An Unexpected Hepatic Hydrothorax After a Successful Kasai Portoenterostomy: A Case Report

Hepatic hydrothorax (HH) represents a rare complication of portal hypertension among adult cirrhotic patients. Here, we describe a pediatric case of HH, observed in a biliary atresia infant. The child presented with recurrent right-sided pleural effusion, after a successful Kasai portoenterostomy with restoration of bile flow and without overt signs of hepatic failure. Recurrence of HH led the patient to liver transplant despite a low pediatric end-stage liver disease value. Although rare, HH can also occur in children and should be suspected in patients with portal hypertension and respiratory distress. HH may be an indication for liver transplantation.

1376. Cryptococcal Infection Presenting Solely as a Pleural Effusion

Background Cryptococcal infections are frequently seen in immunosuppressed hosts. To date, few cases of cryptococcal infections presenting solely as pleural effusion have been described in liver transplant recipients. To our knowledge, this is the first case of cryptococcal pleuritis presenting with acute respiratory failure early post liver transplant. Methods 51- year old male with non- alcoholic cirrhosis complicated by chronic right hydrothorax underwent deceased donor liver transplantation with methylprednisolone induction. A week later, he developed acute respiratory failure requiring intubation. Pleural fluid was exudative with lymphocyte predominance; aerobic culture grew C. neoformans. Serum cryptococcal antigen was initially negative (prozone phenomenon was excluded) and subsequently turned positive titer 1:16. He was started on liposomal amphotericin and flucytosine, but developed acute kidney injury; induction therapy was changed to fluconazole with flucytosine for 2 weeks followed by fluconazole consolidation for 8 weeks. He remains on maintenance therapy. Donor serum cryptococcal antigen was negative, and recipients of other organs from the donor were clinically well. Results Pleural effusions are common in cirrhotic patients with ascites from hepatic hydrothorax. Although rare, Cryptococcal infection can manifest as isolated pleural effusion. Our patient was diagnosed with Cryptococcal empyema early post-transplant, though likely had subclinical or latent infection pre-transplant; evaluation for donor-derived infection was negative. Diagnosis of isolated pleural disease may be missed if only serum Cryptococcal antigen is tested, as antigen may not be detectable. Diagnosis is mainly established by pleural fluid culture and may be delayed, as pleural fluid is not routinely cultured when effusions are attributed to hepatic hydrothorax. Cryptococcal antigen in the pleural fluid may have a better diagnostic yield. Conclusion Cryptococcal infection should be considered in patients with cirrhosis and liver transplant recipients presenting with pleural effusion without any other abnormalities on chest imaging. Diagnosis may be missed if only serum cryptococcal antigen is used. Disclosures All Authors: No reported disclosures

Recurrent pleural effusion in patient with liver cirrhosis – a case report

Liver cirrhosis is caused by necrosis of liver cells leading to fibrosis and nodule formation. Structural abnormalities of the liver causing impaired hepatocyte function and portal hypertension. Hepatic hydrothorax is a less common pulmonary complication of portal hypertension. We present a 47 years old man with liver cirrhosis and recurrent massive pleural effusion. Diagnosis can be challenging because it can be associated with pulmonary or systemic disorders. Pleural fluid analysis is necessary to differentiate transudate or exudate as the cause of pleural effusion. Thoracentesis is done to reduce the complaints experienced by the patient.