Acute Hydrothorax Diagnosed Through Scintigraphy in a Patient on Peritoneal Dialysis

Our patient, a 55-year-old woman, had a history of hypertension and chronic glomerulo-nephritis-related uremia. She had undergone peritoneal dialysis (PD) catheter insertion in September 2014 and started receiving continuous ambulatory peritoneal dialysis (CAPD) twice daily 1 month after catheter insertion. She experienced intermittent abdominal pain 3 months after the insertion. No fever or dyspnea were noted with the pain. However, a decrease in ultrafiltration volume or rate after the PD session was noted by the patient herself. A review of her medical history did not reveal recent trauma to the chest or previous diaphragmatic surgery. However, shortness of breath was noted 1 day later; hence, she presented to the emergency department (ED). Tachycardia (104bpm) and elevated blood pressure (185/111mmHg) were noted in triage, and her respiratory rate was 22 breaths/min with 98% oxygen saturation. No chest pain or abnormal findings in the electrocardiogram were noted during her ED stay. Laboratory results did not reveal leukocytosis or acidosis. A chest X-ray revealed a massive right-sided pleural effusion (Figure 1). Pleurocentesis was suggested, but the patient refused. We analyzed the dialysate instead of a sample of the pleural effusion fluid; no evidence of infection was found. We arranged lung perfusion scintigraphy, 5 mCi of Technetium99m macro aggregated albumin (Tc-99m MAA) was injected into the PD fluids, and a rapid accumulation of radioactivity in the right hemithorax was observed in the images recorded at 30 min and 1 h after PD (Figure 2). Thus, peritoneo-pleural communication (right side) caused by diaphragmatic defect was diagnosed. PD was discontinued immediately and videoassisted thoracic surgery with thoracoscopic diaphragmatic fundoplication and pleurodesis was provided 2 days later. The patient was discharged uneventfully without the recurrence of pleural effusions during a 3-month follow-up.