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Communications to the Editor |

Pleurodural Fistulas and Neurologic Manifestations Pleurodural Fistulas and Neurologic Manifestations FREE TO VIEW

Frederick A. Zeller, MD, FCCP
Author and Funding Information

Affiliations: Shelby Medical Associates, Shelby, NC ,  Henry Ford Hospital and Medical Centers, Detroit, MI

Correspondence to: Frederick A. Zeller, MD, FCCP, Shelby Medical Associates, 808 Schenck St, Shelby, NC 28150



Chest. 1999;116(2):584-585. doi:10.1378/chest.116.2.584
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To the Editor:

In response to the article by Monla-Hassan et al (December 1998)1 regarding dural pleural fistulas, I bring up two cases of dural pleural fistula that I have encountered. In both cases, the patient presented with neurologic complications.

The first case was an elderly woman undergoing the removal of a non-small cell carcinoma involving the chest wall. The tumor was posterior medial in location, and extirpation required dissection in the vicinity of the dural reflection onto intercostal nerves. In the postoperative period, the patient developed hemiparesis. A CT scan of the head showed pneumoencephaly. The patient was returned to the operating room for re-exploration of the chest, at which time a dural rent was found and subsequently repaired. It was believed that the stroke occurred from cerebrospinal fluid (CSF) loss and caudal displacement of the brain with subsequent compression of the middle cerebral artery.

The second case involved a middle-aged man with underlying obstructive lung disease and pneumonia in the right upper lobe. The patient was treated long-term with antibiotics. However, the pneumonia failed to resolve, and a CT scan of the chest showed evidence of abscess formation/infected bullae in the upper lobe. The failure to resolve the process with antibiotics prompted a right upper lobectomy. The surgeon encountered dense adhesions, which made the dissection and extirpation difficult. In the postoperative period, the patient developed headache and meningismus. A lumbar puncture showed pleocytosis, hypoglycorrhachia, and elevated protein. Results of cultures were negative; however, the patient had been receiving antibiotics in the perioperative period. A pleural dural fistula and associated meningitis were clinically suspected, and the patient was started on broad spectrum antibiotics. While receiving antibiotics, the patient clinically improved. He subsequently underwent a right T6 costotransversectomy with repair of a dural rent. A large collection of CSF in the pleural space was drained. Surgical specimens revealed fungal elements suggestive of Aspergillus. The patient subsequently received an extended course of orally administered itraconazole. Interestingly, approximately 1 year later, this patient developed a subarachnoid hemorrhage.

In summary, these two cases demonstrate dural pleural fistula as a postoperative complication of thoracic surgery involving dissection in the region of the dural reflection onto the intercostal nerve roots. These cases did not present with symptomatic effusion; rather, they presented with the neurologic sequela of the dural pleural communication.

Monla-Hassan, J, Eichenhorn, M, Spickler, E, et al (1998) Duropleural fistula manifested as a large pleural transudate: an unusual complication of transthoracic diskectomy.Chest114,1786-1789. [PubMed] [CrossRef]
 

Pleurodural Fistulas and Neurologic Manifestations

To the Editor:

We appreciate the addition to the literature that Dr. Zeller’s cases provided. However, there are substantial differences between the case that we reported (December 1998)1and the two cases mentioned in Dr. Zeller’s letter. Pneumocephalus following thoracic surgery, such as lobectomy for lung cancer, has been reported in the literature.26 The reported cases were conditions temporally related to surgery, and the patients had presented with neurologic complications similar to the two cases mentioned in Dr. Zeller’s letter.

The case we reported represents an addition to the differential diagnosis of transudative pleural effusion.1 Our patient presented with a large symptomatic pleural effusion 6 months after transthoracic diskectomy, and the condition posed a diagnostic dilemma. The review of the literature did not reveal similar occurrences after diskectomy despite the fact that dural tears and cerebrospinal fluid fistulas are not uncommon after both spinal and thoracic surgery.7 Most of the events reported in the literature represent local complications that are recognized and managed postoperatively. The contribution derived from our case is that a duropleural fistula can be a very rare late complication of transthoracic diskectomy and should be considered as such when a diagnosis of pleural transudate is made in the appropriate setting.

References
Labadie, EL, Hamilton, RH, Lundell, DC, et al Hypoliquorreic headache and pneumocephalus caused by thoraco-subarachnoid fistula.Neurology1977;27,993-995. [PubMed] [CrossRef]
 
Walker, FO, Vern, BA The mechanism of pneumocephalus formation in patients with CSF fistulas.J Neurol Neurosurg Psychiatry1986;49,203-205. [PubMed]
 
D’Addario, R, Greenberg, J, O’Neill, TJ, et al Pneumocephalus: an unusual cause.J Neurol Neurosurg Psychiatry1974;37,271-274. [PubMed]
 
Smith, DN, Munden, RF, Schwartz, RB, et al Bronchopleural-subarachnoid fistula manifested as intracranial gas on CT scans.AJR Am J Roentgenol1995;165,1364-1365. [PubMed]
 
Reid, AC, Davidson, JG, Grossart, KW, et al Spontaneous pneumocephalus following elective thoracotomy.Aust N Z J Med1982;12,67-69. [PubMed]
 
Monla-Hassan, J, Eichenhorn, M, Spickler, E, et al Duropleural fistula manifested as a large pleural transudate.Chest1999;114,1786-1789
 
Kitchel, SH, Eismont, FJ, Green, BA Closed subarachnoid drainage for management of CSF leakage after an operation on the spine.J Bone Joint Surg1989;71,984-987. [PubMed]
 

Figures

Tables

References

Monla-Hassan, J, Eichenhorn, M, Spickler, E, et al (1998) Duropleural fistula manifested as a large pleural transudate: an unusual complication of transthoracic diskectomy.Chest114,1786-1789. [PubMed] [CrossRef]
 
Labadie, EL, Hamilton, RH, Lundell, DC, et al Hypoliquorreic headache and pneumocephalus caused by thoraco-subarachnoid fistula.Neurology1977;27,993-995. [PubMed] [CrossRef]
 
Walker, FO, Vern, BA The mechanism of pneumocephalus formation in patients with CSF fistulas.J Neurol Neurosurg Psychiatry1986;49,203-205. [PubMed]
 
D’Addario, R, Greenberg, J, O’Neill, TJ, et al Pneumocephalus: an unusual cause.J Neurol Neurosurg Psychiatry1974;37,271-274. [PubMed]
 
Smith, DN, Munden, RF, Schwartz, RB, et al Bronchopleural-subarachnoid fistula manifested as intracranial gas on CT scans.AJR Am J Roentgenol1995;165,1364-1365. [PubMed]
 
Reid, AC, Davidson, JG, Grossart, KW, et al Spontaneous pneumocephalus following elective thoracotomy.Aust N Z J Med1982;12,67-69. [PubMed]
 
Monla-Hassan, J, Eichenhorn, M, Spickler, E, et al Duropleural fistula manifested as a large pleural transudate.Chest1999;114,1786-1789
 
Kitchel, SH, Eismont, FJ, Green, BA Closed subarachnoid drainage for management of CSF leakage after an operation on the spine.J Bone Joint Surg1989;71,984-987. [PubMed]
 
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