Therapeutic Thoracentesis Research Articles

Pleuroperitoneal Leak as an Uncommon Cause of Pleural Effusion in Peritoneal Dialysis: A Case Report and Literature Review

Pleural effusions are frequently seen in patients on dialysis. A pleuroperitoneal leak or communication is a rare but important cause of pleural effusion in patients on peritoneal dialysis. This diagnosis can be made with a combination of biochemical tests and radiological modalities, in the absence of a gold standard diagnostic test. In addition to thoracocentesis, treatment often involves cessation of peritoneal dialysis and transition to hemodialysis. We describe a case of an 80-year-old man who presented with unilateral right-sided pleural effusion. He underwent therapeutic thoracocentesis and was subsequently diagnosed with a pleuroperitoneal leak through pleural fluid analysis. Peritoneal dialysis was ceased, and he transitioned temporarily to hemodialysis. He was subsequently treated with talc pleurodesis and successfully recommenced on peritoneal dialysis at six weeks after operation. In our report, we also review diagnostic imaging modalities, as well as advantages and disadvantages of each modality. A pleuroperitoneal leak is a rare but important complication of peritoneal dialysis and needs consideration in any patient on peritoneal dialysis presenting with unilateral pleural effusion.

LATE SEQUELAE OF EARLY IMPERFECTIONS: LINKED CONGENITAL DEFECTS MANIFESTING AS ORGAN FAILURE IN PREVIOUSLY HEALTHY YOUNG ADULT; A CASE REPORT

TYPE: Case Report Publication TOPIC: Genetic and Developmental Disorders INTRODUCTION: Developmental anomalies are a major cause of end stage renal disease in the adult population. There are known genetic links between congenital renal anomalies and congenital heart defects. Undiagnosed congenital heart disease in adults may lead to complications with serious physiological implications. Identifying patients with subtle or asymptomatic congenital heart disease is an ongoing challenge. CASE PRESENTATION: 31-year-old male with history of end stage renal disease secondary to congenital renal hypoplasia presents to the emergency room with chronic gradually worsening exertional dyspnea ,volume overload newly refractory to hemodialysis, and markedly reduced exercise tolerance. Physical exam was remarkable for jugular venous distension, pitting edema in bilateral lower extremities, markedly reduced breath sounds and ipsilateral dullness to percussion over the right hemi-thorax. Imaging revealed a large right sided pleural effusion with leftward mediastinal shift and near complete opacification of the right lung, hypoplastic kidneys, small pericardial effusion and previously undiagnosed heart failure along with congenital heart defects. Diagnostic and therapeutic thoracentesis revealed non-malignant noninfectious right sided exudative pleural effusion (an unusual presentation of pleural effusion due to volume overload from right heart failure. DISCUSSION: A previously healthy male with known congenital renal defects was ultimately found to have a severe complication of undiagnosed heart failure as well as congenital heart defects that pose risks of future complications. Despite his empirically frequent utilization of the health care system, structural defects of the heart had gone unrecognized. CONCLUSIONS: Clinical suspicion of genetically linked birth defects in patients who present with any known congenital defect may expedite important diagnoses. DISCLOSURE: No significant relationships. KEYWORDS: Congenital, heart failure, Renal Hypoplasia

Incidence and Management of Effusions during CD19-Directed Chimeric Antigen Receptor (CAR) T-Cell Receptor Therapy in B-Cell Lymphoma: A Single Institution Experience

<h3>Background</h3> In patients with lymphoma, third space fluid accumulations may develop or worsen during cytokine release syndrome (CRS) associated with chimeric antigen receptor (CAR) T-cell therapy. Pre-existing symptomatic pleural effusions were excluded by the ZUMA-1 trial of axicabtagene ciloleucel (axi-cel) for large B cell lymphoma (LBCL) and variants. The optimal management of effusions that develop before or after axi-cel infusion in LBCL is unknown. <h3>Methods</h3> We performed a single center retrospective study evaluating 148 patients receiving CD19 CAR T-cell therapy for LBCL between 05/2015 and 09/2019. We identified all patients who developed pleural, pericardial and peritoneal effusions before (pre-CAR-T) or during the first 30 days after CAR T-cell infusion (post-CAR-T). Clinically relevant effusions were considered symptomatic based upon physician documentation. <h3>Results</h3> Total effusions and symptomatic effusions were noted in 24% (36/148) and 18% (27/148) of patients, respectively. Among 27 patients with symptomatic effusions, 59% (16/27) were pre-CAR-T effusions, 52% (14/27) persisted after day 30, and 44% (12/27) were malignant effusions. Overall, 67% of symptomatic effusions (18/27) were managed with diuretics, 44% (12/27) with a therapeutic thoracentesis or paracentesis and 33% (9/27) were observed with only supplemental oxygen provided. Six patients required pleural or abdominal catheters with a median indwelling duration of 54 (range, 29, 202) days, although 2 of these patients passed away with these indwelling catheters. Among symptomatic effusions developing only post-CAR-T (n=11), time to onset of effusion was median of 5 (range, 2-11) days and none of these patients required interventional drainage. Table 1 differentiates between effusions based on whether they were present (n = 19) or not (n = 17) prior to CAR T cell infusion. <h3>Conclusions</h3> Nearly half of all effusions diagnosed in patients receiving CAR T cell therapy develop after infusion but most can be medically managed. Patients with pre-CAR-T effusions may require procedural drainage or indwelling catheters, as these effusions may persist beyond the acute CRS period.

