Unusual presentation of acute ruptured penetrating aortic ulcer of descending thoracic aorta with right hemothorax

Right-sided hemothorax is a rare presentation of ruptured penetrating aortic ulcers. A 72-year-old female presented to the hospital with a penetrating aortic ulcer of the mid-thoracic aorta and a right-sided hemothorax. The patient was taken for thoracic endovascular aortic repair and right-sided tube thoracostomy. The diagnosis was complicated by the patient’s history of pacemaker placement causing prominent venous collaterals in the mediastinum. The postoperative course was complicated by lower extremity weakness, requiring lumbar cerebrospinal fluid drain placement. The patient regained full function of her lower extremities. This case illustrates that patients with ruptured acute aortic syndromes may present with right hemothorax, so index of suspicion should remain high in this population.