A young man with pleural effusion and headache: What could b
The present case has been reported in the journal CHEST. A 26-year-old man presented to the ED with dizziness and gait imbalance. He noted dizziness for 3 months, but symptoms progressed more rapidly over the last 3 weeks when he began experiencing nausea, vomiting, and “wobbly legs.”

These symptoms would worsen with physical exertion, especially when lifting heavy objects. On review of systems, he also reported subjective fevers and chills.

He had no appreciable dyspnea, cough, chest pain, or increased sputum production. The patient recalled a history of “brain surgery” approximately 4 years prior to his presentation, but no further details could be provided at the time.

The results of a complete blood count and chemistry panel were unremarkable. In light of the patient’s chiefly neurologic complaints, a CT scan of the brain was performed and demonstrated chronic-appearing hydrocephalus as well as a density within the aqueduct of Sylvius.

A plain radiograph of the chest revealed an opacity in the right lower lung field, correlating with the patient’s clinical examination. Bedside thoracic ultrasound demonstrated a large free-flowing pleural effusion. A CT scan of the thorax further corroborated the presence of a large right-sided pleural effusion with atelectasis of the adjacent lung. When the pleural fluid was sampled, it was found to be transudative, with elevated levels of β2-transferrin.

The final diagnosis of a cerebrospinal fluid pleural effusion due to ventriculopleural shunt failure was established. The patient’s previous “brain surgery” was, in fact, the placement of a ventriculopleural shunt (without an antisiphon valve) for treatment of chronic hydrocephalus.

Clinical pearls:-
1.Communication between the dural and pleural spaces is uncommon, but can occur through a number of pathologies including ventriculopleural shunt failure, meningocele in neurofibromatosis, and duropleural fistula in cancer or trauma.

2.In CSF pleural effusions, negative intrathoracic pressure following large-volume thoracentesis can place patients at high risk of brain herniation.

3.Elevated β2-transferrin levels can be useful in confirming the diagnosis of a CSF pleural effusion.

4.Large-volume thoracentesis should be avoided if possible in CSF effusions, trapped lung, hepatic hydrothorax, stable hemothorax, and possible lung abscess.

5.Large-volume drainage of a CSF hydrothorax is safe following the placement of an antisiphon valve or other pressure control device.

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Dr. A●●●●y P●●●●a Internal Medicine
Interesting case!
Jan 7, 2019Like