P1431 Safety of thoracentesis in patients with refractory heart failure: lung ultrasound guidance is obligatory and blind procedures are not justified

Abstract Background Pleural effusion refractory to diuretic treatment is frequent in advanced heart failure. Therapeutic thoracentesis (TT) is a time-honored practice, recently made simpler and safer by guidance with lung ultrasound. Purpose In order to elucidate safety of lung ultrasound-driven TT in refractory heart failure, we compared incidence of pneumothorax requiring surgical drainage in patients undergoing TT with or without lung ultrasound. Methods and results In a single-centre retrospective analysis we recruited 373 patients with heart failure with reduced ejection fraction (26 ± 12%), New York Heart Association class ≥3, and pleural effusion ≥ moderate at lung ultrasound. They underwent overall 493 TT. Evacuated pleural fluid by passive drainage was 1030 ± 534 mL. The maximal interpleural space was 73.6 ± 15.6 mm before, and 12.4 ± 3.1 mm after TT (p &amp;lt; .001). Two groups of TT were identified ex-post: 462 guided by lung ultrasound (Group 1); 31 without ultrasound guidance (Group 2), performed by cardiologist/pneumologist lacking access to ultrasound machine or expertise in lung ultrasound). The rate of complications (pneumothorax) was 0/462 in Group 1 and 3/31 in Group 2 (0 vs 10%, p &amp;lt; 0.001) Conclusion Lung ultrasound-driven TT of pleural effusion in decompensated heart failure patients is feasible and safe when performed by cardiologists guided by lung ultrasound. A blind TT without ultrasound guidance is associated with higher rate of pneumothorax, and should be avoided.

The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial

Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration. This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated≥ 500mL 1:1 to undergo active aspiration or gravity drainage. Patients rated chest discomfort on 100-mm visual analog scales prior to, during, and following drainage. Thoracentesis was halted at complete evacuation or for persistent chest discomfort, intractable cough, or other complication. The primary outcome was overall procedural chest discomfort scored 5min following the procedure. Secondary outcomes included measures of discomfort and breathlessness through 48h postprocedure. A total of 142 patients were randomized to undergo treatment, with 140 in the final analysis. Groups did not differ for the primary outcome (mean visual analog scale score difference, 5.3mm; 95%CI, -2.4 to 13.0; P= .17). Secondary outcomes of discomfort and dyspnea did not differ between groups. Comparable volumes were drained in both groups, but the procedure duration was significantly longer in the gravity arm (mean difference, 7.4 min; 95%CI, 10.2 to 4.6; P< .001). There were no serious complications. Thoracentesis via active aspiration and gravity drainage are both safe and result in comparable levels of procedural comfort and dyspnea improvement. Active aspiration requires less total procedural time. ClinicalTrials.gov; No.: NCT03591952; URL: www.clinicaltrials.gov.

AMBULATORY PLEURODESIS: SUCCESSFUL USE OF TALC WITH INDWELLING PLEURAL CATHETER FOR MANAGEMENT OF BILATERAL MALIGNANT PLEURAL EFFUSIONS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Malignant pleural effusions affect more than 750,000 patients each year in Europe and the United States and account for greater than 125,000 hospitalizations and have an estimated cost of $5 billion per year1,2. Treatment for malignant pleural effusions with expandable lung would favor treatment with talc pleurodesis and often requires days of inpatient hospitalization for management and observation3. Placement of indwelling pleural catheters (IPCs) can be used as successful alternative for management of symptoms in an ambulatory setting3,4. Additionally, administration of talc through an IPC shows increased probability of pleurodesis4. We present a patient with bilateral malignant pleural effusions with successful bilateral pleurodesis using talc instilled through bilateral IPCs. CASE PRESENTATION: A 72-year-old man with a past medical history significant for metastatic melanoma presented to the ED with complaints of progressive dyspnea at rest. Imaging revealed large bilateral pleural effusions with symptomatic improvement with therapeutic thoracentesis. Initial studies were consistent with exudative effusion with negative cytology and patient was discharged with follow-up in Pulmonary Clinic. He underwent repeat large-volume thoracentesis with repeat cytology showing metastatic melanoma. Given rapidly re-accumulating fluid and symptoms, a left IPC was placed with significant improvement and a right IPC was placed 2 weeks later with continued improvement and decreased effusions on repeat U/S. At this time, further management with talc pleurodesis was discussed to ideally eliminate the need of IPCs and enhance the patient’s quality of life. Talc was instilled per IPC plus protocol4 with subsequent ultrasound monitoring with <25 cc of output daily. Given good apposition, the left IPC was removed and 2 weeks later, talc was administered to the right IPC with similar results on ultrasound with upcoming removal of right IPC given continued good apposition and decreased drainage. DISCUSSION: We demonstrate a validated alternative treatment strategy in a patient with bilateral malignant pleural effusions. This presents a plausible alternative to patients to decrease hospital days and expenses, while improving quality of life and allowing for pleurodesis in an outpatient setting. We show success using bilateral IPCs with sequential talc pleurodesis and removal of IPCs. No hospitalizations were made during this time period and the patient tolerated all procedures well. CONCLUSIONS: Given continued advancement in techniques, we continue to show patient-centered care in a challenging population with an outpatient centered treatment approach and use of U/S imaging for clinical management. Reference #1: 1. Marel M, Zrustova M, et al. The incidence of pleural effusion in a well-defined region: epidemiology study in Central Bohemia. Chest 1993; 104:1486-9. Reference #2: 2. Taghizadeh N, Fortin M, Tremblay A. US hospitalizations for malignant pleural effusions: data from the 2012 National Inpatient Sample. Chest 2017;151:845–854. Reference #3: 3. Feller-Kopman D, Reddy C, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guidelines. Am J Respir Crit Care Med. 2018 Oct 1; 198(7):839-849. 4. Bhatnagar R, Keenan E, et al. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. N Engl J Med. 2018 Apr 5;378(14):1313-1322. DISCLOSURES: No relevant relationships by Michael Gonzales, source=Web Response No relevant relationships by Tyson Sjulin, source=Web Response No relevant relationships by John Untisz, source=Web Response

