Hrev_master [page 8] [Emergency Care Journal 2025; 21:13973] Emergency Care Journal 2025 volume 21: Question Given the radiological findings and the patient’s clinical history, what is the possible diagnosis? 1. Austrian syndrome 2. Poland syndrome 3. Tieze syndrome 4 Buffalo chest syndrome Answer The correct answer is buffalo chest syndrome. The “buffalo chest” is a rare condition in which a simultaneous bilateral pnx occurs due to a communication of both pleural cavities caused by an iatrogenic or idiopathic fenestration of the mediastinum.1-8 The term “buffalo chest” derives from an old legend in which Native Americans were said to be able to kill a buffalo (or bison) instantly with a single arrow to in the chest, by creating a simultaneous bilateral pnx, due to the animal’s peculiar anatomy in which there is one contiguous pleural space due to an incomplete mediastinum.8 The pathophysiology is based on the presence of defects or communications between the two pleural cavities, allowing the passage of air or fluid from one hemithorax to the other. Most of the reported cases are of iatrogenic origin, often fol- lowing the Nuss procedure or cardiac surgery.1-7 Out of 47 reported cases, only 6 are spontaneous.8 To date, the underlying cause or A legendary chest X-ray Gea Nicoletti,1 Davide Tizzani,2 Paola Molino3 1Emergency Medicine Department, University of Palermo, Palermo; 2Emergency Department, Ospedale degli Infermi, Rivoli, Torino; 3Emergency Department, Ospedale degli Infermi, Rivoli, Torino, Italy A healthy 19-year-old male non-smoker presented to our emergency department with symptoms of vomiting, fever, and retrosternal chest pain. The patient’s personal and family medical histories were unremarkable. Upon admission, he was alert and oriented, with blood pressure of 115/65 mmHg, heart rate of 90 bpm, respiratory rate of 18 breaths per minute, and peripheral oxygen saturation of 98% on room air. On physical examination, breath sounds were decreased over the left hemithorax. Laboratory tests documented a slight leukocytosis (WBC 10.4 ×10⁹/L) in absence of increased C- reactive protein value. Ultrasensitive troponin I was in the normal range (7 ng/L, normal value <14 ng/L). Arterial blood gas analysis showed no respiratory abnormalities (pH 7.38; PaO₂ 90 mmHg; PaCO₂ 39 mmHg; HCO₃ 22 mmol/L; lactates 1 mmol/L). An elec- trocardiogram documented a sinus rhythm at 89 bpm, with a normal ventricular repolarization pattern. A lung ultrasound revealed the absence of lung sliding on the left side, with no identifiable lung point, while an A-line pattern was observed on the right. A chest X- ray was requested, showing a bilateral pneumothorax (pnx). Correspondence: Gea Nicoletti, Emergency Medicine Department, University of Palermo, Palermo, Italy E-mail: nicolettigea@gmail.com Key words: pneumothorax, buffalo chest syndrome, spontaneous bilateral pneumothorax. Contributions: GN, conception, design, and analysis and interpreta- tion of data; drafting the article and contributing important intellec- tual content; DT, PM, analysis and interpretation of data; revising the article for important intellectual content. All authors approve the version to be published and agreement to be accountable for all aspects of the work. Conflict of interests: the authors declare that they have no conflict of interest. Availability of data and material: the datasets used and/or analyzed during the current study are available upon reasonable request from the corresponding author. Ethics approval: not applicable. Acknowledgments: the authors thank Daniela Forno for her support in the analysis and interpretation of the case, and the useful revision of the manuscript with her important intellectual content. Received: 23 June 2025. Accepted: 24 June 2025. Early view: 22 July 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13973 doi:10.4081/ecj.2025.13973 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Emergency Care Journal 2025 volume 21:13973 pathophysiological mechanism remains unknown, as there is no identifiable personal or family predisposition,8 similar to our case. Diagnosis is based on imaging and dynamic testing. A chest X-ray typically usually reveals bilateral pnx, while a chest CT scan can helps assess any communication between the two pleural spaces. A definitive diagnosis requires dynamic tests that demonstrate the migration of gas or contrast medium into the contralateral hemithorax after being introduced through a chest drain.8 The most clinically relevant complication is the tension pnx, which can lead to rapid clinical deterioration with potentially fatal shock.3 In our case, the patient was immediately treated with an urgent placement of a left-sided chest drainage tube, which led to a signif- icant reduction of the massive pnx. He was then admitted to the thoracic surgery unit. During his hospital stay, a right chest drain was also inserted. Due to a suboptimal clinical response and incomplete re-expansion of the left lung, the patient ultimately required surgical bullectomy and pleurodesis with talc. A chest CT scan was performed and ruled out a potential communication between the two pleural spaces, probably due its very small size. The patient was discharged in good clinical condition after 12 days of hospitalization. References 1. Darwich NS, Tyrrell RL. Bilateral pneumothorax after pace- maker placement ‘Buffalo chest’. Respir Med Case Rep 2019;26:227-8. 2. Hartin DJ, Kendall R, Boyle AA, et al. Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleu- ropleural communication. Emerg Med J 2006;23:483-6. 3. Ikezoe K, Tanaka E, Tanizawa K, et al. Bilateral dissemination of malignant pleural mesothelioma via iatrogenic buffalo chest: a rare route of disease progression. Gen Thorac Cardiovasc Surg 2012;60:595-8. 4. Rali AS, Manyam H. Bilateral pneumothoraces following BiV ICD placement: a case of buffalo chest syndrome. Am J Case Rep 2015;16:703-6. 5. Sakamoto K, Ando K, Noma D. Spontaneous bilateral pneu- mothorax resulting from iatrogenic buffalo chest after the Nuss procedure. Ann Thorac Surg 2014;98:1463-5. 6. Kawakami N, Namkoong H. Buffalo chest syndrome follow- ing esophagectomy. Intern Med 2019;58:2413. 7. Salman S, Lofino L, Mastinu S, et al. Buffalo Chest: An Overlooked Risk Factor for Thoracic Interventional Procedures? Cardiovasc Intervent Radiol 2023;46:697-700. 8. Blacha MMJ, Smesseim I, van der Lee I, et al. The legend of the buffalo chest. Chest 2021;160:2275-82. Images in emergency [Emergency Care Journal 2025; 21:13973] [page 9]