MASSIVE HEMOTHORAX MASQUERADING AS HEPATIC HYDROTHORAX

Abstract

TYPE: Case Report TOPIC: Disorders of the Pleura INTRODUCTION: Hepatic hydrothorax commonly occurs in cirrhosis. We present a case with clinical and radiological characteristics of hepatic hydrothorax nonetheless revealed as massive hemothorax. CASE PRESENTATION: 47-year-old male with decompensated cirrhosis was hospitalized for lower extremity cellulitis. Initial Chest X-ray (CXR) showed right-sided pleural effusion and known chronic rib fractures. Subsequently the patient developed mild respiratory distress. Repeat CXR demonstrated significant worsening of the pleural effusion. A large simple effusion was seen on ultrasonography. The patient was hemodynamically stable with no decrease in hematocrit but had mild coagulopathy (INR 1.7). The initial impression was worsening hepatic hydrothorax. Thoracentesis revealed pleural fluid consistent with blood (hematocrit 39%). CT-Chest angiography showed contrast extravasation adjacent to the chronic rib fracture into the pleural space. He underwent thoracostomy tube drainage of 3 liters of blood. Patient achieved hemostasis and hemodynamic stabilization after transfusion of blood products in the peri-thoracostomy period. DISCUSSION: The unique characteristics of this case are: 1. The appearance of fluid on sonography was anechoic, in contrast to the homogeneous echogenicity seen with hemothorax. 2. Delayed development of clinical and laboratory evidence of hemorrhage despite large accumulation of blood in the pleural cavity. 3. Delayed hemothorax weeks after evidence of rib fractures. These characteristics lead to the initial impression of hepatic hydrothorax. Rarely, patients with decompensated cirrhosis can develop hemothorax secondary to ruptured intercostal varices. Albeit a possibility in our case, it is hard to discern with certainty. CONCLUSIONS: A high index of suspicion for hemothorax should be maintained in cirrhotic patients with new onset pleural effusion. DISCLOSURE: Nothing to declare. KEYWORD: hemothorax