A RARE CASE OF CHYLOTHORAX SHROUDING A MALIGNANT PLEURAL EFFUSION

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Chylothorax is the collection of lymph in the pleural space and it is extremely rare to find an underlying malignant pleural effusion. Chylothorax is also usually unilateral and seldom a bilateral finding. Here we present a patient with underlying gastric malignancy with chylothorax and underlying malignant pleural effusion. CASE PRESENTATION: This was a 38 year old male who was diagnosed with gastric adenocarcinoma a month prior and completed the first round of chemotherapy, and presented to the hospital with shortness of breath and cough. Clinical exam showed a patient in no respiratory distress at rest and pulmonary exam shows stony dullness on percussion of the posterior lower lung zones. Auscultation revealed diminished vesicular breath sounds in the same area. A computerized tomography (CT) scan of the chest showed large bilateral pleural effusions and significant mediastinal lymphadenopathy. Patient underwent thoracentesis bilaterally which revealed large amount of turbid orange colored fluid. Analysis showed 58375 RBC/mm3, 2170 WBC/mm3, glucose of 64mg/dL, protein of 3.3g/dL, LDH of 873U/L, cholesterol of 64mg/dL, and triglycerides of 123mg/dL. Cytopathology revealed malignant cells positive for adenocarcinoma with gastric primary. Unfortunately, he developed recurrent pleural effusions. In view of developing recurrent episodes of respiratory distress, placement of a PleurX® catheter was planned. Unfortunately, the patient went into multi-organ system failure and eventually expired. DISCUSSION: In the review of articles of patients with gastric carcinoma, as in this case presenting with chylothorax as one of the presenting manifestations, there have been 14 accessible case reports so far and only one of them reports the fluid being malignant. A review of the primary malignancies showed that 9 exhibited signet ring cell carcinoma and 3 had poorly differentiated gastric adenocarcinoma and has been associated with high mortality and morbidity. Gastric malignancy with underlying chylothorax is a rare presentation. The mechanism is likely from tumor cells invading lymphatic channels diffusely. This obstruction causes the chylothorax however less likely is the cause for the malignant pleural effusion. The local invasion of metastatic cells into the pleural lining may have caused the malignant component. Chylothorax can also be associated with lymphedema. The chylothoraces have been treated by therapeutic thoracentesis, intercostal tube drainage and restriction of oral intake and continued treatment of the underlying cause. CONCLUSIONS: Although gastric adenocarcinoma has known to metastasize to pleural space to cause pleural effusion, this is the second case known to the best of our knowledge to have concurrent findings of chylothorax with a malignant pleural effusion. This also stands true for chylothorax from other reasons as well with the rarity of underlying malignant effusion. Reference #1: Devaraj U, Ramachandran P, Correa M, D'souza GA. Chylothorax in gastric adenocarcinoma: A case report and systematic review of the English literature. Lung India. 2014 Jan-Mar;31(1):47-52. https://doi.org/10.4103/0970-2113.125906. PubMed PMID: 24669083; PubMed Central PMCID: PMC3960811. Reference #2: Wu J, Lv L, Zhou K, Huo J. Chylothorax and lymphedema as the initial manifestations of gastric carcinoma: A case report and review of the literature. Oncol Lett. 2016 Apr;11(4):2835-2838. https://doi.org/10.3892/ol.2016.4285. Epub 2016 Feb 29. PubMed PMID: 27073560; PubMed Central PMCID: PMC4812189. DISCLOSURES: No relevant relationships by Jacob Mathew, source=Web Response No relevant relationships by Anish Samuel, source=Web Response No relevant relationships by Ahmed Sharaan, source=Web Response

