Acupuncture-Induced Hemothorax with Hypovolemic Shock: A Case Report

Abstract

This report describes a very rare but life-threatening complication that occurred in a 43-year-old woman after an acupuncture (AC) for lumbago. The patient presented to the emergency department displaying symptoms indicative of shock. Physical examination revealed the absence of breath sounds on the right thoracic side, further investigations indicated the presence of a hemothorax. Emergency surgery was performed to evacuate the hemothorax and control bleeding from two intercostal veins. Although AC is often considered a gentle form of medicine, it is important to recognize that it can occasionally result in severe complications, especially when acupoints are used on the thorax.

Introduction

Acupuncture (AC) is gaining popularity as a complementary approach for addressing health-related issues, with numerous studies continuously confirming its beneficial effects and increasing recognition of its potential. In Germany, health insurance funds cover AC treatment for conditions such as low back pain and osteoarthritis of the knee, acknowledging its positive evidence.¹ With the increasing number of patients receiving AC,² the likelihood of encountering complications in emergency rooms may rise. Despite their rarity, it is crucial for modern physicians to possess knowledge about the potential side effects associated with AC.

Severe complications related to AC, including spinal cord injury, infection, cardiac tamponade, and pneumothorax, have been reported. AC-induced hemothorax has only been reported in a few cases.^3
–5

Case

After undergoing AC treatment for nonspecific lumbar back pain, a 43-year-old woman was brought to the emergency department by ambulance due to hypotension and dizziness, with symptoms appearing ∼2 h after the treatment. She had no previous medical conditions or known history of coagulation disorder.

She had a body mass index (BMI) of 18.1 kg/m². Upon physical examination, breath sounds diminished on the right side. Clinical signs of hypovolemic shock, such as tachycardia, hypotension with a systolic reading of 60–70 mmHg, dry mucous membranes, decreased skin turgor, and low jugular venous distention, were present.

A minor puncture was observed below the scapula in the right paravertebral region. No other visible wound was observed. Initial blood tests revealed a hematocrit (Hct) level of 22%, hemoglobin count of 7.7 g/dL, red blood cell count of 2.66 × 10¹²/L, and white blood cell count of 17 × 10⁹/L. Pleurocentesis was performed in the emergency department. A significant amount of bright red bloody fluid was aspirated. Given these findings and the patient's deteriorated general condition, a video-assisted thoracoscopic surgery was performed to evacuate the right-sided hemothorax.

Due to the severity of the patient's condition, no further imaging procedures were conducted.

During the surgery, two bleeding sites were identified: a small hemorrhage over the eighth intercostal (IC) space paravertebrally (correlating to AC point bladder meridian 17; Geshu) and a more severe hemorrhage at the confluence of the fourth IC vein paravertebrally (correlating to AC point bladder meridian 13; Feishu). Lacerations were observed in both vessels. The bleeding was successfully stopped using electrosurgical techniques. A total of 2000 mL of blood and coagels were removed from the thorax. Two units of red blood cells and 4 U of fresh frozen plasma were transfused during the operation.

The chest tube inserted during the surgery was removed soon after the surgery. The patient did not experience any surgical complications, and her hemoglobin levels remained stable. Postoperative X-ray was unremarkable. Two days after admission, the patient was discharged successfully.

Patient Perspective

The patient underwent AC treatment for lower back pain administered by an orthopedic surgeon with additional qualifications in AC. She had previously undergone AC sessions for headaches and had a positive experience with this form of treatment. During the session, the patient was placed in a prone position, and needles were inserted into her thorax, neck, arms, and legs. She did not report any sensation related to the needles during the treatment. However, after the AC session, she experienced significant fatigue and decided to go home to rest. Approximately 2 h after the treatment, she developed severe dizziness and subsequently called for an ambulance.

She declined any future AC treatments. The patient expressed satisfaction with the treatment that she received at this hospital.

Discussion

AC, an ancient treatment for various diseases and disorders, has gained significant attention in Western countries. Although generally considered a relatively safe intervention, it is important to acknowledge that AC is an invasive procedure and carries inherent risks.⁶ Most complications associated with AC are mild, including bleeding or hematoma (4.9%–6.1%), pain (2%–2.4%), vegetative symptoms (0.7%–2.2%), and inflammation (0.3%). However, there is a possibility of rare severe complications, including pneumothorax (0.0003%–0.001%).^7,8

However, AC-induced hemothorax has rarely been described in the literature. Still there are two case reports of AC-induced hemothorax^3,4 and one case report of an accidental breakage of an AC needle leading to a hemopericardium and a hemothorax.⁵ To the best of the authors' knowledge, this report describes a unique case of AC-induced hemothorax involving two different lacerated vessels that has not been previously published. Complications associated with AC are typically attributed to improper insertion or manipulation of the needles.⁴

The length of the needles used can vary from a few millimeters to several centimeters, and the depth, direction, and angle of needle insertion, particularly in the chest/thoracic region, are crucial factors. Adequate education of acupuncturists, especially regarding anatomical regions and critical points for AC, is necessary to minimize adverse reactions.⁹ To obtain an additional qualification in AC, medical doctors need 200 h of training in Germany. Whereas the WHO recommends for limited AC treatments 200 h for treatments on their clinical work and at least 1500 h for a full course of training.

