VANISHING PLEURAL EFFUSION: DRESSLER-LIKE SYNDROME IN PATIENT WITH FOREIGN BODY REACTION

Abstract

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: We describe a patient who developed bilateral right greater than left pleural effusions after surgical alteration of her prior silicone breast implants. She had near-complete resolution of her effusion with a course of non-steroidal anti-inflammatory drugs (NSAIDs). CASE PRESENTATION: We describe a 42 y/o lady, former 5.5 pack-year smoker, triple-negative breast cancer in remission, status-post bilateral mastectomy and silicone breast implantation. She since had bilateral breast reconstruction, involving superior gluteal artery perforator (SGAP) flap. She developed dyspnea and pleuritic pain within 2 weeks of her SGAP procedure, and presented to our center. She had stable vitals on admission, and did not require supplemental oxygen; however, her dyspnea and pleuritic pain were affecting her daily activities. Chest X-ray revealed a moderate right and a small left pleural effusion, confirmed on PE protocol CT scan, which was negative for PE. She was initially treated with diuretics which failed to improve her symptoms or pleural effusion size. Right thoracentesis was then performed, yielding 800 mL of serous yellow fluid. Fluid studies were consistent with an exudative effusion, with negative cytology and no bacterial or fungal growth, pH 7.48, LDH 200, glucose 88, total protein 4.1. Immediate post-procedure chest x-ray showed significant improvement in right effusion, and dyspnea was alleviated. Within 24 hours, the effusion on the right re-accumulated to a size equivalent to prior to thoracentesis. She was once again dyspneic. Suspecting an underlying inflammatory process, the patient was started on ibuprofen 600 mg QID. Within 2 days, patient felt symptomatic improvement. Outpatient follow-up chest X-ray 10 days after NSAID initiation was revealing of near-complete resolution of right effusion and symptoms. NSAID taper was then initiated. Repeat chest-XR 1 month after first dose of NSAID’s showed total resolution of pleural effusions. DISCUSSION: Foreign body reaction (FBR), or an inflammatory response to non-native entities such as breast implants, has been described as a cause of systemic release of inflammatory factors [1]. One report describes the development of pleural effusion 6 weeks after silicone breast implants [2]. We postulate the SGAP flap procedure resulted in manipulation of her prior silicone implants, resulting in an FBR. Neither IV diuretics nor therapeutic thoracentesis resulted in lasting resolution of her effusion, making fluid overload less likely. Pleural fluid studies were negative for cancer cells. The marked improvement with NSAIDs suggests an underlying systemic inflammatory response, not unlike Dressler’s Syndrome. CONCLUSIONS: Clinicians should be aware of pleural effusions that are secondary to a foreign body reaction, and consideration of a course of non-steroidal anti-inflammatory drugs should be considered if other causes of effusion have been ruled out. Reference #1: Tralhão, António et al. “The return of a disappearing entity: Dressler's syndrome after transvenous pacemaker implantation.” BMJ case reports vol. 2014 bcr2013203401. 20 Mar. 2014, doi:10.1136/bcr-2013-203401 Reference #2: Silicone Breast Implants: A Rare Cause of Pleural Effusion Shaik, Imam et al. CHEST, Volume 148, Issue 4, 444A DISCLOSURES: no disclosure on file for Alexander Geyer; No relevant relationships by Saamia Hossain, source=Web Response