A CASE OF URINOTHORAX

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A urinothorax is a rare cause of pleural effusion which can occur in urinary obstruction or from trauma to the genitourinary system. We present a case of urinothorax in a patient with bilateral hydronephrosis. CASE PRESENTATION: A 70 year old female with metastatic cholangiocarcinoma presented with abdominal pain, anuria, and shortness of breath for three days. She was found to have an acute kidney injury with bilateral hydronephrosis and left sided forniceal rupture. Physical examination also revealed decreased breath sounds over the left hemithorax. Chest imaging revealed complete opacification of the left hemithorax with mediastinal shift to the right. She was admitted to the intensive care unit and a diagnostic and therapeutic thoracentesis was performed with removal of 1.9L of straw colored transudative fluid. Pleural fluid creatinine was 12.6. The pleural fluid creatinine to serum creatinine ratio was >1. Bilateral percutaneous nephrostomy tubes were placed and renal function and urine output improved. Chest imaging done two months later did not show any re-accumulation of pleural effusion. DISCUSSION: A urinothorax is an uncommon complication of obstructive uropathy and genitourinary tract abnormalities that can occur in malignancy or traumatic injury. It is typically a unilateral, straw-colored effusion with a pH lower than 7.40 and transudative in nature by Light’s criteria. A urinothorax has two possible mechanisms. Urine can collect in the retroperitoneal space if an obstruction is present and the fluid enters the peritoneal cavity and thereafter leaks through transdiaphragmatic holes into the pleural space. Urine may also travel through lymphatics into the pleural cavity. A high degree of clinical suspicion is needed to make the diagnosis. In patients with concomitant urinary tract infections, especially with ammonia producing organisms, the effusion may be exudative as well as having a pH higher than 7.40, thereby confusing the clinical picture. A pleural fluid creatinine to serum creatinine ratio of greater than 1 clinches the diagnosis of a urinothorax. Further confirmatory workup can be done with a renal scintigraphy study to reveal extravasation of urine from the genitourinary system into the pleural space. Treatment of a urinothorax is aimed at the management of the underlying genitourinary condition. CONCLUSIONS: A urinothorax should be included in the differential diagnosis in a patient with obstructive uropathy or recent surgical genitourinary interventions presenting with a pleural effusion. The condition is completely reversible after treatment of the underlying cause. Reference #1: Handa A, Agarwal A, Aggarwal AN. Urinothorax: an unusual cause of pleural effusion. Singapore Med J 2007; 48(11):e289–e292 Reference #2: Chandra A, Pathak A, Kapur A, Russia N, Bhasin N. Urinothorax: A rare cause of severe respiratory distress. Indian J Crit Care Med. 2014 May; 18(5): 320–322. Reference #3: Garcia-Pachon E, Romero S. Urinothorax: a new approach. Curr Opin Pulm Med. 2006; 12: 259-263 DISCLOSURES: No relevant relationships by Sujith Cherian, source=Web Response No relevant relationships by Rosa Estrada-Y-Martin, source=Web Response No relevant relationships by Bibi Aneesah Jaumally, source=Web Response

CHARACTERIZATION OF ABNORMAL CELL DIFFERENTIAL IN THORACENTESIS FOR MALIGNANT PLEURAL EFFUSIONS

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Malignancy is the second leading cause of pleural effusions in the US1 and account for approximately 125,000 hospital admissions per year2. Malignant pleural effusions are often diagnosed by cytology, but the turnaround time can be several days. Pleural fluid cell count differential is a routine part of pleural fluid analysis; results are obtained within a few hours, giving the clinician the opportunity to make patient care decisions before the definitive diagnosis is made. Pleural fluid cell differentials are typically obtained with automated cell counters, these counters cannot identify malignant cells. However, the presence of non-classifiable “other cells” may suggest a malignant diagnosis. METHODS: We performed a retrospective review of our institution’s internal database (Clinical Query 2) including all patients that underwent diagnostic and/or therapeutic thoracentesis from January 2016 to December 2018. Pleural fluid analysis and pleural fluid cytology were reviewed for all patients. Two groups were created based on the presence of “other cells” in the pleural fluid cell count differential. Atypical but non-diagnostic cytology was considered negative. A logarithmic regression analysis including the variables sex, active malignancy, heart failure, presence of other cells, exudate and glucose was performed. RESULTS: A total of 100 patients were included. The group of patients with “other cells” in pleural fluid had a total of 52 patients, within these patients, 28 had pleural fluid cytology positive for malignancy. The most common comorbidities were active malignancy, heart failure, chronic kidney disease and cirrhosis. The median time to obtain a cytology results was similar in both groups (3 vs 2.5 days). When pleural fluid parameters were compared between groups, it could be seen that the “other cells” group had a higher total number of cells (1243 vs 767.5, p=0.03), higher total protein (435 g/dL vs 355 g/dL, p<0.01), lower glucose levels (104 mg/dL vs 113.5 mg/dL, p=0.02), higher LDH (199 IU/L vs 150 IU/L, p=0.01), higher albumin (2.75 g/dL vs 2.1 g/dL, p<0.01) and higher cholesterol (81 mg/dL vs 53 mg/dL, p<0.01). Pleural fluid containing “other cells” was more likely to be exudative (43 vs 31, p=0.04); but more importantly a higher number of samples had malignant cytology (28 vs 4, p <0.01). When “other cells” are present in pleural fluid, the odds ratio for a malignant cytology result is 5.79 times higher than when these cells are absent (p= 0.01, CI=1.38-24.28). CONCLUSIONS: The presence of “other cells” in pleural fluid cell count differential increases the probability of a positive pleural fluid cytology for malignancy. CLINICAL IMPLICATIONS: This often-discarded value of the pleural fluid analysis holds potential as a screening tool for malignant pleural effusions. DISCLOSURES: Consultant relationship with Boston Scientific Please note: $1001 - $5000 Added 03/15/2019 by Alex Chee, source=Web Response, value=Consulting fee Consultant relationship with Boston Scientific Please note: $1001 - $5000 Added 03/16/2019 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 Added 03/16/2019 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 Added 03/16/2019 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 Added 03/16/2019 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Daniel Ospina-Delgado, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response

