latrogenic Pneumothorax Caused by Thoracic Puncture Secondary to Anti-aging Medicine

Introduction: Pneumothorax is deﬁ ned as air in the pleural cavity, the iatrogenic cause happens after invasive procedures as thoracic needle aspiration, central line placement, pacemaker placement, etc. Nevertheless, it is possible to be found in non-medical procedures, such as alternative medicine, more speciﬁ cally acupuncture. There are medications used against aging that FDA has warned to be used only in its ﬁ rst objective, an example is procaine hydrochloride. Case: A 63 y/o female, Mexico City resident, with anxiety, came to a follow-up appointment for an aging cohort, where CT, PFT, and laboratories are made for pulmonary healthy subjects to investigate normal lung aging and how other environmental factors can aﬀ ect the lungs; at physical examination, we did not ﬁ nd any pleuropulmonary syndrome, but in the CT a left Iatrogenic pneumothorax was found; we re-asked for antecedents and she described that 15 days before the date she had 2 punctures in the middle clavicular line to apply procaine hydrochloride as an anti-aging treatment. Discussion: There is diverse evidence of adverse eﬀ ects associated with acupuncture, and even if pneumothorax has a small percentage of incidence, in some cases it can be severe and can even cause fatalities. Conclusion: The pneumothorax in this case was iatrogenic due to the thoracic puncture for an anti-aging treatment, with a total resolution with conservative treatment, however we as health professionals have the responsibility to inform our patients that initiatives of administration ways can cause important complications.


Introduction
Pneumothorax is de ined as air in the pleural cavity, there are different types of pneumothorax: spontaneous and traumatic, which we can include iatrogenic; classically consist of a penetrating thoracic injury, and it usually occurs after invasive procedures, the most common cause is a central line placement, it also is related with thoracic needle aspiration, pacemaker placement, bronchoscopic lung biopsies, and pleural biopsy; however, it is possible to be found, in procedures, especially in the ones that consist in chest puncture, such as acupuncture [1][2][3].
The epidemiology of pneumothorax in Mexico is unknown, however using other countries as examples, men have more risk of having pneumothorax than women; besides Abstract Introduction: Pneumothorax is defi ned as air in the pleural cavity, the iatrogenic cause happens after invasive procedures as thoracic needle aspiration, central line placement, pacemaker placement, etc.Nevertheless, it is possible to be found in non-medical procedures, such as alternative medicine, more specifi cally acupuncture.There are medications used against aging that FDA has warned to be used only in its fi rst objective, an example is procaine hydrochloride.
Case: A 63 y/o female, Mexico City resident, with anxiety, came to a follow-up appointment for an aging cohort, where CT, PFT, and laboratories are made for pulmonary healthy subjects to investigate normal lung aging and how other environmental factors can aff ect the lungs; at physical examination, we did not fi nd any pleuropulmonary syndrome, but in the CT a left Iatrogenic pneumothorax was found; we re-asked for antecedents and she described that 15 days before the date she had 2 punctures in the middle clavicular line to apply procaine hydrochloride as an anti-aging treatment.
Discussion: There is diverse evidence of adverse eff ects associated with acupuncture, and even if pneumothorax has a small percentage of incidence, in some cases it can be severe and can even cause fatalities.

Conclusion:
The pneumothorax in this case was iatrogenic due to the thoracic puncture for an anti-aging treatment, with a total resolution with conservative treatment, however we as health professionals have the responsibility to inform our patients that initiatives of administration ways can cause important complications.
the adverse effects, increases if the subject has a medical history of thoracic surgery, chronic bronchitis, emphysema, tuberculosis, and pulmonary cancer [4].
There are different adverse effects caused by acupuncture, being the most severe pneumothorax, cardiac tamponade, and nervous injury; that is the reason why we have to be careful when needles puncture in body risk areas, in this case, the thorax, which can cause important organ damages and can be fatal if not treated [5].
Procaine hydrochloride, H3 (Gerovital ®), an inhibitor of monoamine oxidase, was initially used in patients with depression, however during the 70's decade, it was used, as a treatment against aging; during that time, there was no scienti ic evidence that demonstrated this effect, and FDA https://doi.org/10.29328/journal.acr.1001073 in 1982 decided to make an alert, with the purpose to only be used for its irst indication, patients with depression; and being intramuscular its administration way [6].Some studies made by different authors such as Cohen, Zwerling, and Zung, in the 1970s showed an improvement in patients with depression in treatment with procaine hydrochloride, all of them using an intramuscular administration [7][8][9].
According to Ostfeld, the literature on this drug for the elderly did not have the quality of trials of new treatments, therefore it is not secure to use this drug in this population [10].

