SESSION TITLE: Pleural Cases
SESSION TYPE: Case Reports
PRESENTED ON: Sunday, March 23, 2014 at 09:00 AM - 10:00 AM
INTRODUCTION: Neurofibromatosis is an autosomal dominant syndrome. Lateral thoracic meningocele (LTM) is rare but is known to be associated with neurofibromatosis type 1 upto 68.8%1 of times. Here we present an unusual case of pleural drain placement in LTM which mimicked a loculated pleural effusion.
CASE PRESENTATION: 45 years old caucasian male with history of neurofibromatosis admitted for right perinephric abscess. He was managed with percutaneous perinephric drain placement along with broad spectrum intravenous antibiotics. CXR and CT thorax revealed a right sided fluid collection reported by radiology as loculated pleural effusion along with bilateral layering pleural fluid. A 14 french pleural drainage catheter was placed in the loculated fluid collection under ultrasound guidance with consideration of empyema. Pleural drain was connected to negative pressure with approximately 600 cc removed in 24 hours. Drain was removed the next day. Fluid was exudative with negative cultures. Later, old CT scans were made available from outside hospital which showed the same fluid collection five years ago. CT scans were reviewed again and an MRI of spine was ordered which confirmed that the loculated fluid collection was in continuation with subarachnoid space and indeed was a meningocele. Fortunately, patient did not develop significant headache or any other neurologic deficits. Subsequent CXR revealed re-accumulation of fluid in meningocele. Patient slowly improved and perinephric drain was removed. Patient was discharged home on oral antibiotics.
DISCUSSION: Intrathoracic meningocele is a rare entity with approximately 150 case reports1. Although mostly asymptomatic, LTM may present with backache, cough, shortness of breath and palpitations. In two reported cases surgery was performed on thoracic and pelvic cystic lesions which later proved to be meningocele. In one reported case patient developed persistent large quantity CSF leakage into pleural cavity which was drained through chest tube2. To the best of our knowledge we are reporting first ever case where LTM mimicked pleural effusion and a pleural drain was placed inadvertently. Meningo-pleural fistula, headache and infection were potential risks but our patient did not develop any of the above.
CONCLUSIONS: Large LTM may look like loculated pleural effusion on imaging. In patients with neurofibromatosis, LTM should be considered in the differentials of loculated pleural effusion.
Reference #1: de Andrade e al. Giant intrthoracic meningoceles associated with cutaneous neurofibromatosis type I. Arq Neuropsiquiatr. 2003 Sep;61(3A):677-81. Epub 2003 Sep 16
Reference #2: M. Kubota, N. Saeki, A. Yamaura. Lateral thoracic meningocele presenting as a retromediastinal mass. Br. J Neurosurgery Dec;16(6):607-8
DISCLOSURE: The following authors have nothing to disclose: Naveed Sheikh, Dipaben Modi, Micheal McCormmack
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