1431 A Bad Connection: Chronic Pancreatitis Leading to a Pancreticopleural Fistula

INTRODUCTION: Pancreatic-pleural/mediastinal fistulas are a rare complication of chronic pancreatitis. Fistulous connections occur through fenestrations in the diaphragm. Pancreatic ductal stenting can be valuable, though medical and surgical options may still be required. We describe a case of pancreatic-pleural fistula with mediastinal tracking successfully treated with combined endoscopic and medical management. CASE DESCRIPTION/METHODS: The patient is a 53-year-old male with a history of chronic pancreatitis secondary to alcohol abuse, a pancreatic pseudocyst, and compensated heart failure. The patient was admitted with new onset shortness of breath and epigastric abdominal pain. CT showed acute on chronic pancreatitis with a pseudocyst in the uncinate process, lower mediastinal inflammatory changes, and bilateral pleural effusions. Thoracentesis was performed, demonstrating an amylase of &gt;7500. Though MRCP did not show a discrete connection, the clinical presentation was consistent with pancreatic-pleural fistula. ERCP was performed, but the endoscopist was unable to cannulate the pancreatic duct. Patient was placed on octreotide and continued to undergo therapeutic thoracenteses as needed. Patient returned 1 month later with complaints of neck fullness, continued shortness of breath, and abdominal pain. CT was significant for a fluid collection extending from pancreatic head to the mediastinum tracking along the anterior aspect of the esophagus and persistent pleural effusions. MRCP was performed and revealed a fistulous connection between the pseudocyst, pleural space, and mediastinum. Repeat ERCP was done with successful pancreatic stent placement. Patient subsequently had resolution of both mediastinal and pleural fluid collections. The pancreatic stent was removed with durable resolution of fluid collections. DISCUSSION: Pancreatic fistulas are reported to resolve with supportive care alone in 80% of external and 50-65% of internal fistulas. In our case, supportive care including octreotide use was insufficient for fistula resolution. The patient was ultimately treated successfully with pancreatic stenting. Had this failed, alternative approaches could have included nasojejunal feeding, endoscopic sealants, or surgical correction. This case highlights a rare, but serious complication of chronic pancreatitis and management options to be considered.

