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Case 198

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Male patient, 1 year and 3 months old, has Prune Belly syndrome and is in continuous ambulatory peritoneal dialysis (DPAC) due to chronic kidney disease. He was admitted to etiological clarification of recurrent peritoneal effusions. On examination: tachypnea, slight decrease of breath sounds on the right, diffuse breathing snoring, without respiratory effort signals. Exams attached were requested.

Analyzing the imaging tests and the clinical data, it can be concluded that the most likely cause of recurrent pleural effusions is:

a) Congestive heart failure

25%

b) Lobar pneumonia

25%

c) Peritoneal/pleural fistula

25%

d) Lung entrapment

25%
   

Image Analysis

Image 1: Chest radiography, AP incidence, showing hyperinflated lungs.

 

 

 

Images 2 and 3: Chest radiographies in AP and lateral view after peritoneal dialysis: medial displacement of right visceral pleura and compression of the ipsilateral lung conditioned by pleural effusion (red arrows).

 

 

Image 4: Peritoneal/pleural fistula in 99mTc - MAA (macroaggregated albumin labeled with metastable technetium 99m), infused into the peritoneal dialysis fluid demonstrated by the presence of the material in the right hemithorax.

Highlights

- The pleural effusion that results from peritoneal/pleural fistula is a rare complication of continuous ambulatory peritoneal dialysis (CAPD).
- About 25% of the patients are asymptomatic. When symptomatic, they may show only dry cough and dyspnea.
- There is no consensus on which diagnostic method has better accuracy, but scintigraphy using 99mTc-MAA infusion into the peritoneal dialysis fluid has been a fast and appropriate examination to diagnose peritoneal origin of the pleural fluid.
- Therapeutic approaches include suspension of peritoneal dialysis, at least temporarily, and surgical treatment in cases of relapse.
- Currently, talc pleurodesis is the surgical approach of first choice.

References

- Rajnish, Anshu, Muffazal Ahmad, and Pradeep Kumar. "Peritoneal scintigraphy in the diagnosis of complications associated with continuous ambulatory peritoneal dialysis." Clinical nuclear medicine 28.1 (2003): 70-71.

- Szeto, Cheuk Chun, and Kai Ming Chow. "Pathogenesis and management of hydrothorax complicating peritoneal dialysis." Current opinion in pulmonary medicine 10.4 (2004): 315-319.

- Maude, Rapeephan R., and Michael Barretti. "Severe “sweet” pleural effusion in a continuous ambulatory peritoneal dialysis patient." Respiratory Medicine Case Reports 13 (2014): 1-3.

- Herbrig, Kay, et al. "Dry cough in a CAPD patient." Nephrology Dialysis Transplantation 18.5 (2003): 1027-1029.

- Chavannes, M., et al. "Diagnosis by Peritoneal Scintigraphy of Peritoneal Dialysis-Associated Hydrothorax in an Infant." Peritoneal Dialysis International 34.1 (2014): 140-143.

- Daugirdas, John T., Peter G. Blake, and Todd S. Ing. Manual de diálise. Medsi, 2003.

Authors

Caroline dos Reis, 6th year medical student at UFMG.

E-mail: creis.caroline[arroba]gmail.com

 

Bárbara Queiroz Bragaglia, 6th year medical student at UFMG.

E-mail: barbara.bragaglia[arroba]hotmail.com

 

Gustavo Campos, 6th year medical student at UFMG.

E-mail: fcamposgustavo[arroba]gmail.com

Supervisor

Gláucia Santos, pediatric nephrologist of the Dialysis Service of HC-UFMG

E-mail: glauciaplacidonio[arroba]gmail.com

Reviewers

Júlia Petrocchi, Fernando Bottega, Ana Luiza Mattos Tavares, Luísa Bernardino, Professor Viviane Parisotto e Professor José Nelson Mendes Vieira.

Translated by

Luísa Bernardino Valério, 4th year medical student at UFMG.

E-mail: luisabernardino[at]gmail.com

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