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Massive transudative pleural effusion due to CSF fistula – A case report

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A 33-year-old paraplegic female patient presented with a massive pleural effusion a few years after two spinal surgeries. She was evaluated and found to have pleural effusion due to CSF leak into …

A 33-year-old paraplegic female patient presented with a massive pleural effusion a few years after two spinal surgeries. She was evaluated and found to have pleural effusion due to CSF leak into pleural cavity.

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  • 1.                                                                                                   Massi                                      ive trans        sudative fistula - pleural e A case r    effusion d report  due to CCSF
  • 2. Case Report Massive transudative pleural effusion due to CSF fistula e A case report V. Vinod Kumar Consultant Pulmonologist, Apollo First Med Hospital, India a r t i c l e i n f o Article history: Received 17 October 2013 Accepted 1 May 2014 Available online xxx Keywords: CSF Massive Pleural effusion a b s t r a c t A 33-year-old paraplegic female patient presented with a massive pleural effusion a few years after two spinal surgeries. She was evaluated and found to have pleural effusion due to CSF leak into pleural cavity. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Patients presenting with massive pleural effusions are a common presentation in clinical practice. The usual causes of such massive pleural effusions include malignancy, para- pneumonic effusions and empyemas, occasionally tubercu- losis and chylothorax. Most of the massive effusions are exudative in nature. Transudative effusions are seldom massive in nature. The commonest causes of transudative effusions being congestive cardiac failure and hepatic hydrothorax. Here is presented an unusual patient presenting with a massive transudative pleural effusion. 2. Case report A 33-year-old female with paraplegia was referred with breathlessness at rest and CXR suggestive of a massive right- sided pleural effusion (Fig. 1). In view of her severe dyspnoea, an ICD right was done and a pleural fluid drained to relieve her breathlessness. The appearance of pleural fluid was clear, non viscous, colourless and odourless. Biochemical analysis of the same confirmed the presence of a transudative pleural effusion. This patient has a history of two surgeries for detethering of cord e the first 4 years earlier for post arachnoiditis tethered cord at D6 D7. Two years after the first surgery this patient again developed progressive weakness of her lower limbs and urinary incontinence and reedetethering of cord at D6 D7 level was done using a lateral extra cavitary approach. For one month prior to her current admission this patient developed progressively increasing breathlessness and was very dysp- noic at the time of admission. Though the patient became symptomatically better after drainage of the pleural effusion, she continued to have drainage of about 800 ml of pleural fluid daily. An MRI dorsal spine was done which revealed post- operative changes in the right side of D6 D7 vertebral bodies and posterior elements and adjacent ribs. Focal CSF collection was seen in the postoperative region communicating with the E-mail address: drvinodkumar_v@yahoo.com. Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001 http://dx.doi.org/10.1016/j.apme.2014.05.001 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  • 3. right lateral spinal canal CSF spaces at D6 vertebral level and communicating with the pleural spaces at D7 level. Focal altered signal intensity was also noted in the D6 D7 vertebra levels suggestive of myelomalacic changes. Clumping of cauda equinae and lumbosacral nerve roots was noted sug- gestive of chronic arachnoiditis (Figs. 2 and 3). Fig. 2 e MRI of the patient demonstrating the CSF fistula. Fig. 3 e MRI of the patient demonstrating the CSF fistula. Fig. 1 e Chest radiograph of the patient at presentation showing large right-sided pleural effusion. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e32 Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001
  • 4. This patient was referred to our neurosurgery colleagues for further management and subsequently a flap closure of the duropleural fistula was done. 3. Discussion The accumulation of cerebrospinal fluid in the pleural cavity is a rare occurrence and usually follows migration of ven- triculoperitoneal shunt to pleural cavity or following a ven- triculopleural shunting.1 Traumatic CSF fistulas can develop following penetrating injuries and fractures of the thoracic spine. Iatrogenic CSF leaks into pleural cavity have been reported after spinal sur- geries especially diskectomies using an anterolateral approach.2 The diagnosis is suggested by the appearance of pleural fluid, which is clear and colourless and has low protein like the CSF.1 Detection of beta 2 transferrin, a protein found only in CSF and perilymph, in the pleural fluid has been reported as a useful test in detecting such CSF leaks.3 Due to lack of lab facilities this test could not be done in our patient. This case is presented here due to its rarity and several unique features namely the onset of symptoms 2 years after spinal surgery, a transudative effusion presenting as a massive pleural effusion and diagnosis confirmed by MRI. Conflicts of interest The author has none to declare. r e f e r e n c e s 1. Light RW. Pleural Diseases. 4th ed. Lippincott Williams and Wilkins; 2001. 2. Monla hassan J. Duropleural fistula manifested as a large pleural effusion. Chest. 1998;114:1786e1789. 3. Haft GF. Use of beta 2 transferrin to diagnose csf leakage following spinal surgery. Iowa Orthop J. 2004;24:115e118. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 3 Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001
  • 5. Apollohospitals:http://www.apollohospitals.com/ Twitter:https://twitter.com/HospitalsApollo Youtube:http://www.youtube.com/apollohospitalsindia Facebook:http://www.facebook.com/TheApolloHospitals Slideshare:http://www.slideshare.net/Apollo_Hospitals Linkedin:http://www.linkedin.com/company/apollo-hospitals Blog:Blog:http://www.letstalkhealth.in/