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It is necessary to consider catheter-related events when a previously stable patient has an acute change in cardiopulmonary status, regardless of the duration of catheter use; and to recognize that hydrothorax from vein perforation may be bilateral, necessitating bilateral drainage procedures.
PURPOSE: To evaluate safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for hepatic hydrothorax (HHyd). MATERIALS AND METHODS: Twenty-one patients underwent TIPS creation for HHyd. A prospective TIPS database and medical records were reviewed. Clinical and radiographic outcomes were recorded as complete (symptom/effusion resolution), partial (improved symptoms/effusion), or none. Data patterns were examined with chi(2) tests and Kaplan-Meier analysis. RESULTS: Patients included 12 women and nine men, with a mean age of 56 years, all with Child class B (n = 7) or C (n = 14) disease. The technical success rate was 100%. Mean follow-up was 223 days. Twenty-nine percent (six of 21) died within 30 days of TIPS creation, 10% (two of 21) underwent transplantation within 30 days, and 62% (13 of 21) survived beyond 30 days. Data were incomplete in two patients. Clinical response was classified as complete in 63% (12 of 19), partial in 11% (two of 19), and none in 26% (five of 19). Radiographic response was classified as complete in 30% (six of 20), partial in 50% (10 of 20), and none in 20% (four of 20). Nonresponders had multisystem organ failure, and all but one died within 30 days. However, of the 13 patients surviving longer than 30 days, 10 (77%) had a complete clinical response. CONCLUSION: TIPS is a relatively safe and effective method of controlling HHyd. The majority of patients experienced improvement or resolution of clinical symptoms with a variable reduction in the quantity of pleural fluid. There was a tendency among nonresponders to die within 30 days.
Hydrothorax as a result of pleuroperitoneal communication occurs in approximately 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. Although our understanding of its mechanisms is incomplete, it is apparent that the key to successful therapy is obliteration of a transdiaphragmatic route of dialysate leakage (pleuroperitoneal communication), possibly coupled with reduction of intra-abdominal pressure. This review corroborated the findings from 10 major population-based case series in which 60 of the 104 cases (58%) were able to resume long-term peritoneal dialysis (PD). Temporary interruption of PD alone was successful in half of them. As compared to this conservative approach, as well as chemical pleurodesis via intercostal chest drain, video-assisted thoracoscopic intervention (including direct pleurodesis and diaphragmatic repair) has shown a promising role. Efficacy of thoracoscopic treatment has been confirmed by several case series from various centers and the demonstration of a success rate in excess of 90%. With accumulating experience using the thoracoscopic technique, it remains to be seen whether this mode of treatment will obviate the traditional closed pleurodesis.
Central venous catheters (CVCs) have become more common in the care of very low birthweight newborns. Nutrition is enhanced, fluid delivery is more secure, and stress from the intervention of starting new IVs is reduced. Complications of these devices include infection, thrombus or embolus, damage to vessels and organs, and extravascular collections of fluid. Pleural fluid collections can occur due to superior vena caval obstruction with obstruction of lymphatic drainage, and erosion or perforation of the catheter through the vein into the pleural space. Three infants weighing less than 1000 gm had CVCs placed in an antecubital vein. Severe respiratory compromise developed in 1 at 5, 1 at 6, and 1 at 40 hours after line placement, and chest radiograph suggested fluid in the right pleural space. Milky fluid was found in two cases in which the infants received lipid emulsion and parenteral nutrition fluid (PNF). Bright yellow fluid, resembling PNF, was found in the third, not receiving lipids. None of the patients was enterally fed. The tips of the CVCs were adjusted to a more peripheral location and there was no recurrence of pleural fluid, nor were signs of superior vena cava syndrome seen. Etiologies for the unilateral hydrothorax include vein perforation and erosion, but another cause is discussed. A right pleural fluid collection in a patient with a CVC tip in the right subclavian vein is a serious problem, which may be solved with repositioning of the CVC instead of removal.
A 49-year-old woman with alcoholic cirrhosis was hospitalized for severe respiratory distress. A moderate amount of ascites was noted on physical examination, and the right hemithorax was completely opacified on the chest x-ray film. Thoracentesis was performed, and a follow-up chest x-ray film showed marked reduction of pleural effusion. Two days later the patient again was in respiratory distress, and a chest tube was inserted. On the tenth hospital day, a peritoneovenous (Denver) shunt was inserted and the chest tube was removed. Follow-up chest x-ray films showed almost complete resolution of pleural effusion, and the patient has remained free of symptoms. When hepatic hydrothorax does not respond to conventional therapy, we believe aggressive treatment with a Denver shunt may be successful. To our knowledge this procedure has been performed successfully in only one other patient. Further study is needed to assess its value as a possible alternative method of treatment.
Thoracic complications of ventriculoperitoneal (VP) shunt are very rare. We report an unusual case of VP shunt intrathoracic migration, associated with symptomatic hydrothorax. The patient was successfully managed with revision. We reviewed the 10 cases reported in the literature and discussed the mechanism of shunt-tip migration.
Acute unilateral hydrothorax may appear as the sole extra-ovarian expression of severe ovarian hyperstimulation syndrome (OHSS). This case report describes two such cases, in one of which the patient developed this rare complication in two consecutive ovarian stimulation cycles. Awareness is needed for the timely and appropriate diagnosis of this rare complication that occurs 9-14 days following human chorionic gonadotrophin (HCG) administration and may recur in consecutive stimulation cycles. Thoracocentesis and fluid balance maintenance are efficient modes of therapy resulting in good outcome.
