Spontaneous diaphragmatic hernia in a 16 year-old female in the absence of trauma

Introduction: This case describes an adolescent female who presented with a spontaneously acquired diaphragmatic hernia, a rare occurrence in the absence of trauma. Case Report: A 16 year-old female with history of 31-week prematurity, chronic idiopathic abdominal distention, constipation, and gastro-esophageal reflux disease status post fundoplication, presented to an outside hospital (OSH) with a chief complaint of seizure activity. She had no recent head or body trauma. She received a head and abdominal CT due to chronic abdominal distention in the OSH emergency department (Figure 1), which were both read as normal. She was transferred to the general pediatric ward at the regional children's hospital for work-up of new seizure, where her physical exam was documented as normal albeit with baseline abdominal distention. Review of systems was positive for abdominal distension and tenderness, but negative for fever, dyspnea, cough, chest pain, nausea, vomiting, or diarrhea. After returning from a brain MRI with general anesthesia, she was noted to have "decreased breath sounds on the left" without change in work of breathing or oxygenation and symmetric chest rise. Incentive spirometer was prescribed for presumed atelectasis. Within hours, she developed a fever (38.7 C) and tachycardia. A chest radiograph revealed spontaneous herniation of colon and small bowel loops into the left hemithorax with associated significant rightward mediastinal shift (Figure 2) for which she received emergent surgical repair. Discussion: Spontaneously acquired diaphragmatic hernias rarely occur in the absence of trauma. Over 75% of diaphragmatic hernias are related to road traffic accidents. Predisposing factors also include athletics, dancing, exercise, weight-lifting, eclampsia, child labor, emesis, asthma, and pertussis; all of which cause stress on the diaphragm. Other causes of diaphragmatic hernia include delayed presentation of congenital diaphragmatic hernia, persistent infection such as pneumonia or empyema, or iatrogenic injury during abdominal or thoracic surgery. The etiology of this patient's diaphragmatic hernia is unknown, as she lacked any identifiable risk factors. Furthermore, she had normal diaphragm anatomy on a prior chest radiograph when hospitalized four years ago for a right basilar uncomplicated pneumonia (Figure 2). Old trauma or a less visible structural defect may have played a role in this case. In all cases, early recognition of a spontaneously acq