BILATERAL CHYLOTHORAX SECONDARY TO SPONTANEOUS THORACIC DUCT ANEURYSM

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Chylothorax is a rare cause of pleural effusion despite a normal thoracic duct draining 1-2 liters of fluid per day. Diagnosis is made by confirming the presence of chylomicrons in pleural fluid and defined by pleural fluid triglyceride levels >1.24 mmol/l (110 mg/dl) with a cholesterol CASE PRESENTATION: A 61 year old male without past medical history was admitted for 2 days of dyspnea and bilateral large pleural effusions. Diagnostic right thoracentesis was exudative, milky, with markedly elevated triglyceride level (3,315 mg/dL) and low cholesterol level (<50 mg/dL) consistent with chylothorax. Thoracentesis of the left was transudative but also consistent with chylothorax (triglyceride of 3,585 mg/dL; cholesterol <50 mg/dL). Therapeutic thoracenteses involved 3L removed from the right pleural space on day 1, 1.5L from the left side on day 2. Subsequent draining of 0.8L from the right on day 5. All samples were consistent with chylothorax. Extensive medical and surgical histories were negative for any traumatic, surgical, or iatrogenic etiologies. Computerized tomography of the chest, abdomen, and pelvis was negative for malignant etiology. Given rapid recurrence and severity of symptoms, the patient underwent lymphangiography identifying a thoracic duct aneurysm at the T10-T11 level measuring 12mm with evidence of chyle leak into the left pleural space. There was no identified leak into the right pleural space. The rapid reaccumulation and symptom severity drove a decision to occlude the leaky aneurysm with multiple microcoils and n-Butyl cyanoacrylate with complete resolution of pleural effusions and symptoms. DISCUSSION: Only a few cases of idiopathic thoracic duct aneurysm resulting in chylothorax have been reported. Consideration for this etiology should be given when standard evaluation remains negative. Lymphangiography remains a useful clinical tool in diagnostic evaluation of patients with idiopathic and recurrent symptomatic chylothorax. Thoracic duct embolization has been shown to successfully cure recurrent chylothorax in 60-90% of patients. It is theorized that dormant venous anastomoses take up the lymphatic drainage following thoracic duct embolization. CONCLUSIONS: Thoracic duct aneurysm is an uncommon cause of non-traumatic chylothorax. Lymphangiography remains an option for diagnosis and intervention for idiopathic chylothorax. Reference #1: Eric Chen, M.D.1 and Maxim Itkin, M.D.. Thoracic Duct Embolization for Chylous Leaks. Semin Intervent Radiol. 2011 Mar; 28(1): 63–74. Reference #2: Gomes AO, Ribeiro S, Neves J and Mendonça T. Uncommon aetiologies of chylothorax: superior vena cava syndrome and thoracic aortic aneurysm. Clin Respir J 2015; 9: 185–188. DISCLOSURES: No relevant relationships by Jack Buckley, source=Web Response No relevant relationships by Nichole Smith, source=Web Response

FATAL CONSEQUENCES OF THERAPEUTIC THORACENTESIS IN PATIENTS WITH SYSTEMIC SCLEROSIS

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pulmonary complications are common and a leading cause of death in patients with systemic sclerosis (SSc). Pleural effusions, however, are rare. Thoracentesis is a common procedure, performed to reveal the cause of pleural effusion or to drain it and relieve dyspnea. Although generally considered a low-risk intervention, complications of thoracentesis can lead to increased morbidity and mortality. We Here by describe our experience with patients with SSc requiring therapeutic thoracentesis. CASE PRESENTATION: We describe three patients with SSc and symptomatic pleural effusion who required thoracentesis. All patients deteriorated shortly after the procedure and died. The patients all had advanced heart failure either from left heart disease and/or severe pulmonary hypertension. DISCUSSION: We assume that patients with SSc are at high-risk to develop complications after thoracentesis, most likely due to the low compliant lungs and the low elastance of the pleura, in addition to significant cardiac compromise as etiology for pleural effusions. CONCLUSIONS: Pleural effusion in patietns with SSc is associated with grave prognosis secondary to heart failure or pulmonary hypertension. In such patients thoracentesis should be done with caution, while measuring the pleural pressure, either invasively, or with noninvasive surrogates. Reference #1: Luo YF, Robbins IM, Karatas M, et al. Frequency of pleural effusions in patients with pulmonary arterial hypertension associated with connective tissue diseases. Chest 2011; 140:42-7. Reference #2: Thompsom AE and Pope JE. A study of the frequency of pericardial and pleural effusions in scleroderma. Br J Rheumatol 1998; 37:1320-3. Reference #3: Bouros D, Pneumatikos I, and Tzouvelekis A. Pleural involvement in systemic autoimmune disorders. Respiration 2008; 75:361-71. DISCLOSURES: no disclosure on file for Yair Levy; no disclosure on file for aiman Natur; no disclosure on file for Tsvi Sirotkin; No relevant relationships by ori wand, source=Web Response

Tuberculous pleural effusion.

Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti-tuberculous therapy or a guideline-based individualized regimen in the case of drug resistance. There is low-quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short- and long-term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.

Assessment of Diaphragm Function and Pleural Pressures During Thoracentesis

This prospective observational study reports on diaphragm excursion, velocity of diaphragm contraction, and changes in pleural pressure that occur with thoracentesis. Twenty-eight patients with pleural effusion underwent therapeutic thoracentesis. Diaphragm excursion and velocity of diaphragm contraction were measured with M-mode ultrasonography of the affected hemidiaphragm. Pleural pressure was measured at each aliquot of 250mL of fluid removal. Fluid removal was continued until no more fluid could be withdrawn, unless there was evidence of nonexpandable lung defined as a pleural elastance greater > 14.5cm H2O/L and/or ipsilateral anterior chest discomfort. Twenty-three patients had expandable lung, and five patients had nonexpandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 1.5 ± 0.4cm/s to 2.8 ± 0.4cm/s pre-thoracentesis and post-thoracentesis, respectively (CI, 0.93-1.61; P< .001) in subjects with expandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 2.0 ± 0.4cm/s to 2.3 ± 0.4cm/s pre-thoracentesis and post-thoracentesis (P= .45) in subjects with nonexpandable lung. Diaphragm excursion was significantly increased in subjects with expandable lung at the end of thoracentesis; diaphragm excursion did not increase to a significant extent in patients with nonexpandable lung. The velocity of diaphragm contraction and diaphragm excursion increased in association with fluid removal with thoracentesis in patients with expandable lung, whereas it did not significantly change in patients with nonexpandable lung. This may derive from improvement in loading conditions of the diaphragm in patients with expandable lung related to its preload and length-tension characteristics.

