TRAPPED LUNG SYNDROME: UNCOMMON BUT NOT UNSEEN, A RARE COMPLICATION OF PLEURAL FLUID DRAINAGE

AbstractPancreaticopleural fistula is a rare complication of chronic pancreatitis caused by disruption of the pancreatic duct and fistulous communication with the pleural cavity. It usually presents with respiratory symptoms from recurrent large volume pleural effusions. Paucity of abdominal symptoms makes it a diagnostic challenge, leading often to delayed diagnosis. Marked elevation of pleural fluid amylase, which is not a commonly performed test, is a sensitive marker in its detection. Imaging with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography can help delineate the fistula. In this report, we present the clinical features, imaging, and management of a 59-year-old male patient with pancreaticopleural fistula, wherein the diagnosis was suspected only after repeated pleural fluid drainages were performed for re-accumulating pleural effusions and it was eventually successfully treated with pancreatic duct stenting. We review the literature with regards to the incidence, presentation, diagnosis, and management of this rare entity.

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ID: 61: WARFARIN, HEMOTHORAX AND THROMBOLYTICS

Journal of Investigative Medicine ◽

10.1136/jim-2016-000120.130 ◽

2016 ◽

Vol 64 (4) ◽

pp. 973.2-974 ◽

Cited By ~ 1

Author(s):

S Naqvi ◽

KS Allen

Keyword(s):

Pleural Fluid ◽

Rare Complication ◽

Treatment Options ◽

Rare Condition ◽

Bleeding Risk ◽

Supplemental Oxygen ◽

Tube Thoracostomy ◽

Safe Procedure ◽

Retained Hemothorax ◽

Intrapleural Administration

IntroductionHemorrhagic complications due to Warfarin use are frequently seen. Hemothorax is a rare complication, and trauma is a major risk factor. Massive non-traumatic hemothorax is an extremely rare condition.Tube thoracostomy drainage is the primary mode of treatment. In cases of retained hemothorax, surgical procedures are recommended. Treatment options are limited for patients who are not surgical candidates.First described in 1981, intrapleural administration of fibrinolytics seems to be a safe procedure for treatment of retained traumatic hemothorax. Intrapleural administration of t-PA & DNase has also been successfully used for infected pleural fluid & is associated with reduced hospital stay & need for surgery.Our report focuses on successful treatment of Coumadin induced non-traumatic hemothorax with these agents.Case ReportA 72 yo male on Coumadin for Afib, was brought to the hospital because of SOB, confusion & hypoxemia in the 70's. CXR revealed new large left sided pleural effusion. Relevant labs included Hgb of 6.7 g/dl (4 gram below baseline), INR 7.1 & platelet count 323. Sampling of the pleural fluid showed Hgb of 7.2 & hemotocrit 21.6. Coagulopathy was corrected and decision was made to proceed with tube thoracostomy.Patient drained almost a liter of old blood in the subsequent 24 hrs. It stopped afterwards. CXR revealed improved but persistent opacity. His health precluded surgery as an option. After long discussion with the patient, t-PA 10 mg & DNase 5 mg Once Daily was started. Pt. received a total of 3 doses with significant improvement in symptomatology and imaging. He drained almost 7 liters of old blood and was able to come off of supplemental oxygen. Hgb stayed stable after initial resuscitation.DiscussionFor treatment of retained hemothorax secondary to trauma, administration of fibrinolytics has been validated in several studies. Response measured by radiologic/clinical improvement as well as PFTs is impressive. Bleeding risk is low & pleuritic pain is the most common reported adverse effect.We propose that t-PA & DNase at the dose of 10 mg & 5 mg Daily respectively, is a safe treatment for selected patients with spontaneous non-traumatic hemothorax secondary to Coumadin use.More data is needed in medical ICU patients before this regimen can be generalized.Abstract ID: 61 Figure 1

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CHARACTERISTICS OF TRAPPED LUNG: MANOMETRY, PLEURAL FLUID ANALYSIS, AND AIR-CONTRASTED COMPUTED TOMOGRAPHY

CHEST Journal ◽

10.1378/chest.128.4_meetingabstracts.157s-b ◽

2005 ◽

Vol 128 (4) ◽

pp. 157S

Author(s):

John T. Huggins ◽

Jay Heidecker ◽

Peter Doelken ◽

Steven A. Sahn

Keyword(s):

Computed Tomography ◽

Pleural Fluid ◽

Fluid Analysis ◽

Trapped Lung

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Ruptured mediastinal pseudocyst with pancreaticopleural fistula formation in a 15-year-old boy presenting with white-out hemithorax: A case report

Indian Journal of Case Reports ◽

10.32677/ijcr.v7i12.3207 ◽

2022 ◽

pp. 547-549

Author(s):

Mohd Monis ◽

Md Khalaf Saba ◽

Syed M Danish Qaseem ◽

Nadeem Arshad

Keyword(s):

Pleural Fluid ◽

Rare Case ◽

Rare Complication ◽

Necrotizing Pancreatitis ◽

Magnetic Resonance Cholangiopancreatography ◽

Fistula Formation ◽

Direct Visualization ◽

Pleural Effusions ◽

Fluid Analysis ◽

Progressive Dyspnea

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis described more commonly in adults with alcoholic and necrotizing pancreatitis. We report a rare case of ruptured mediastinal pseudocyst with the formation of PPF in a 15-year-old boy who presented with progressive dyspnea and large left-sided pleural effusion that recurred despite repeated drainage. On the basis of imaging findings and pleural fluid analysis, the diagnosis of PPF with ruptured mediastinal pseudocyst was made. The diagnosis of PPF should be considered in patients with non-resolving large left-sided pleural effusions. The diagnosis can be confirmed either by significantly raised amylase levels in pleural fluid or direct visualization of the fistula on Computed tomography/magnetic resonance cholangiopancreatography.

