Defying gravity: subdiaphragmatic causes of pleural effusions

Clinical overview of the physiology and pathophysiology of pleural fluid movement: a narrative review

In physiological conditions, the pleural space couples the lung with the chest wall and contains a small amount of fluid in continuous turnover. The volume of pleural fluid is the result from the balance between the entry of fluid through the pleural capillaries and drainage by the lymphatics in the most dependent areas of the parietal pleura. Fluid filtration is governed by Starling forces, determined by the hydrostatic and oncotic pressures of the capillaries and the pleural space. The reabsorption rate is 28 times greater than the rate of pleural fluid production. The mesothelial layer of the inner lining of the pleural space is metabolically active and also plays a role in the production and reabsorption of pleural fluid. Pleural effusion occurs when the balance between the amount of fluid that enters the pleural space and the amount that is reabsorbed is disrupted. Alterations in hydrostatic or oncotic pressure produce a transudate, but they do not cause any structural damage to the pleura. In contrast, disturbances in fluid flow (increased filtration or decreased reabsorption) produce an exudate via several mechanisms that cause damage to pleural layers. Thus, cellular processes and the inflammatory and immune reactions they induce determine the composition of pleural fluid. Understanding the underlying pathophysiological processes of pleural effusion, especially cellular processes, can be useful in establishing its aetiology.

Transient Urinothorax Following Nephrostomy Tube Placement and Percutaneous Nephrolithotomy: A Case Report

Urinothorax is a rare complication of urological procedures. This report presents a case of a patient who developed urinothorax following nephrostomy tube placement and percutaneous nephrolithotomy (PCNL). The patient was managed conservatively with chest tube and Foley catheter placement, without the need for surgery. Computed tomography (CT) and chest tube output indicated that the urinothorax occurred immediately after nephrostomy tube placement but resolved within a couple of days without further intervention. Unlike some other cases that required surgical intervention due to persistent urine leakage, this case underscores the importance of prompt identification and tailored management of this rare condition based on clinical judgment.

Pancreatitis as a Pulmonary Pathology: A Rare Case of a Pancreaticopleural Fistula Presenting as Recurrent Pleural Effusions Causing Mediastinal Shift

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis and pancreatic pseudocyst. It can present as recurrent pleural effusions and can be difficult to diagnose and treat. We present the case of a 37-year-old male with a history of chronic idiopathic pancreatitis complicated by a pseudocyst who came in with progressive dyspnea, cough, and pleuritic chest pain. The chest X-ray on presentation showed near-complete opacification of the left hemithorax, suggesting a large pleural effusion. Upon thoracentesis, black-bloody fluid was drained, and the pleural fluid analysis was consistent with an exudate with significantly elevated levels of amylase, lipase, and bilirubin. Cytology revealed abundant lipofuscin-laden macrophages, suggesting an intra-abdominal source of the accumulated fluid. A post-drainage CT of the chest showed the resolution of the pleural effusion and an interval decrease in the pancreatic pseudocyst size, indicating a fistulous connection to the pleural space. An endoscopic ultrasound (EUS) was performed with efforts to perform cystogastrostomy aspiration that was hindered by the interference of splenic vasculature obstructing the needle's path. The patient was transferred to another facility for definitive treatment with surgical pancreatectomy and auto islet cell transplant. This case underscores the importance of considering PPF as a possible diagnosis, especially in cases of recurrent pleural effusions and a history of pancreatitis and pancreatic pseudocyst. It also emphasizes the significance of EUS as the preferred modality for pseudocyst evaluation and its potential for minimally invasive treatment.

Imaging and Interventions for Lymphatic and Lymphatic-related Disorders

The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.

Pyo pneumothorax revealing splenic tuberculosis abscess in a COVID-19 femmal: A case report

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In areas where tuberculosis is prevalent, a splenic tuberculosis should be considered in the differential diagnosis of patients presenting with fever of unknown origin and splenomegaly.

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The diagnosis can be made later when complications occur as well as spontaneous rupture of the spleen.

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Although rare, chest rupture can occur and symptoms can be respiratory as well as pyopneumothorax or empyema, which can lead to inaccurate diagnosis and inappropriate treatment of the an underlying condition.

Pancreaticopleural Fistula: A Rare Complication of Alcoholic Pancreatitis

Pancreaticopleural fistula (PPF) is an uncommon complication of chronic pancreatitis. The authors describe a case of a 41-year-old male with a history of chronic alcoholic pancreatitis and pancreatic pseudocyst who presented with dyspnea and right-sided chest pain for three days. A chest radiograph showed near-complete opacification of the right hemithorax. A diagnostic thoracentesis revealed an exudative, amylase-rich pleural effusion. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a normal appearance of the ampulla of Vater and common bile duct; however, there was disruption of the pancreatic duct with leaking beyond the pancreatic neck. A sphincterotomy was performed, and a double-flanged stent was placed, which resulted in the resolution of the dyspnea and the right-sided pleural effusion.