Sarcoid- like Phenomenon - ustekinumab induced granulomatous reaction mimicking diffuse metastatic disease: a case report and review of the literature

BackgroundThe utilization of monoclonal antibodies has become more widespread over the past decade. However, the development of non-caseating granulomas with the use of monoclonal antibodies, such as ustekinumab, is not widely reported in the literature.Case presentationWe report a case of a 50-year-old Caucasian male who presented complaining of weight loss and shortness of breath. He was receiving ustekinumab for refractory psoriasis but had no other significant medical comorbidities. On physical examination, reduced breath sounds on the right side were noted. Blood cultures were drawn on presentation and came back negative in 48 hours. A chest computed tomography scan revealed a large right lung mass in addition to right-sided pleural effusion. Therapeutic thoracocentesis was done; fluid cytology and analysis were negative for malignancy, acid-fast bacilli, or fungal infections. A positron emission tomography scan showed multifocal radiotracer uptake including within right lung mass, multiple bones, lymph nodes, liver and spleen. Biopsies showed hyalinized non-necrotizing granulomas. Immunohistochemical stains for AE1/AE3, cytokeratin 7 and 20, and thyroid transcription factor 1, were all negative. He was started on steroid therapy, and ustekinumab was discontinued and the follow-up computed tomography after a few months showed substantial improvement. However, over the course of next 4 months patient developed hepatic dysfunction and recurrent ascites and ultimately underwent transjugular intrahepatic portosystemic shunt placement. Furthermore, he was started on azathioprine and steroids were tapered. He improved clinically and was discharged from our hospital within a week.ConclusionsThis case highlights the need for careful consideration of patient medication history while evaluating the possible differential diagnoses that may contribute to a patient’s presentation.

Quality of life after interventions for malignant pleural effusions: a systematic review

BackgroundMalignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL following invasive interventions in MPE.MethodsFive electronic databases...

Intercostal artery pseudoaneurysm following thoracentesis: multi-modal imaging and treatment

BackgroundA pseudoaneurysm occurs as the result of a contained rupture of an arterial wall, yielding a perfused sac that communicates with the arterial lumen. Pseudoaneurysm of an intercostal artery is an extremely rare event but it carries with it a significant risk of rupture and subsequent hemothorax. It must be considered as a potential complication of thoracentesis.Case presentationHere, we report a rare case of an intercostal artery pseudoaneurysm following thoracentesis in an 82-year old male. The patient presented with respiratory distress 1 day after a therapeutic thoracentesis had been performed. Computed tomography (CT) with contrast revealed a left intercostal pseudoaneurysm with hemothorax and adjacent compressive atelectasis. Doppler ultrasound revealed bidirectional blood flow in the pseudoaneurysm sac. An intercostal arteriogram and thoracic aortogram aided in confirmation of the pseudoaneurysm and successful treatment with coil embolization.ConclusionsAn intercostal pseudoaneurysm complication following thoracentesis is very rare but important to rule out as a possible cause of hemothorax after the procedure. Capturing this finding with the aid of multiple imaging modalities allowed for diagnostic certainty and rapid treatment with coil embolization, leading to a successful patient recovery.

The Impact of Continuous Positive Airway Pressure upon Pleural Fluid Pressures during Thoracentesis

Background: Excessive drop of pleural pressure (Ppl) during therapeutic thoracentesis may be related to adverse events and/or to repeated procedures due to incomplete drainage. Objective: This was a pilot study of the impact of the application of continuous positive airway pressure (CPAP) at +5 cm H₂O upon the Ppl profile during thoracentesis. Methods: This was a prospective, controlled study of 49 consecutive adults who underwent thoracentesis. Enrollment was via alternation on a one-to-one basis. Pleural manometry was used to compare serial Ppl in patients using CPAP at +5 cm H₂O (CPAP group) with Ppl in patients without CPAP (control group). Results: Mean volumes drained were comparable between CPAP and control groups (1,380 vs. 1,396 mL). Patients in the CPAP group had a significantly greater change in volume per centimeter water column pressure (p = 0.0231, 95% confidence interval 6.41–82.61). No patient in the CPAP group had a Ppl less than –20 cm H₂O at termination of the procedure, while 8 (33%) control group patients developed a pressure lower than –20. No patient in either group developed re-expansion pulmonary edema. Conclusion: The application of CPAP at +5 cm H₂O mitigates the decreases in Ppl caused by thoracentesis via an increase in pleural compliance. The clinical implications of this finding merit study.

AGA Clinical Practice Update: Coagulation in Cirrhosis.

