Massive Right-sided Pleural Effusion Research Articles

Chylothorax as the Initial Manifestation of Follicular Lymphoma

Chylothorax is the presence of chyle in the pleural space, which can occur with any disruption of the thoracic duct or its main tributaries. Here we describe the case of a 64-year-old nonsmoking woman who presented with shortness of breath and had findings of a massive right-sided chylous pleural effusion. She was subsequently diagnosed with high-grade follicular lymphoma and had chest tube placement and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone therapy with complete response.

Massive Right-sided Pleural Effusion due to Pancreaticopleural Fistula: A Rare Case Report

Pancreaticopleural Fistula (PPF), a rare occurrence, is characterised by an abnormal connection between pleural and peritoneal cavity. It forms usually due to the rupture of pancreatic pseudocyst. Pancreatic pseudocyst is formed due to the repeated episodes of acute or chronic pancreatitis. Most pancreatic pathologies, such as acute and chronic pancreatitis, cause clinically insignificant effusions that resolve with disease control, whereas PPF causes massive effusion and is thus rarely considered as a cause of massive pleural effusion due to its low incidence. PPF are most common in middle-aged alcoholic males and typically present as massive recurrent left-sided pleural effusions. In the present case, a 50-year-old male presented to the Department of Respiratory Medicine with the complaint of right-sided chest pain, progressive breathlessness, abdominal pain and loss of appetite. Patient was labourer by occupation, chronic alcoholic, non diabetic. Contrast Enhanced Computed Tomography (CECT) thorax with abdomen showed massive right-sided pleural effusion and pancreatitis. A diagnosis of PPF was confirmed as its cause. Pleural fluid analysis for elevated amylase, confirms the diagnosis and investigations such as CECT thorax and abdomen, Endoscopic Retrograde Cholangiopancreatography (ERCP), or Magnetic Resonance Cholangiopancreatography (MRCP) may be used to establish the fistulous communication between the pancreas and the pleural cavity. PPF should always be considered as a differential diagnosis while finding a cause for right-sided pleural effusion.

Mediastinal extension of amoebic liver abscess: A case report on the rare thoracic complication of Entamoeba histolytica

Amoebic liver abscess is one frequently encountered intra-abdominal infection, caused by Entamoeba histolytica and has various abdominal and thoracic life-threatening complications. Herein, describe a case of a 30-year-old female, who suffered from multiple amoebic liver abscesses and presented with massive right-sided pleural effusion. She was managed with recommended antibiotics and pigtail catheter for liver abscess and an intercostal drainage tube for massive pleural effusion. However, postintercostal drainage, her chest X-ray demonstrated a right mediastinal shadow, which was confirmed as an intrathoracic extension of the hepatic liver abscess on computed tomography. An ultrasound-guided pigtail catheter was manipulated and placed at the site of thoracic communication. This led to clinical and radiological improvement, but unfortunately, she developed ventilator-acquired pneumonia and died due to her illness. The case represents an uncommon complication of amoebic liver abscess, which is rarely described and adds more knowledge on the thoracic complexities of this infectious disease.

Right-Sided Pancreaticopleural Fistula: An Unusual Presentation of Chronic Pancreatitis

Pleural effusions due to pancreatitis are more common on the left side, but right-sided pleural effusion is very rare. This case report describes a young male who presented with features of right-sided massive pleural effusion. Magnetic resonance cholangiopancreatography showed, chronic pancreatitis with pseudocyst extending into the mediastinum through esophageal hiatus and communicating with right pleural cavity (pancreaticopleural fistula). The patient improved clinically after placing an intercostal drainage tube and stenting of the main pancreatic duct. A clinician should consider pancreatic pathology also in the differential diagnosis of right-sided pleural effusion, even in the absence of abdominal symptoms and risk factors for pancreatitis, when initial evaluation is inconclusive.

