A very complicated pleural effusion

Abstract

A 33-year-old male attended the emergency department with a three day history of dyspnoea. He had previously completed treatment for pulmonary tuberculosis and was HIV-positive on antiretroviral therapy. On examination, he was tachypnoeic with saturations of 89% on air. He had reduced air entry throughout the right lung and muffled heart sounds. He was afebrile and haemodynamically stable. Plain chest radiograph showed large bilateral pleural effusions, worse on the right. Urgent small-bore catheter drainage of the right lung was performed. Biochemistry showed an exudative effusion. 3.2 litres of fluid was drained within 4 hours, with an improvement in clinical condition. The patient then became increasingly tachypnoeic and rapidly desaturated. Repeat chest radiograph showed partial drainage of the effusion, however now with a 2 cm pneumothorax and oedematous right lung field. Sublingual nitrate, furosemide and an intercostal drain were placed with initial good response. The patient was admitted, but unfortunately died overnight. Discussion: Re-expansion pulmonary oedema is a recognised complication of large pleural effusion drainage. The mechanism remains unclear, although reduced left ventricular function, in this case from a possible pericardial effusion, may be a precipitant. To prevent this phenomenon the British Thoracic Society recommends draining a maximum of 1.5 litres of fluid. This case was further complicated by a pneumothorax; again a recognised complication, especially if there is underlying poor compliance of the lung parenchyma. Re-expansion pulmonary oedema has an incidence of <1% and pneumothorax <5%. Their occurrence has not previously been reported simultaneously. Large pleural effusions are commonly encountered in clinical practice in South Africa. The existence of multiple co-morbidities including tuberculosis, HIV and impaired cardiac function may complicate their management. This case highlights the need for close monitoring and controlled drainage of pleural effusions in emergency practice.