Case report
Female 63 years old, Mexico City resident, who has lived the majority of her life in Mexico City, with a history of anxiety that started 5 years ago, she denies any history of other chronic disease, traumas, hospitalizations, or trips; she comes to the INER-Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas" (National Institute of Respiratory Diseases) to the aging cohort; which pulmonary healthy people older than 60 years old are studied; respiratory function test, 6-minute walk, Computed Tomography (CT) and laboratories are made, to know the normal lung aging, and how other factors can affect the lungs.
CT was reviewed and found a left iatrogenic pneumothorax; at the interrogation, she referred that 15 days prior to the INER appointment, procaine hydrochloride was applied as an anti-aging treatment, with a thoracic puncture in the middle clavicular line 2 times.Three months later, thoracic radiography was made with the objective of following the pneumothorax, in which we found a total resolution of pneumothorax Figure 1.

Discussion
Iatrogenic pneumothorax can be caused by health workers, but it can also be found in procedures not made in the hospital, such as alternative medicine, like acupuncture, and it can affect the health of healthy subjects in the short, medium, and long term.
The treatment of pneumothorax depends on its size and symptoms; if it is small (<4 cm or < 20%) and with no dyspnea or pleuritic chest pain, like in this case, conservative treatment can be used as a management strategy, and weekly x-ray checks are suf icient [2,3].
There have been reported mild complaints of nausea and headache in intramuscular administration, however, it has never been reported pneumothorax with the use of Gerovital®, because its administration way is intramuscular; not thoracic.Therefore, this case report will be compared with acupuncture cases, with the consideration that this type of application is made with a needle gauge bigger than the ones used in acupuncture [11].
Many reports have demonstrated adverse effects associated with acupuncture if not done correctly; one of them is a study made in Germany; in which 8.6% of the population evaluated (19,726 out of 229,230 subjects) presented adverse effects, going from hematoma (58%) to pneumothorax (2 cases) or nervous injuries (31 cases) [12].It was also observed in a study made in Taiwan that an incidence of adverse effects is 0.87 for every 1.000.000procedures in general, but it increases to 1.75 for every 1.000.000 in procedures in risk anatomic areas, such as thorax, especially in middle scapular or middle clavicular areas [4,13].
According to Cohen et al. the administration dose is 100-200 mg 3 times weekly intramuscular for 4 weeks, however in this case was not used administration indicated, and was made as thoracic puncture, which incremented the risk of puncturing the lung, and therefore having pneumothorax [7].
In recent years, there are few studies made of this drug, one of them in 2009, to treat dementia and cognitive impairment, in which the data did not support the use to treat or prevent either of them; also in the year 2020, an in vitro study was made for radioprotective effect, however, there was not a difference between young and aged individuals; there are no recent clinical trials for its anti-aging use; this supports that this drug should not be used in any other pathologies but depression [14,15].

Conclusion
Pneumothorax, in this case, was iatrogenic and caused by a non-indicated way of administration, thoracic puncture, for anti-aging, it had a total resolution with conservative treatment; despite this, an initiative of new administration ways can result in an important complication, the presentation of this case has the inality to inform that even if alternative medicine can be helpful, it is important that patients are sensitized to the complications that can outcome if it is not used as an indicated administration way.

Figure 1 :
Figure 1: High-resolution computed tomography shows left pneumothorax in the superior lobe both images taken from the aging appointment.