Non-Traumatic Chylothorax and Chylopericardium: Diagnosis and Treatment Using an Algorithmic Approach Based on Novel Lymphatic Imaging

RATIONALE

Outcomes of interventional lymphangiographic treatment of nontraumatic chylous pleural effusions using traditional approaches have been highly variable. Recent advances in lymphatic imaging have revealed variations in underlying pathophysiology enabling improved targeting of therapeutic interventions.

OBJECTIVE

To assess outcomes of an algorithm for management of nontraumatic chylous pleural effusions based on advanced MR identification of various abnormalities in the thoracoabdominal lymphatic network that give rise to chylothorax.

METHODS

Novel lymphatic MR imaging was performed in 52 patients ages 11 to 89 years. Three distinct pathophysiological patterns were found: (1) abnormal pulmonary lymphatic flow from the thoracic duct only; (2) abnormal pulmonary lymphatic flow from retroperitoneal lymphatic networks with or without involvement of the thoracic duct; and (3) chylous ascites presenting as chylous pleural effusion. Lymphatic interventions were individualized to the underlying pathophysiological patterns.

RESULTS

In 41/52 (79%) patients, imaging revealed abnormal pulmonary lymphatic flow from the thoracic duct and/or retroperitoneal lymphatic networks. Thoracic duct embolization and/or interstitial embolization of retroperitoneal lymphatic resulted in resolution of chylothorax in this group in 38/41 (93%) of those patients. Five patients experienced Grade 1 or 2 complications. One patient succumbed to post-operative stress-induced cardiomyopathy and pulmonary embolism. Chylous ascites was the cause of chylothorax in 11/52 (21%) patients. Eight chose to undergo interventions for chylous ascites with clinical success in 6/8 (75%).

CONCLUSIONS

Application of MRI-guided intervention algorithm resulted in successful control of non-traumatic chylothorax in 93% patients with abnormal pulmonary lymphatic flow. Appropriate treatment of chylous ascites presenting as a pleural effusion requires systematic evaluation and diagnosis prior to potential treatments.

Chylothorax and Pseudochylothorax

Classically, both chylothorax and pseudochylothorax present as a pleural effusion with a characteristic milky white appearance to the pleural fluid. Although both are rare causes of pleural effusion, they have distinct etiologies and clinical implications, and as a result require different management strategies. Pleural fluid analysis of cholesterol and triglyceride levels is key to differentiating the 2 entities from one another and then guide the clinician to determine the best next steps in evaluation and management.

A left-sided cerebrospinal fluid hydrothorax and a right ventricular-peritoneal shunt: a unique clinical case study

We describe the case of a 84-year-old woman with a right ventricular-peritoneal shunt and a left-sided pleural effusion, the analysis of which was positive for cerebrospinal fluid. We consider the potential causative mechanisms. Our patient was managed conservatively due to her frailty, the effusion being asymptomatic and her preference not to pursue further invasive diagnostic testing. This case report is unique due to the contralateral nature of the effusion to the shunt, which has not been described before in the literature.

Urinothorax: Case report and systematic review of the literature

Urinothorax, the presence of urine in the pleural space, is a rare cause of pleural effusion, usually associated with obstructive uropathy, or urinary trauma. We present the case of a 3 year-old boy and a systematic review of the literature of the 44 cases encountered. After resection of a Wilm's tumour in the right kidney our patient presented acute respiratory distress associated with radiographically confirmed pleural effusion. With the initial diagnosis of pneumonia or malignant pleural effusion, a closed thoracotomy was performed. The liquid obtained suggested urine, which was confirmed by the laboratory. Cystoscopy with retrograde pyelography detected a fistula on the posterior wall of the right kidney. The report of cases worldwide is low, probably due to its low incidence but also to underdiagnosis. Respiratory symptoms are not always present and urological symptoms usually predominate. Diagnosis requires a high degree of clinical suspicion and is confirmed by the main biochemical marker: The ratio >1.0 pleural fluid creatinine and creatinine serum.

Thoracic duct embolization for the management of chylothoraces

PURPOSE OF REVIEW

The aim is to inform the reader on the recent advancements in the minimally invasive treatment of chylothorax.

RECENT FINDINGS

Intranodal lymphangiography has been demonstrated to be a superior alternative to traditional pedal lymphangiography for thoracic duct embolization (TDE). TDE is associated with less morbidity and better clinical success than conservative management or surgical intervention in both traumatic and nontraumatic causes of chylothorax. TDE embolization in the pediatric population was found to be feasible.

SUMMARY

Recent advances in the lymphangiography techniques and the accumulation of experience in treating chylous effusions have significantly broadened the adoption of TDE to treat chylothorax. TDE for traumatic chylothorax has been demonstrated to be less morbid and more effective than surgical and conservative treatment. In cases of nontraumatic chylothorax, the patient has to be evaluated by MRI and lymphangiography to exclude causes of chylothorax which cannot be managed by interruption of the thoracic duct (e.g. lymphatic malformations or chylous ascites). Future advancements in noninvasive imaging of the thoracic duct and imaging guidance during TDE will continue to refine the percutaneous management of chylous effusions.