed on both sides and the patient had complete re-expansion of both lungs. Despite the American College of Chest Physicians Delphi Consensus Statement regarding the management of secondary spontaneous pneumothorax (SSP) and after careful discussion with a chest physician, chemical or surgical pleurodesis was not considered at this point since there was a complete resolution after the use of chest drains. From the aetiological investigation, it stood out a decreased serum level of α1-antitrypsin. Its association with the high smoking load (44 pack years) in this patient was assumed to be the cause of the bilateral SSP episode. He was later discharged, being advised to cease smoking.Several months later, he was again admitted with a new left pneumothorax. This time, after evaluation by a chest physician, he underwent a wedge resection of the left upper lobe and mechanical pleurodesis by video-assisted thoracoscopic surgery. He has remained asymptomatic since then, with no further pneumothorax recurrences.Spontaneous pneumothorax is frequently associated with smoking habits, making smoking cessation

Sarcoidosis is a systemic inflammatory disease of unknown etiology, characterized by non-necrotizing granuloma formation in multiples organs. Isolated extrathoracic sarcoidosis has been reported in under 10% of the patients, and so isolated spleen sarcoidosis is extremely rare. A 68-year-old woman presented to our hospital with 6-month history of anorexia, left hypochondrial discomfort and early satiety, aggravated with high fever, fatigue and generalized myalgia two days before coming to the hospital. The physical examination detected splenomegaly. Laboratory analysis revealed pancytopenia with hemolysis and an elevated angiotensin converting enzyme. Image studies showed splenomegaly with multiple hypoechoic lesions. Infectious and autoimmune etiology was excluded. Bone marrow biopsy excluded lymphoproliferative disease. Patient underwent ultrasonography-guided spleen biopsy finding noncaseating epithelioid cell granulomas. The patient was started on corticosteroids with symptom improvement. Two years after the diagnosis the pancytopenia recurred, and bone marrow biopsy was repeated revealing non-Hodgkin lymphoma infiltration. Although splenic sarcoidosis was treated and the regular follow-up of the patient it was impossible to predict the development of lymphoma as it is still unknown what is the cause effect link between sarcoidosis and lymphoma.