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C35 CAUSES OF PLEURAL EFFUSIONS: CASE REPORTS / Thematic Poster Session
Mysterious Pleural Effusion
Z. Dhanani, E. Oweis; Internal Medicine, Washington Hospital Center, WASHINGTON, DC,
United States.
Introduction Hepatic hydrothorax is referred to the presence of pleural effusion that occurs in the
setting of liver cirrhosis. These pleural effusions are most commonly right sided and almost
always occur in the presence of clinically obvious ascites. Here we present a rare case of right
sided hepatic hydrothorax which presented without any abdominal ascites. Case A 67 year old
male with a history of esophageal cancer, prostate cancer, and radiographically-proven
undifferentiated cirrhosis is admitted with acute dyspnea of one week duration. Admission vital
signs were unremarkable. On exam, decreased breathing sounds and dullness to percussion
were evident over the lower one‐third of the right hemithorax. Initial laboratory data was
only significant for mild hypoalbuminemia (3.2 g/dL), normal aspartate transaminase and alanine
aminotransferase, elevated alkaline phosphatase (824 IU/L) with no hyperbilirubinemia, and
normal renal function. Chest X‐ray revealed a right‐sided pleural effusion.
Abdominal ultrasonography revealed a shrunken and liver with modularity and no ascites or
splenomegaly. Echocardiogram was unremarkable. 1500 mL of thoracic fluid was drained by
thoracentesis. The pleural fluid was yellow and pleural fluid analysis was consistent with
transudate by Light’s criteria. Pleural fluid cultures and cytology were negative. The
thoracentesis was repeated again in 3 days and diuretics were started. Analysis again was
consistent with transudative physiology. The effusion did not respond to therapy and an
indwelling catheter was placed for repeat drainage. Discussion Hepatic cirrhosis and ascites are
a well known cause of pleural effusion. We described a case with right-sided hepatic hydrothorax
in the absence of ascites. The formation of pleural effusion in these patients is probably a result
of fluid movement from peritoneal to pleural space across diaphragmatic defects before ascites
can form. The other pertinent differential diagnoses of a right-sided transudative pleural effusion
include congestive left ventricular failure and nephrotic syndrome. These diseases are usually
ruled out with standard clinical tests and imaging. This case report demonstrates that the
absence of ascites cannot exclude cirrhotic etiology as the cause of pleural effusion and liver
cirrhosis should be suspected as the cause of pleural effusion when all the other causes of
pleural effusion have been ruled out in a patient with liver cirrhosis. In terms of treatment,
although diuretics remain the first line, often a combination of pleurodesis and peritoneal
shunting have to be employed and medical management often fails.
This abstract is funded by: None
Am J Respir Crit Care Med 2020;201:A4848
Internet address: www.atsjournals.org Online Abstracts Issue