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Six Weeks Intercostal Drainage for Recurrent Tuberculous Hydropneumothorax-Port Sudan Teaching Hospital

Journal of Internal Medicine and Emergency Research ◽

10.37191/mapsci-2582-7367-1(1)-004 ◽

2020 ◽

Author(s):

Murwan Mohamed Saeed

Keyword(s):

Thoracic Surgery ◽

Pleural Fluid ◽

Teaching Hospital ◽

Rare Complication ◽

Antituberculous Therapy ◽

Major Health Problem ◽

Therapy Strategy ◽

Cystic Changes ◽

Surgical Emphysema ◽

Morbidity Risk

Background: Tuberculosis is a major health problem in Sudan; the annual rate is 77/100.000, and it is the commonest endemic disease in Port Sudan. Hydro pneumothorax which is a rare complication that may recurrent after first intercostal drainage which is usually not respond to intercostal drainage up to seven days after which it needs thoracic surgery intervention either video assisted thoracoscope or even open thoracic surgery and there is no facilities for both in Port Sudan - Red sea state “ Sudan, so a trail of six weeks intercostal drainage and antituberculous therapy under direct observed therapy strategy (DOTS ) was done in order to overcome this problem and it showed a reasonable respond with minimal complications. Method: This is a prospective interventional hospital-based study which was done in Port Sudan teaching hospital from July 2010 to June 2018.10356 tuberculous patients were seen, (0.002%) of them developed recurrent hydropneumothorax, those were hospitalized, history was taken, physical examination and CXR were done and pleural fluid was examined for protein, cells and gene X pert. 28 F chest tube introduced and those patients. were followed clinically and radiologically while they continue on antituberculous therapy Results: From 10356 tuberculous patients 24 patients (0.002%) developed recurrent hydropneumothorax, 20 (83%) male, 4 (17%) female. Recurrence occurs between two to twelve days after first intercostal drainage. 16 patients (67%) were cases of hydropneumothorax, 4 patients pyopneumothorax and 2 patients (8.3%) were haemopneumothorax. 18 patients (75%) presented with cough, 18 patients (75%) SOB, 22 patients (91.7%) presented with chest pain and 5 patients (20.8%) presented haemoptysis. Pleural fluid was exudative in all patients and in all samples mycobacterium tuberculosis was not detected with gene Expert. Radiological findings beside hydropnemothorax showed cystic changes in 16 patients (66.7%), fibrotic changes in 16 patients (66.7%), and cavity formation in 6 patients (25%). Reexpansion occur in 22 patients (91.7%) and in 2 (8.3%) patients intercostal drainage didn't success and they died, 10 patients (41.7%) developed surgical emphysema, 4 (16.7%) patients developed brochopleural fistula and 2 (8.3 %) patients intercostal drainage didn't success and they died, 10 patients (41.7%) developed surgical emphysema, 4 (16.7%) patients developed brochopleural fistula and 2 (8.3 %) patients developed empyema necessitates.Success rate for management of hydropneumothorax(16.7%) patients developed brochopleural fistula and 2 (8.3 %) patients developed empyema necessitates. Success rate for management of hydropneumothorax in Port Sudan teaching hospital with six weeks intercostal drainage was 91.7% with 100% success in those with hydropneumothorax and haemopneumothorax and 50% in those with pyopneumothorax. Conclusion: Recurrent tuberculous hydropneumothorax although it is very rare, but it has serious morbidity. Risk factors for recurrent hydropneumothorax in those tuberculous patients are bronchiectasis sand patients with fibrotic and /or cavitatory radiological changes. 6 weeks intercostal drainage can replace thoracic surgery in managing recurrent hydropneumothorax and it showed good outcome with minimal complications that in majority resolved during course of management and rarely need further intervention.

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The Use of Pleural Fluid to Serum Glucose Ratio in Establishing the Diagnosis of a Not So Sweet PD-Related Hydrothorax: Case Report and Literature Review

Case Reports in Nephrology ◽

10.1155/2020/8811288 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Nidrit Bohra ◽

Abigayle Sullivan ◽

Haseeb Chaudhary ◽

Trudy Demko

Keyword(s):

Peritoneal Dialysis ◽

Pleural Fluid ◽

Rare Complication ◽

Serum Glucose ◽

Intermittent Hemodialysis ◽

Diagnostic Dilemma ◽

Delay In Diagnosis ◽

Pleuroperitoneal Communication ◽

Glucose Ratio ◽

The Right

Hydrothorax is a well-known but rare complication of peritoneal dialysis (PD), with an average incidence of 2% mainly in cases of continuous ambulatory peritoneal dialysis (CAPD). In more than 80% of these cases, the hydrothorax is attributed to an abnormal pleuroperitoneal communication. It commonly manifests as unilateral effusion, predominantly on the right. A thoracentesis to determine pleural glucose has been a diagnostic aid well relied on, as the dextrose rich dialysate raises the pleural fluid glucose. A pleural fluid glucose to serum glucose gradient greater than 50 mg/dL is suggestive of a leak with a specificity of 100% according to some studies; however, its sensitivity is variable. Our case illustrates a diagnostic dilemma due to a relatively low pleural fluid to serum glucose gradient of 21 mg/dL that caused a delay in diagnosis. A pleural fluid to serum glucose ratio >1.0 was used as a diagnostic marker that pointed toward a peritoneal leak. For confirmation, a peritoneal scintigraphy with nuclear technetium 99 scan was performed that revealed a pleuroperitoneal fistula as the source of the recurring hydrothorax in the setting of automated peritoneal dialysis (APD). The hydrothorax completely resolved with termination of APD on follow-up as the patient was transitioned to intermittent hemodialysis (HD).

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