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- 3. PMH
- 4. HPI
- 5. ROS
- 6. Objectives
- 7. Physical Exam • Cardiovascular: Rate and Rhythm: irregular rhythm. • Pulmonary: Examination of the right lobe decreased breath sounds Abdominal: Abdomen distension. No tenderness, guarding, or rebound. • Musculoskeletal: • General: B/l legs edema
- 8. Labs
- 9. Imaging
- 10. Cardiovascular Echocardiogram: LVEF 20-25%.. Global left ventricle hypokinesis. There is abnormal left ventricle septal motion consistent with right bundle branch block. Left atrial pressure is elevated, difficult due to afib but probably grade III diastolic dysfunction. There is no thrombus in the left ventricle. There is no left ventricle mass.
- 11. • Acute on chronic decompensated HFrEF • Recurrent right pleural effusion • Ascites • Electrolytes imbalance • Noncompliance with dialysis? • Agoraphobia
- 12. Hemodialysis Tap
- 15. Indications for Thoracentesis • Pleural effusion of unknown cause and greater than 1 cm of fluid thickness on ultrasound or lateral decubitus radiograph.
- 16. Pleural fluid analysis Pleural fluid only three-test combination (PFO3) ●Pleural fluid protein greater than 3.0 g/dL ●Pleural fluid cholesterol greater than 55 mg/dL ●Pleural fluid LDH greater than 0.67 times the upper limit of the laboratory's normal serum LDH
- 17. Light's criteria (three-test combination rule) ●Pleural fluid-to- serum protein ratio greater than 0.5 ●Pleural fluid-to- serum LDH ratio greater than 0.6 ●Pleural fluid LDH greater than 0.67 (ie, two-thirds) the upper limits of the laboratory's normal serum LDH
- 18. Pleural fluid only two-test combination rule (PFO2) Pleural fluid cholesterol greater than 40 mg/dL•Pleural fluid LDH greater than 0.60 times the upper limit of the laboratory's normal serum LDH
- 19. Cell counts and cell differential • Polymorphonuclear-predominant pleural effusion • Counts above 50,000/microL in an exudative pleural effusion are usually found only in complicated parapneumonic effusions, including empyema. • Counts above 10,000/microL in an exudative pleural effusion are typically due to bacterial pneumonia, acute pancreatitis, and lupus pleuritis. • Counts below 5000/microL are likely due to chronic exudates
- 20. Back to the case • 1.5 serous fluids were removed
- 25. Pulmonology and ID were consulted CT scan A/P done 4 months ago: Loculated fluid collections are noted adjacent to the distal stomach. Thus, a diagnostic and therapeutic paracentesis was ordered. CT scan A/P was repeated.
- 27. She had repeat thoracentesis with consistent transudative chemistries.
- 29. CT scan A/P three months ago
- 30. Paracentesis
- 34. Back again SAAG: < 1.1
- 38. Spontaneous bacterial empyema ●Positive pleural fluid culture and a PMN cell count >250 cells/mm3 ●Negative pleural fluid culture and a PMN cell count >500 cells/mm3 ●No evidence of pneumonia on a chest imaging study
- 39. QUESTION??? This Photo by Unknown Author is licensed under CC BY-NC
- 41. References • Norvell JP, Spivey JR. Hepatic hydrothorax. Clin Liver Dis 2014;18:439–49. 10.1016/j.cld.2014.01.005 [PubMed] [CrossRef] [Google Scholar] • Kinasewitz GT, Keddissi JI. Hepatic hydrothorax. Curr Opin Pulm Med 2003; 9:261 • Tu CY, Chen CH. Spontaneous bacterial empyema. Curr Opin Pulm Med 2012; 18:355. • Gurung P, Goldblatt M, Huggins JT, et al. Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax. Chest 2011; 140:448 • Rubinstein D, McInnes IE, Dudley FJ. Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management. Gastroenterology 1985; 88:188