Pleural effusion (large right sided)

Case contributed by Dr Shailaja Muniraju

Presentation

Steroid resistant nephrotic syndrome. Acute breathlessness.

Patient Data

Age: 5 years
Gender: Female

There is homogeneous opacification of the right hemithorax with underlying collapse of its upper lobe. There is secondary obscuration of right hemidiaphragm, cardiac silhouette and hilum. 

No obvious mediastinal shift.

Postural rotation seen.

X-ray

Post pleural tapping

There is right sided intercostal drainage in situ with right sided subcutaneous emphysema. There is near total drainage of pleural fluid. A few atelectatic bands are seen in the right lower zone. The rest of the lung fields shows prominent bronchovascular markings.

X-ray

Seven days later

Right sided intercostal drainage in situ. Adjacent subcutaneous emphysema has resolved.

There is no pleural effusion seen.

The atelectatic bands in the right lower zone shows near total resolution.

Atelectatic bands seen in the right upper zone.

There is a small pneumothorax on the right side.

Case Discussion

In patients with nephrotic syndrome, there would be transudative pleural effusion secondary to raised hydrostatic pressure or reduced capillary oncotic pressure.

Unilateral hemithorax opacification has few differential diagnosis in paediatrics age group:

1. Pulmonary agenesis/hypoplasia: Ipsilateral mediastinal shift with contralateral hyperinflation. Usually neonatal presentation.

2. Congenital diaphragmatic hernia: Few cystic lucencies can be identified in the affected side. The diaphragm would not be sharply defined. Usually neonatal presentation.

3. Foreign body aspiration: If the affected lung is collapsed, it would appear opaque with ipsilateral mediastinal pull seen. Please note that clinical history is very important.

4. Large volume pleural effusion: Positive meniscus sign sometimes. There would be mediastinal shift towards contralateral side. However there can be ipsilateral mediastinal shift, if there is significant collapse. 

6. Malignant lesions: examples are malignant germ cell tumours, Askins tumour, pleuropulmonary blastoma etc.

7. Childhood pneumonectomy: The affected side would show mediastinal shift(due to volume loss),
 post surgical changes in the ribs and surgical clips.

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Case information

rID: 49979
Case created: 13th Dec 2016
Last edited: 26th Dec 2016
Inclusion in quiz mode: Included

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