A Well Disguised Pleural Metastasis of Breast Carcinoma

Distant metastasis of breast carcinoma frequently occurs within five years after the diagnosis of the primary tumor. A 58-year-old female sharing a history of mastectomy for invasive ductal carcinoma six years previously admitted to our clinic with dyspnea progressively ongoing for past two weeks. A right-sided massive pleural effusion was diagnosed and also pleural catheter drained. Radiologic studies and cytological examination of the fluid did not introduce any evidence of malignancy while she lately underwent thoracoscopy for the residuary effusion and atelectasis. Pathological study of the punch biopsies through the parietal pleura reported the pleural metastasis of the breast carcinoma but still negative evidence of malignancy for the pleural fluid. After discharge, evaluation with positron emission tomography also did not verify an uptake in any of the pleura, lungs or primary malignancy site. This event is of importance revealing that the patients sharing a past of malignancy should be approached with more caution and suspicion since the routine diagnostic algorithms pending to be reliable may not be applicable for all patients.

Mediastinal teratoma presenting with hemoptysis and pleuritis misdiagnosed as tuberculosis (empyema)

BackgroundMediastinal teratoma is uncommon in children. It can be very difficult to diagnose especially in early stage. Rarely, teratoma may rupture into adjacent structures and lead to lung lesions or pleuritis. The main rarity of our reported cases was the dynamic imaging findings very similar to the developmental process of tuberculosis in patients 1 and 2, the pachypleuritis in patients 2 and 3, the extremely elevated inflammatory markers very similar to empyema in patient 3, and the extremely atypical tumor shape in all patients.Case presentationWe present three pediatric patients presenting predominantly with recurrent hemoptysis and/or chest pain who were ultimately diagnosed with mediastinal teratoma containing pancreatic tissue. All three patients were initially suspected to have tuberculosis or empyema, and underwent relevant treatment, but without improvement. Patient 1 had left hilar enlargement, and subsequently an enlarging calcified cavity within high-density consolidation was identified. Patient 2 initially presented with right-sided pulmonary consolidation and pleuritis, and subsequently developed right lower lobe calcification, pleural thickening, and irregular soft tissue in the right inferior mediastinum. Patient 3 was initially found to have right lobe consolidation accompanied by a massive right-sided pleural effusion with extremely elevated inflammatory markers in serum and pleural effusion. The effusion later acquired heterogeneous density and appeared to become encapsulated. In patients 2 and 3, pleural biopsy identified fibrous tissue (with and without granuloma). Thoracotomy/thoracoscopy revealed mediastinal teratoma in each case, all of which were completely excised and the patients made uneventful recoveries. Histopathologic analysis revealed mature cystic-solid teratoma containing pancreatic tissue in all patients, and calcification in patients 1 and 2.ConclusionsClinicians should be mindful that mediastinal teratoma is a potential cause of hemoptysis, lung lesions and pleuritis. Calcification and pachypleuritis on chest imaging especially in patients without fever should be highly suspected of mediastinal teratoma. Pleural biopsy sometimes fails to assist in making a definitive diagnosis.

Recurrent pleuroperitoneal leak caused by diaphragm blebs in a peritoneal dialysis patient: a case report with literature review

BackgroundPleuroperitoneal leak is an uncommon but significant complication of peritoneal dialysis. Although the exact pathogenesis of pleuroperitoneal communication remains unclear, the pressure gradient between the thorax and abdominal cavity has been thought to play a major role.Case presentationA 48-year-old man with diabetes mellitus and hypertension who had been treated with continuous ambulatory peritoneal dialysis (1.5 L dwells four times a day) for 3 months was admitted because of massive right-sided pleural effusion. He underwent video-assisted thoracoscopic surgery for blebs on the diaphragm. Six weeks after diaphragmatic repair, he resumed peritoneal dialysis (1.5 L dwells four times a day) with once-a-week hemodialysis. Thereafter, pleural effusion was not significant on a chest radiogram. Six months after surgery, his dwell volume increased from 1500 to 2000 ml, and significant right-sided pleural effusion also developed.ConclusionPleuroperitoneal leak caused by blebs can recur even after surgical treatment, and reducing the dwell volume may be effective for patients with pleuroperitoneal communication.

