Commentary on A Patient with Third-Space Fluid Loss.

Abstract

This is an interesting clinical case highlighting the value of body fluid testing to assist in diagnosing a complex patient presenting with multiple effusions. The clinical presentation of unilateral pleural effusion is usually more suggestive of exudative causes, although bilateral effusion with right-side predominance is observed in transudative effusions. Bilateral leg swelling is observed more often with transudates, such as those caused by heart or liver failure (1). Severe hypoalbuminemia is frequently caused by renal failure associated nephrotic syndrome and/or end stage liver failure associated with reduced synthetic output. Renal and liver impairment were inconsistent with clinical findings until the globin predominance prompted protein electrophoresis, which returned a diagnosis of myeloma as an explanation for severe hypoalbuminemia. It is possible that severe hypoalbuminemia may have contributed to the transudative pleural effusion as well as ascites. The successful chemotherapeutic treatment for myeloma resolved the ascites and presumably the pleural effusion as serum albumin normalized. Lack of measurement of serum or plasma NT-ProBNP makes heart failure a questionable contributor to the transudative effusion, and follow-up may be warranted posttreatment to definitively rule out cardiac disease.