Acute dyspnoea—not always above the diaphragm

Abstract

In October, 2010, a 55-year-old woman was admitted to our department for investigation of recurrent ascites. She had a medical history of adult polycystic kidney disease with hepatic cysts. 9 months earlier, she had started peritoneal dialysis, which was changed to haemodialysis after 5 months because of poor catheter fl ows and underdialysis. Subsequently, she developed ascites which required frequent drainage. The fl uid was borderline for transudate or exudate with no malignant cells and was initially attributed to peritoneal irritation from her dialysis catheter. Her ascites persisted despite removal of the catheter and she was then admitted for further investigation. Blood tests showed hypoalbuminaemia but normal liver function and coagulation. CT abdomen confi rmed polycystic kidneys and massive polycystic hepatomegaly with large-volume ascites. Before further drainage could be done, she developed sudden-onset dyspnoea, tachypnoea, tachycardia, and hypoxia while straining at stool. Bedside echocardiogram showed normal left and right heart function with no right heart strain or pericardial eff usion. Chest radiograph (fi gure A) showed a large right pleural eff usion that had not been present 2 days earlier. An intercostal drain was inserted and 10 L of fl uid were drained over 3 days. Repeat abdominal CT showed no residual ascites. Review of the previous CT showed focal herniation of the right hemidiaphragm into the right pleural cavity (fi gure B) that was absent in the later study. We believe that the diaphragmatic defect had ruptured while our patient was straining, leading to translocation of ascites into the pleural cavity. After intercostal drain removal, she underwent regular paracentesis to prevent another similar episode. Further investigations confi rmed portal hypertension; she had a combined liver and kidney transplant in February, 2011. At last follow-up in October, 2011, she was well with good renal and hepatic function and no ascites. Lancet 2012; 379: 384