Recurrent Atypical Meningioma with Pleural Metastases

AbstractMeningiomas are the most common primary intracranial tumors in adults. Although Grade I meningiomas are considered benign, Grade II/III (atypical and anaplastic) meningiomas are known to be locally aggressive, recurrent, and rarely present with distant metastases. We report a 40-year-old female with recurrent atypical meningioma (WHO Grade II) who presented with features suggestive of a massive right-sided pleural effusion. Imaging showed bilateral large pleural-based lesions, and histopathological examination and immunohistochemistry of the mass were consistent with metastatic atypical meningioma. A high index of suspicion is warranted to detect extracranial metastases, especially in patients with recurrent meningiomas and higher WHO grade of tumor.

Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report

BackgroundPatients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature.Case PresentationA 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen revealed a decompressed hepatic abscess extending into the right pleural space and the right lower lobe. A sigmoid-rectal fistula was also revealed with focal colonic thickening, presumed to be the sequelae of remote or chronic diverticulitis. An interventional radiologist inserted a percutaneous drain into the decompressed hepatic abscess and the instillation of contrast revealed immediate filling of the right pleural space, lung parenchyma, and bronchial tree, confirming a hepato-bronchial fistula. After two concurrent chest tube insertions failed to drain the remaining pleural effusion completely, surgical lung decortication was conducted. Markedly thickened pleura were seen and a significant amount of gelatinous inflammatory material was debrided from the lower thoracic cavity. He recovered well and was discharged 10 days post-thoracotomy on oral antibiotics. The percutaneous liver abscess tube was removed 3 weeks post-discharge from hospital after the drain check revealed that the fistula and abscess had entirely resolved.ConclusionsRefractory right-sided pleural effusion combined with constitutional symptoms should alert clinicians to search for possible hepatic abscess, especially in the context of diverticulitis. The rupture of an untreated hepatic abscess could lead to death from profound sepsis or rarely, as in this case, a hepato-bronchial fistula. Timely investigation and a multidisciplinary treatment approach can lead to improved patient outcomes.

A case of Ewing’s sarcoma presenting with massive pleural effusion

A 16-year-old girl presented with swelling and heaviness on the right side of her chest and progressive dyspnoea since 20 days. Radiological examination revealed a mass lesion in the right lower zone with right-sided massive pleural effusion and rib erosion. Histopathology and immunohistochemistry were suggestive of Ewing’s sarcoma. We reported this case because of the uncommon presentation of this rare tumour and its associated pleural effusion. Early diagnosis of this case led to favourable outcomes.

Image Diagnosis: Pericardial Cyst in a Dialysis Patient

Pericardial cysts are rare, usually benign congenital anomalies but may also be acquired. They represent 6% of mediastinal masses and 33% of all mediastinal cysts.1) The vast majority are asymptomatic and are usually found incidentally on chest radiographs, computed tomography scans, magnetic resonance images, or echocardiography.2) Large pericardial cysts may cause compression on adjacent structures and organs, resulting in dyspnea, chest pain, or persistent cough.3) There have been reports of cyst rupture, cardiac compression, atrial fibrillation, and even sudden cardiac death from these cysts, although these complications are uncommon.4) A 55-year-old Italian dialysis patient with a shortness of breath, asthenia and excessive fatigability was referred to our institution. He had history of pericarditis, myocarditis and massive pleural effusion. His electrocardiogram showed sinus rhytm. Transthoracic echocardiography (TTE) revealed normal left and right ventricular systolic performance, with normal wall thicknesses and chamber sizes and a pericardial thickening. Color Doppler imaging showed a mild mitral and tricuspid regurgitation. Apical and subcostal views of TTE showed an oval echolucent structure at the right cardiophrenic angle, minimally compressing the right atrium, and of approximately 10 × 4 cm, consistent with a pericardial cyst (Fig. 1). Cardiac magnetic resonance (CMR) confirmed echocardiography findings, showing the presence of the pericardial cyst with several fibrinous strands inside associated with right-sided massive pleural effusion. Late gadolinium-enhanced CMR images showed intramural myocardial enhancement in anterior and inferior wall and enhancement of pericardium, as an expression of myocardial and pericardial inflammation (Fig. 2). The patient was treated conservatively because of high surgical risk attributed to severe kidney failure. A repeated TTE with the apical 4-chamber view at 20 months later showed minimal increase in the size of the pericardial cyst. The discovery of a pericardial cyst obliges the clinician to perform a broad differential diagnosis with a coronary artery aneurysm, dextrocardia, malignancy, and even pneumonia.5) CMR may help in this diagnosis. Fig. 1 Echocardiographic evaluation revealed a pericardial cyst in the inferior wall of the left ventricle. Fig. 2 Vertical long-axis (A and D) and short-axis (B, C, E, and F) cardiac magnetic resonance (CMR) images of pericardial cyst in patient with pericarditis, myocarditis and massive pleural effusion. Cyst (white asterisks) has low signal intensity on T1-weighted ...

