Pleural effusion from pleuroperitoneal communication.

A 52‐year‐old woman with end‐stage renal disease for chronic glomerulonephritis was started on inpatient peritoneal dialysis (PD).

We increased infusion volume of PD exchange every 2 days without observing any symptoms, including respiratory symptoms. After changing infusion volume on the 5th day, the patient complained of dyspnea and continuous cough. Decreased breath sounds were noted in the right lung field; chest X‐ray revealed right‐sided pleural effusion (Figure 1). Pleurocentesis revealed clear and transparent pleural fluid, consistent with a transudative type of effusion. Pleural fluid and serum glucose levels were 325 and 115 mg/dL, respectively, both suggesting that the effusion came from the dialysate fluid because of pleuroperitoneal communication.

Figure 1

Chest X‐ray image of a 52‐year‐old female on peritoneal dialysis showed massive right‐sided pleural effusion

Isotopic peritoneography with technetium‐99m‐labeled macroaggregated albumin revealed a prompt reflux of the tracer in the right pleural space (Figure 2), which confirmed the presence of a right‐sided pleuroperitoneal communication. PD was discontinued and switched to temporary hemodialysis. After due consideration, hemodialysis with internal shunt was started.

Figure 2

Isotopic peritoneography with Tc‐99m MAA in a 52‐year‐old female with massive right‐sided pleural effusion. There was a shifting of the tracer into the right thoracic cavity after 120 min. Tc‐99m MAA, technetium‐99m‐labeled macroaggregated albumin

Hydrothorax is a PD‐associated complication that is mainly secondary to pleuroperitoneal communication.1 Pleuroperitoneal communication occurred in approximately 1.6%‐10% of patients on PD; it was more frequent in women than men and was located more on the right side than on the left.1, 2

Pleuroperitoneal communication is caused by congenital or acquired diaphragmatic defects because of an elevated intra‐abdominal pressure during peritoneal fluid infusion.2

Although congestive heart failure, hypoalbuminemia, and fluid overload should be considered in the differential diagnoses,3 a high glucose level of the pleural fluid is an important finding because no other form of hydrothorax showed elevated glucose levels.1

Recently, technetium‐99m peritoneal scintigraphy has been utilized for the definitive diagnosis of pleuroperitoneal communication,1, 2, 3 as in this case. Hemodialysis offers a temporary or sometimes permanent alternative for renal replacement therapy if PD is discontinued.2 Patients wanting to restart PD need to undergo therapies such as pleurodesis or video‐assisted surgical approach to repair the pleuroperitoneal communication, without which PD cannot be resumed.3

If PD is started, physicians should be alert for the appearance of general symptoms, including respiratory symptoms, with the pleuroperitoneal communication.

Conflict of Interest

The authors have stated explicitly that there are no conflicts of interest in connection with this article.