A very complicated pleural effusion

Case reportA 33-year-old male attended the emergency department with a three day history of dyspnoea. He had previously completed treatment for pulmonary tuberculosis and was HIV-positive on antiretroviral therapy. On examination, he was tachypnoeic with saturations of 89% on air. He had reduced air entry throughout the right lung and muffled heart sounds. He was afebrile and haemodynamically stable. Plain chest radiograph showed large bilateral pleural effusions, worse on the right. Urgent small-bore catheter drainage of the right lung was performed. Biochemistry showed an exudative effusion. 3.2litres of fluid was drained within 4hours, with an improvement in clinical condition. The patient then became increasingly tachypnoeic and rapidly desaturated. Repeat chest radiograph showed partial drainage of the effusion, however now with a 2cm pneumothorax and oedematous right lung field. Sublingual nitrate, furosemide and an intercostal drain were placed with initial good response. The patient was admitted, but unfortunately died overnight.DiscussionRe-expansion pulmonary oedema is a recognised complication of large pleural effusion drainage. The mechanism remains unclear, although reduced left ventricular function, in this case from a possible pericardial effusion, may be a precipitant. To prevent this phenomenon the British Thoracic Society recommends draining a maximum of 1.5litres of fluid. This case was further complicated by a pneumothorax; again a recognised complication, especially if there is underlying poor compliance of the lung parenchyma. Re-expansion pulmonary oedema has an incidence of <1% and pneumothorax