Reversible Pulmonary Hypertension due to Extrinsic Compression Caused by Massive Pleural Effusion

Pulmonary hypertension is commonly seen with multiple complex disorders managed in the intensive care unit. Common causes of pulmonary hypertension in critically ill patients include severe hypoxia, sepsis, left ventricular failure, massive pulmonary emboli, drugs, and worsening of chronic pulmonary hypertension, among others. Reversible pulmonary hypertension is rare and it has been reported with mediastinal involvement of sarcoidosis and in critically ill patients with severe acute chest syndrome. We present a 43-year-old male who was admitted with acute-onset shortness of breath. A massive right-sided pleural effusion and left-sided pneumonia was found on chest roentgenogram. Echocardiogram showed severe pulmonary hypertension with normal left ventricular function. Patient was treated for presumptive pneumonia and underwent pleural fluid drainage. An echocardiogram repeated after removal of pleural fluid showed resolution of pulmonary hypertension. We hypothesize that the large pleural effusion produced mechanical compression of mediastinal and pulmonary vessels leading to severe pulmonary hypertension, which reversed upon drainage of pleural effusion. This has both diagnostic and management implications.

Flummoxing paradox of contralateral pleural effusion developing during successful drug treatment of a tubercular pleural effusion

Tuberculosis often manifests as pleural effusion which generally shows clinical and radiological response to antitubercular therapy. However, it is not common to find a paradoxical contralateral effusion to develop despite successful therapy, especially in immuno competent treatment responsive patients with no other etiology of the same. We report such a rare case in which the patient presented with left-sided pleural effusion, which resolved with treatment, only to follow-up with massive right-sided pleural effusion which resolved spontaneously on continuation of antitubercular therapy.

Recurrent Right-sided Massive Pleural Effusion of Pancreatic Etiology

ABSTRACTPleural effusion secondary to chronic pancreatitis is an uncommon condition accounting for less than 1% of patients. Patients are alcoholic but only 50% of patients have clinical symptoms and signs of previous pancreatitis. Symptoms are predominantly respiratory than abdominal. Raised pleural fluid amylase level in hemorrhagic fluid is diagnostic of pancreatic pleural effusion. Presence of pancreaticopleural fistula (PPF) can be demonstrated by computed tomography (CT) imaging or magnetic resonance cholangiopancreatography (MRCP), but these imaging methods sometimes fail to demonstrate fistulous tract. Herewith, we are presenting a rare case of recurrent right-sided massive pleural effusion secondary to chronic pancreatitis.How to cite this articleNagendra SS, Patil MB. Recurrent Right-sided Massive Pleural Effusion of Pancreatic Etiology. J Med Sci 2016;2(4):62-64.

Successful Continuation of Peritoneal Dialysis after "Sweet" Hydrothorax

Abstract A 44-year-old woman with end-stage renal disease presented with dyspnea on exertion and a vague chest pain about two weeks after commencing continuous ambulatory peritoneal dialysis (CAPD) four months ago. A chest x-ray revealed massive unilateral right-sided pleural effusion. Laboratory analysis of the effusion revealed low protein and lactate dehydrogenase but elevated glucose levels were consistent with transudate and pleuroperitoneal leakage. Pleural glucose concentration was much higher than patients’ serum glucose concentration, which was suggestive of "sweet" hydrothorax because of this high glucose concentration. It is advisable to keep this condition in mind among the differenttial diagnoses of hydrothorax in patients on CAPD.