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership. The intent is to evaluate the current data on mechanism of altered coagulation in patients with cirrhosis, provide guidance on the use of currently available testing of the coagulation cascade, and help practitioners use anticoagulation and pro-coagulants appropriately in patients with cirrhosis. This review is framed around the best practice points, which were derived from the most impactful publications in the area of coagulation in cirrhosis and agreed to by all authors. BEST PRACTICE ADVICE 1: Global tests of clot formation, such as rotational thromboelastometry, thromboelastography, sonorheometry, and thrombin generation, may eventually have a role in the evaluation of clotting in patients with cirrhosis, but currently lack validated target levels. BEST PRACTICE ADVICE 2: In general, clinicians should not routinely correct thrombocytopenia and coagulopathy before low-risk therapeutic paracentesis, thoracentesis, and routine upper endoscopy for variceal ligation in patients with hepatic synthetic dysfunction-induced coagulation abnormalities. BEST PRACTICE ADVICE 3: Blood products should be used sparingly because they increase portal pressure and carry a risk of transfusion-associated circulatory overload, transfusion-related acute lung injury, infection transmission, alloimmunization, and/or transfusion reactions. BEST PRACTICE ADVICE 4: The following transfusion thresholds for management of active bleeding or high-risk procedures may optimize clot formation in advanced liver disease: hematocrit ≥25%, platelet count >50,000, and fibrinogen >120 mg/dL. Commonly utilized thresholds for international normalized ratio correction are not supported by evidence. BEST PRACTICE ADVICE 5: Thrombopoietin agonists are a good alternative to platelet transfusion, but require time (about 10 days) to elevate platelet levels. BEST PRACTICE ADVICE 6: The large volume of fresh frozen plasma required to reach an arbitrary international normalized ratio target, limitations of the usual target, minimal effect on thrombin generation, and adverse effects on portal pressure limit the utility of this agent significantly. BEST PRACTICE ADVICE 7: The 4-factor prothrombin complex concentrate contains both pro- and anticoagulant factors that offer an attractive low-volume therapeutic to rebalance a disturbed hemostatic system. However, dosage is, in part, based on international normalized ratio, which is problematic in cirrhosis, and published experience in liver disease is limited. BEST PRACTICE ADVICE 8: Anti-fibrinolytic therapy may be considered in patients with persistent bleeding from mucosal oozing or puncture wound bleeding consistent with impaired clot integrity. Both ε-aminocaproic acid and tranexamic acid inhibit clot dissolution. Neither is believed to generate a hypercoagulable state, although both may exacerbate pre-existing thrombi. BEST PRACTICE ADVICE 9: Desmopressin releases von Willebrand factor as its primary hemostatic mechanism. As this factor is usually elevated in cirrhosis, the agent lacks a sound evidence-based foundation, but may be useful in patients with concomitant renal failure. BEST PRACTICE ADVICE 10: Systemic heparin infusion is recommended for symptomatic deep vein thrombosis and portal and mesenteric vein thrombosis, but there are unresolved issues regarding monitoring with both the anti-Xa assay and the partial thromboplastin time due to cirrhosis-related antithrombin deficiency (heparin cofactor). BEST PRACTICE ADVICE 11: Treatment of incidental portal and mesenteric vein thrombosis depends on estimated impact on transplantation surgical complexity vs risks of bleeding and falls. Therapy with low-molecular-weight heparin, vitamin K antagonists, and direct-acting anticoagulants improve portal vein repermeation vs observation alone. BEST PRACTICE ADVICE 12: Direct-acting anticoagulants, such as the factor Xa and thrombin inhibitors, are relatively safe and effective in stable cirrhotic patients, but are in need of further study in patients with more advanced liver disease.

Lung ultrasound-guided therapeutic thoracentesis in refractory congestive heart failure

Background: Pleural effusion refractory to diuretic treatment is frequent in advanced heart failure. Therapeutic thoracentesis is a time-honored practice, recently made simpler and safer by guidance with lung ultrasound. To assess the feasibility and clinical impact of lung ultrasound-driven therapeutic thoracentesis in refractory heart failure.Methods and results: In a single-centre retrospective analysis we recruited 373 patients with heart failure with reduced ejection fraction (26 ± 12%), New York Heart Association class ≥3, and pleural effusion ≥ moderate at lung ultrasound. All patients underwent lung ultrasound-guided therapeutic thoracentesis. Total of 462 lung ultrasound-guided therapeutic thoracentesis procedures were successfully performed without complications. Evacuated pleural fluid by passive drainage was 1030 ± 534 mL. The maximal interpleural space was 73.6 ± 15.6 mm before, and 12.4 ± 3.1 mm after therapeutic thoracentesis (p < .001). Therapeutic thoracentesis induced an immediate symptomatic improvement in all patients, with New York Heart Association class decrease from 3.84 ± 0.37 pre- to 2.7 ± 0.55 post-therapeutic thoracentesis (p <.001). The improvement was long-lasting (for weeks/months) in 89% of patients. The 6-min walking test was 52 ± 29 m before, and 287 ± 56 m one month after therapeutic thoracentesis (p < .05).Conclusion: Lung ultrasound-driven therapeutic thoracentesis of pleural effusion in decompensated heart failure patients is feasible, safe, and efficient. Therapeutic thoracentesis induces immediate and substantial symptomatic relief followed by long-lasting improvement.