SWEET HYDROTHORAX: A RARE COMPLICATION OF PERITONEAL DIALYSIS

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) with an incidence of approximately 2%(1). We present a case of hydrothorax secondary to CAPD. CASE PRESENTATION: 72-year-old female with past medical history of end-stage renal disease requiring peritoneal dialysis 4 times a day and type 2 diabetes mellitus presented with shortness of breath, productive cough, chest congestion and nausea for 2 days. She denied any fevers or chills. Vitals were stable with oxygen saturation of 97% on 2 L nasal cannula. Physical exam was significant for diminished breath sounds at the base of the right lung on auscultation. Electrocardiogram showed normal sinus rhythm with no ST changes. Laboratory results were significant for an elevated creatinine of 6.4 mg/dL whereas white blood cell count, lactic acid and troponins were unremarkable. A comprehensive respiratory panel including Influenza A & B, urine antigen testing for streptococcus pneumonia and legionella were also negative. Chest x-ray PA and lateral showed middle to lower lung lobe infiltrate with pleural effusion. Blood cultures that were obtained on admission did not grow any organisms. Patient was started on antibiotics for presumed community acquired pneumonia. Pulmonology performed right sided thoracentesis and 1600 mL of colorless clear fluid was drained. Patient experienced significant symptomatic relief post thoracentesis. Pleural fluid analysis revealed a pH of 7.3 and a high glucose concentration of 438 mg/dL (simultaneous blood glucose level of 103 mg/dL). Additionally, LDH and protein were suggestive of a transudative effusion as per Light’s criteria. Pleural fluid cultures remained negative. Given that pleural effusion was transudative with an elevated glucose level, the diagnosis of sweet hydrothorax was established. Antibiotics were discontinued. The patient was then transitioned to hemodialysis (HD). DISCUSSION: Sweet hydrothorax most commonly occurs on the right as compared to the left side and is more prevalent in women. Mechanisms of this phenomenon include pleuro-peritoneal pressure gradient, congenital diaphragmatic defects and lymphatic drainage disorders (2). Diagnoses involves thoracentesis with pleural fluid analysis revealing a marked elevation of glucose when compared to serum levels. This finding is pathognomonic for sweet hydrothorax. Imaging modalities used for diagnosis involve demonstrating the transfer of radiopaque dye across the diaphragm e.g. peritoneal scintigraphy, CT and MR Peritoneography, or direct visualization with video-assisted thoracoscopic surgery (VATS) (3). CONCLUSIONS: Management involves temporary cessation of CAPD, therapeutic thoracentesis, short dwell periods or dry days. Video-assisted thoracoscopic pleurodesis may be performed for patients who have failed conservative management. Most patients however end up switching permanently to HD. Reference #1: Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Current Opinion in Pulmonary Medicine. 2004 Jul;10(4):315-319. DOI: 10.1097/01.mcp.0000127901.60693.d0. Reference #2: Chow, K.M., Szeto, C.C. and Li, P.K.-T. (2003), Review Articles: Management Options for Hydrothorax Complicating Peritoneal Dialysis. Seminars in Dialysis, 16: 389-394. doi:10.1046/j.1525-139X.2003.16080.x Reference #3: Sydney Tang, Wing Hung Chui, Anthony W. C. Tang, Fu Keung Li, Wing Shun Chau, Yiu Wing Ho, Tak Mao Chan, Kar Neng Lai, Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis, Nephrology Dialysis Transplantation, Volume 18, Issue 4, April 2003, Pages 804–808, https://doi.org/10.1093/ndt/gfg042 DISCLOSURES: No relevant relationships by Muhammad Hamza, source=Web Response No relevant relationships by Travis Hanson, source=Web Response No relevant relationships by Touba Naim, source=Web Response No relevant relationships by Muhammad Omar, source=Web Response