A Miss and a Hit - An Iatrogenic Event

A 55 year old gentleman underwent an ultrasound-guided tube thoracostomy for a right-sided massive pleural effusion (Figure 1). The chest drain revealed yellow-particulate fluid, raising the suspicion of an oesophageal perforation, owing to the history of multiple failed endoscopic retrograde cholangio-pancreatograms. On reviewing the patient’s clinical notes and scans, it was found that the patient had undergone a percutaneous transhepatic cholangiogram (PTC) with insertion of an internal/external drain, ten days prior to clinical worsening (Figure 2). A “check” chest x-ray post-PTC had been done (Figure 3). The tip of the right costo-phrenic angle had been pierced by the catheter. This was missed on radiological and clinical reviewing. This case emphasises the importance of critically assessing the patient by, both, clinical evaluation and supplementary radiological corroboration. This was a missed diagnosis of a rare encounter of an iatrogenic pleurobiliary fistula.

A case of young woman with recurrent right pleural effusion.

Endomterisois is usually found in women of child-bearing age. A case is presented of massive right-sided pleural effusion caused by endometriosis. The final diagnosis was made by thoracoscopic pleural biopsy. Physicians should be aware of this potentially treatable cause of pleural effusion having excluded other possibilities such as malignancy and tuberculosis.

Pancreatico-pleural fistula: A rare cause of massive right-sided pleural effusion

Pancreatico-pleural fistula is a rare entity and it accounts for a small percentage of cases of pleural effusion. We present a case of massive right sided pleural effusion that was attributable to pancreatico-pleural fistula in a 46year old male alcoholic patient who had dyspnea, trepopnea and dull aching right sided chest pain. ERCP showed a fistulous track between the main pancreatic duct and right hemithorax. This case is very rare as the pleural effusion due to pancreatico-pleural fistula is usually left-sided in up to two thirds of cases.

Interpretation of the Low-Voltage ECG

Interpretation of the Low-Voltage ECG

UNILATERAL PLEURAL EFFUSION REVEALING BOERHAAVE‘S SYNDROME

A 72yearold man who was initially admitted because of a brain stem infarction, was referred to the respiratory intensive care unit because of acute onset respiratory distress, following vomitting. In the weeks preceding this deterioration he had multiple episodes of sputum impaction due to swallowing dysfunction. A Chest X-ray showed a rightsided massive pleural effusion. A chest CT-scan revealed an important pleural effusion and a paraesophageal air collection, highly suggestive of rupture of the distal esophagus. A chest drain was placed with evacuation of 1200cc “coffee ground”-looking pleural fluid with high amylase content, suggestive of gastric juice. Because of the unfavorable neurological prognosis due to the brain stem infarction, the decision was made not to perform any surgical procedures. The patient was treated with broad spectrum antibiotics and started on total parenteral nutrition. Esophagoscopy revealed a 2 cm long tear with fistulisation at 5 cm above the diaphragm. A covered stent was placed endoscopically to cover the fistula to prevent further leakage to the pleural cavity. Despite successfully stenting of the esophageal tear, the patient died a few days later due to a hospital acquired pneumonia. Boerhaave’s syndrome is a spontaneous rupture of the esophagus, mostly located on the lower third of the esophagus. The average tear is 2.2 cm long and 3-6 cm above the diaphragm (1). The most common findings on chest X-ray are pleural effusions with an incidence of 91%. This occurs mostly on the left side (75-90%), sometimes bilateral (5-10%), but rarely, as in this case, on the right (2). Diagnostic errors are prevalent; the most common misdiagnosis is a perforated ulcer, followed by myocardial infarction, pulmonary embolism, dissecting aneurysm and pancreatitis. Diagnosis can be made earlier and more accurate with additional radiological examinations such as CT scan (1).