INTRODUCTION: The diaphragm is the primary muscle of inspiration. Diaphragmatic paralysis (DP) can be unilateral or bilateral. DP occurs when traumatic injury, systemic disease, or neurologic process results in the loss of control of a hemidiaphragm. When symptomatic, this condition presents with dyspnea and can affect the ventilatory function. Other presenting symptoms of DP are rare. Severity of symptoms depend on whether or not one or both hemidiaphragms are affected, the onset of paralysis, and the presence or absence of underlying pulmonary disease. We present a case of a patient with a rare complication of longstanding unilateral diaphragmatic paralysis.
CASE PRESENTATION: A 64 year-old woman with history of diaphragmatic paralysis presented to the hospital with left shoulder burning pain that radiated to her left arm and her left anterior chest. She denied dyspnea or pleurisy associated with the pain. Review of systems was positive for nausea, vomiting, progressive dysphagia that started two weeks prior to admission and 20 pound weight loss. She had a history of coronary artery bypass graft surgery, hypertension and hypothyroidism. Diaphragmatic paralysis was documented 15 years prior to admission with a fluoroscopic sniff test. Physical examination was normal, and the pain was not reproduceable on palpation. Cardiac workup for acute coronary syndrome was negative. Spirometry and static lung volumes were suggestive of a mild restrictive disorder. Computed tomography of the chest and gastrograffin esophagram showed significantly elevated left hemidiaphragm leading to an acute angle at the gastroesophageal junction. Upper gastrointestinal endoscopy demonstrated hemorrhagic mucosal changes suggestive of ischemia in the gastric fundus which was confirmed by histopathology. She underwent diaphragm plication without complications. Her symptoms, including the left shoulder pain, dysphagia, nausea and vomiting resolved after surgery.
DISCUSSION: Unilateral diaphragm paralysis (UDP) is more common than bilateral paralysis. The left diaphragm is more commonly affected and men are more often affected than women. In the absence of intrinsic lung disease, patients are often asymptomatic (50% of all patients are completely asymptomatic and UDP is detected as an incidental finding on a chest radiograph obtained for other reasons). UDP in most cases does not require aggressive treatment. Once diaphragmatic paralysis is discovered, the main purpose is to find its cause. The most common cause of UDP is thoracic surgery, occurring at an incidence of 2% to 20%. Surgery for idiopathic UDP remains controversial due to the rarity of the disease and the relatively benign natural course of the illness. When disabling respiratory symptoms are present and there is significant elevation of the hemidiaphragm, surgical plication of the paralyzed hemidiaphragm to minimize its paradoxical motion has shown some success. To our knowledge this is the first case that describes gastric ischemia as a complication of diaphragmatic hernia and its successful treatment with diaphragmatic plication. Chest physicians should be aware about this uncommon but serious complication of diaphragmatic paralysis.
CONCLUSIONS: - UDP is a rare condition, usually found incidentally on chest imaging. - When symptomatic, it usually presents as dyspnea. - Diaphragm plication as a definite treatment for UDP is still controversial. - Gastric ischemia is a complication from diaphragmatic paralysis that has not been described in the past, chest physicians should be aware of this serious complication.
Reference #1 1. Ko MA. Acquired paralysis of the diaphragm. Thorac Surg Clin 2009; 19(4): 501-10
Reference #2 2. Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med 2009; 30(3): 315-20
Reference #3 3. Roberts HC. Imaging the diaphragm. Thorac Surg Clin 2009; 19(4): 431-50
DISCLOSURE: The following authors have nothing to disclose: Enrique Calvo Ayala, Gabriel Bosslet
No Product/Research Disclosure Information