Pneumothorax and wound dehiscence related to collagenase deregulation: Treatment with diphenylhydantoin

Wound dehiscence is an uncommon complication of operation, usually related to a recognized risk factor. A clinical dilemma arises when dehiscence has no identifiable cause or treatment. We describe the case of a previously healthy 45-year-old man in whom recurrent spontaneous pneumothoraces developed followed by multiple dehiscences of thoracotomy, diaphragmatic, and abdominal wounds. Analysis over several years of laboratory investigation of cultured tissue from test incisions was initially unsuccessful. The patient was supported symptomatically until a remarkable laboratory finding enabled us to develop an effective treatment plan. Cultured patient fibroblasts were ultimately found to express abnormally elevated levels of collagenase, which could be inhibited by diphenylhydantoin (phenytoin) in vitro. Treatment of the patient with a course of diphenylhydantoin allowed adequate healing of test incisions and subsequent definitive surgical treatment with successful wound healing. This report of the rigorous application of the scientific method to the investigation and treatment of an enigmatic case of wound dehiscence might serve as a guide to surgeons faced with similar healing problems.