SESSION TYPE: Pleural Cases II
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: We report a rare cause of an exudative pleural effusion in the setting of ovarian hyperstimulation syndrome (OHSS), an uncommon but serious complication of controlled ovarian stimulation used in the treatment of infertility.
CASE PRESENTATION: 23-year-old G0P0 woman with a history of polycystic ovarian syndrome, diabetes mellitus, and pituitary microadenoma with primary infertility underwent gonadotropin therapy with oocyte retrieval. She presented to the emergency department 1 week later with progressive dyspnea and pleuritic right-sided chest pain. She acknowledged seven pound weight gain with increased abdominal girth. Exam was significant for tachypnea with dullness to percussion and decreased breath sounds at the right lung base, abdominal distention, and 1+ pitting lower extremity edema. Labs were unremarkable. Serum HCG was undetectable. CTA Chest demonstrated a large right-sided pleural effusion along with ascites. Transvaginal ultrasound showed normal size ovaries. Therapeutic thoracentesis was performed. Pleural fluid revealed a protein concentration of 4.1 gm/dL and LDH of 247 U/L, consistent with an exudative effusion. Cell count was 340 nucleated cells/CUMM with 23% lymphocytes, RBC count of 19,000/CUMM, negative gram stain and culture, and no abnormal cells on cytology. The clinical presentation and pleural fluid results were consistent with the diagnosis of ovarian hyperstimulation syndrome. Thereafter patient was found to have a rising serum hcg level in the setting of new pregnancy. After another therapeutic thoracentesis, she was monitored for an additional week, whereupon she was discharged to home with obstetric follow-up.
DISCUSSION: Ovarian hyperstimulation syndrome is a complication that occurs in about one-fourth of women receiving hormonal treatment for infertility. Its severe form is very rare and can result in ascites and pleural effusion. The pathophysiology is thought to be cytokine mediated, particularly involving vascular endothelial growth factor, which leads to leaky capillaries and third-spacing of significant amounts of fluid from the ovaries. Our patient was unusual in that transvaginal ultrasound showed normal size ovaries, as opposed to the swollen enlarged ovaries common in this syndrome. Pleural fluid is typically exudative in nature with a high protein count, high red blood cell count and low leukocyte count. Diagnosis is mainly clinical, and treatment is generally supportive in nature, with symptoms typically resolving in ten to fourteen days. As in our patient, however, pregnancy results in elevated serum hcg levels which prolong the duration of the syndrome.
CONCLUSIONS: Ovarian hyperstimulation syndrome is an uncommon complication of infertility treatment, and in its severe form can result in an exudative pleural effusion secondary to cytokine release and vascular hyperpermeability.
1) Kaiser UB. The pathogenesis of the ovarian hyperstimulation syndrome. N Engl J Med 2003; 349:729.
DISCLOSURE: The following authors have nothing to disclose: Deepak Pradhan, David Green
No Product/Research Disclosure InformationNew York University, New York, NY