A rare iatrogenic complication of subclavian vein catheterization for hemodialysis is massive hydrothorax. A case is presented that illustrates the need for adherence to a standard procedure of prompt roentgenologic examination in conjunction with catheterization, and emphasizes the importance of the autopsy as a means of quality assurance.
Massive hydrothorax occurring during continuous ambulatory peritoneal dialysis is a rare complication that may appear at any time during the course of the treatment. Most of the time, it is right-sided and is more frequent in female patients. A case is presented that was investigated by peritoneopleural scintigraphy. A rapid accumulation of the radiopharmaceutical over the right hemithorax was observed. To explain that finding, a macroscopic diaphragmatic defect was suspected. Different therapeutic approaches are presented.
A 44-year-old man had an intractable right-sided pleural effusion due to cirrhosis, despite the absence of abdominal ascites. Instillation of Tc-99m macroaggregated serum albumin under CT guidance into the peritoneal space demonstrated transdiaphragmatic communication. This finding indicated the necessity for decompressing the portal system to treat the hydrothorax. The diagnostic radionuclide ascites scan may play an important role in the treatment approach to such patients.
A 56-year-old woman with a 2-year history of cirrhosis of the liver and frequent right pleural effusion was admitted with intractable shortness of breath. Chest x-ray examination showed marked pleural effusion of the right lung field with a shift of the mediastinum to the left. Ascites was not conspicuous. Except for the liver cirrhosis, there was no clinical evidence of other underlying diseases. The patient died with a relatively short course after hospitalization. At autopsy, an apparent bleb with 1-mm hole in the tendinous portion of the right diaphragm was noted. We suggest that the ascitic fluid directly crossed the diaphragmatic defect to the pleural cavity, which contributed to the hydrothorax. In this article we review the pertinent literature.
We report the first case of an adult presenting with respiratory symptoms caused by hepatic hydrothorax secondary to vitamin A intoxication. The patient was a 52-year-old woman who presented to the hospital with progressive dyspnea. Evaluation demonstrated mild elevation of her liver function tests, ascites, and a right pleural effusion. The patient consumed a variety of vitamins, including vitamin A. Her estimated vitamin A intake was at least 162,300,000 international units (IU) during 18 years. She dramatically escalated her dose the year before admission for a total acute dose of 98,550,000 IU, with a daily intake of 270,000 IU. The recommended daily allowance is 4,000 IU. A transjugular liver biopsy revealed histopathologic changes consistent with vitamin A toxicity: hypertrophy and hyperplasia of hepatic stellate cells, focal pericellular fibrosis, mild perivenular fibrosis, and minimal, predominantly microvesicular steatosis. Despite the absence of cirrhosis, pressure readings demonstrated portal hypertension. During her hospitalization, the patient's symptoms and biochemical profile improved. As the large and generally unregulated United States dietary supplement industry continues to grow, it is increasingly likely that individuals will present with the signs and symptoms of vitamin excess rather than vitamin deficiency. Physicians need to remain alert to the varied presentations and toxic manifestations of excessive vitamin use.
One patient with alcoholic cirrhosis and a massive hydrothorax resistant to medical management and thoracocentesis was treated with a Denver peritoneovenous shunt. This patient's progress has been followed for 14 months and the pleural effusion has not recurred.
A 67-year-old woman with neurofibromatosis type 1 presented with progressive dyspnea. Radiologic evaluation and magnetic resonance imaging revealed progression of a giant meningocele associated with hydrothorax. Laminoplasty with incision of the meningocele and dural plasty was performed, although nerve rootlets were killed. Microsurgical incision of the neck of the meningocele is a favorable operation even in large meningoceles such as the present case.
Unilateral hydrothorax occurring during peritoneal dialysis is well described and has been presumed to be secondary to a pleuroperitoneal communication. Diagnosis of these communications usually requires invasive procedures. A non-invasive method of confirmation of abnormal pleuro-peritoneal communication using radionuclide scanning is outlined. The occurrence of this complication has usually meant cessation of this type of dialysis. However, this patient illustrates that continuation of peritoneal dialysis is possible.
OBJECTIVE: To determine whether abnormally collected fetal body fluid could be used as alternative cell sources for cytogenetic assessment. METHOD: Using modified lymphocyte culture, the abnormal fetal body fluids obtained from the five fetal anomaly cases (3 cystic hygromas, 1 hydrothorax, and 1 isolated ascites) were analyzed in order to determine their karyotypes. RESULTS: Two cases showed 45, X and 46, XX/45, X and the other three showed a normal karyotype. CONCLUSION: The cytogenetic analysis from body fluid aspiration yields a rapid and accurate result within 96 hours. This method could be helpful when cordocentesis or placental biopsy is not feasible or when time requirement for amniotic fluid cell culture is burdensome to patient management.
Ex utero intrapartum treatment (EXIT) of a fetus with severe bilateral hydrothorax is described. EXIT allows therapeutic interventions on the neonate while maintaining fetoplacental circulation. Thus it may be useful for fetuses presenting with severe pleural effusion towards the end of gestation and in whom in utero drainage is technically not possible or available and drainage post partum would result in profound and prolonged hypoxia until sufficient drainage of pleural fluid allowed lung expansion.
A patient is described who developed a right pneumothorax and a left hydrothorax following percutaneous subclavian vein cannulation. The prevention, diagnosis and treatment of this complication are discussed.