In an ancient Chinese literature, The Great Compendium of Acupuncture and Moxibustion (Zhenjiu Dacheng), which was first published in 1601, it was noticed that the ventral side of the abdomen is deep like a well and the back is thin like a pancake.¹⁰ Thus, needle insertion on the thorax should be shallow. Patients with an underweight body status (BMI <18.5 kg/m²), thin chest walls, atrophic neck and thoracic muscles, or chronic respiratory diseases are more susceptible to severe adverse reactions.³ While exercising caution when performing AC in the thoracic region to prevent pleural injuries, it is worth noting that the thicker musculature in the lumbar region carries a lower risk of adverse reactions.

Most reported cases of hemothorax have been successfully managed using conservative or minimally invasive approaches, such as transcatheter arterial embolization.⁴ However, in this case, due to the patient's deteriorating condition and progressive aggravation, emergency surgery in the form of minimally invasive thoracic surgery was necessary.

Conclusion

To the best of the authors' knowledge, this is the first documented report of two lacerated IC vessels on one side of the thorax after an AC treatment. Although AC is generally considered a safe treatment method, it is crucial to recognize its potential for serious and even fatal adverse effects. Enhanced knowledge of anatomy and heightened awareness among acupuncturists, particularly when choosing thoracic AC points, can contribute to the prevention of severe complications. Nevertheless, the administration of AC to the upper back warrants careful consideration, particularly in underweight patients, to minimize the risk of complications.

Footnotes

Acknowledgments

The patient consented to the anonymous publication of her data, which is gratefully acknowledged by the authors. CARE-writer was used to organize, format, and write this Case Report. During the preparation of this work, the authors used Paperpal to improve the grammar and language of this article. After using this service, the authors reviewed and edited the content as needed. They take full responsibility for the content.

Authors' Contributions

E.G. was responsible for the initial article writing, with C.Y. and C.R. critically reviewing and making necessary revisions. The finalization of the article was performed by E.G.

Informed Consent

Written informed consent was obtained.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Data S1

References

Haake

, Muller

, Schade-Brittinger

, et al. German Acupuncture Trials (GERAC) for chronic low back pain: Randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med, 2007; 167(17):1892–1898; doi: 10.1001/archinte.167.17.1892

Cui

, Wang

, Ren

, et al. Use of acupuncture in the USA: Changes over a decade (2002–2012). Acupunct Med, 2017; 35(3):200–207; doi: 10.1136/acupmed-2016-011106

Karavis

, Argyra

, Segredos

, et al. Acupuncture-induced haemothorax: A rare iatrogenic complication of acupuncture. Acupunct Med, 2015; 33(3):237–241; doi: 10.1136/acupmed-2014-010700

Hanabusa

, Kubo

, Watadani

, et al. Successful transcatheter arterial embolization for a massive hemothorax caused by acupuncture. Radiol Case Rep, 2022; 17(9):3107–3110; doi: 10.1016/j.radcr.2022.05.040

Hasegawa

, Noguchi

, Yamasaki

, et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology, 1991; 78(1):58–63; doi: 10.1159/000174766

Corado

, Graca Santos

, Quaresma

, et al. Pneumothorax after acupuncture. BMJ Case Rep, 2019; 12(6); doi: 10.1136/bcr-2018-228770

Witt

, Pach

, Brinkhaus

, et al. Safety of acupuncture: Results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed, 2009; 16(2):91–97; doi: 10.1159/000209315

Baumler

, Zhang

, Stubinger

, et al. Acupuncture-related adverse events: Systematic review and meta-analyses of prospective clinical studies. BMJ Open, 2021; 11(9):e045961; doi: 10.1136/bmjopen-2020-045961

, Hu

, Zhu

, et al. Systematic review of adverse effects: A further step towards modernization of acupuncture in China. Evid Based Complement Alternat Med, 2015; 2015:432467; doi: 10.1155/2015/432467

10.

Yang

, Wilms

The Great Compendium of Acupuncture and Moxibustion: Zhēn Jiǔ Dà Chéng: Chinese Medicine Database; 2010.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

2.31 MB