CONCOMITANT TRANSUDATIVE AND EXUDATIVE PLEURAL EFFUSION: A CASE OF CONTARINI SYNDROME

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bilateral pleural effusion usually has a common etiology and a result of a systemic disease process. Contarini syndrome refers to bilateral pleural effusion with a separate etiology for both sides. We report a case of a patient with bilateral pleural effusion presenting as Contarini syndrome with one side with transudative and the other with exudative pleural effusion. CASE PRESENTATION: A 61-year-old female with a history of alpha-1-antitrypsin deficiency with emphysema and cirrhosis, Crohn's disease with ileostomy, and recurrent right-sided pleural effusion (with multiple thoracenteses) presented with worsening dyspnea on exertion, left-sided pleuritic chest pain, and hypoxia requiring 6L supplemental oxygen otherwise, hemodynamically stable without a fever. Initial laboratory evaluation showed leukocytosis of 26000 cells/mm3 with neutrophilia, macrocytic anemia with hemoglobin of 11 g/dL, and hematocrit of 32.4%. Additional workup showed elevated bilirubin (12 g/dL) with predominant indirect hyperbilirubinemia (8.7 g/dL). Initial chest x-ray showed bilateral pleural effusion with a subsequent computed tomography chest with intravenous contrast showed moderate to large right pleural effusion and moderately sized left pleural effusion with possible loculation. The patient was initially started on intravenous Piperacillin-Tazobactam later switched to Levofloxacin. She underwent ultrasound-guided thoracentesis of the left side with exudative effusion (via 2/3 Light's criteria) with 1L fluid removed. The oxygen requirements did not improve over the next 2 days, and a right-sided thoracentesis was performed with drainage of 1.6L cloudy orange fluid which was transudative via light's criteria. A 10-day course of antibiotics was completed. Her symptoms significantly improved, leukocytosis resolved, and was eventually discharged on 3L/min supplemental oxygen. A month later, she developed right-sided effusion and was drained (fluid not sent for analysis) and required 2L/min supplemental oxygen. DISCUSSION: Contarini syndrome, a rare yet distinct entity might be underdiagnosed. Bilateral thoracentesis is rarely justified however if imaging shows different morphology of effusions, unilateral parenchymal involvement with bilateral pleural effusion, failure of effusion resolution despite treatment, or if the patient is not improving clinically. Our patient's different effusion morphology and clinical status prompted for bilateral thoracentesis. The right-sided pleural effusion was likely due to liver cirrhosis while the left-sided probably a parapneumonic effusion. CONCLUSIONS: Bilateral pleural effusion due to two separate etiology is rare, but a distinctive entity. When clinically justified, a bilateral thoracentesis may be performed. This will help direct treatment, prevent repeat hospitalizations for patients, and direct prudent use of resources. REFERENCE #1: Porcel JM, Civit MC, Bielsa S, Light RW. Contarini's syndrome: bilateral pleural effusion, each side from different causes. J Hosp Med. 2012 Feb;7(2):164-5. doi: 10.1002/jhm.981. Epub 2011 Oct 31. PMID: 22042579. DISCLOSURES: No relevant relationships by Samir Jha, source=Web Response No relevant relationships by Sobia Nizami, source=Web Response No relevant relationships by Lintha Shah, source=Web Response