Pulmonary Manifestations of Systemic Disease: Fellow Case Report Poster - Pulmonary Manifestations of Lung Disease |

Shunted to the Thoracic Cavity FREE TO VIEW

Anupam Gupta, MD; Jessica Gupta, MD; Terence Mc Garry, MD
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Elmhurst Hospital Center, Bronx, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1058A. doi:10.1016/j.chest.2016.08.1165
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SESSION TITLE: Fellow Case Report Poster - Pulmonary Manifestations of Lung Disease

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Ventriculoperitoneal (VP) shunt is a safe neurosurgical procedure for managing symptomatic hydrocephalus. Rare complication is cerebrospinal (CSF) pleural effusion. We present an unusual case of spontaneous symptomatic CSF pleural effusion in a middle-aged female, due to VP shunt migration into thoracic cavity.

CASE PRESENTATION: 38-year-old female with history of Chiari I malformation and communicating hydrocephalus managed with right frontal VP shunt insertion in 2014 presented with two-week history shortness of breath and productive cough, white sputum 15 months post-procedure. Physical examination: temperature 100.7°F, pulse 124 beats/minute, increased work of breathing, and absent breath sounds on entire right lung field. Laboratory results significant WBC 13,200 cells/mcL. Chest CT revealed VP shunt located within RT pleural effusion (Figure 1). Thoracentesis revealed yellow, non-purulent fluid, total protein 2.8 g/dL, lactate dehydrogenase 218 U/L & culture negative. Chest tube was placed. Right frontal VP shunt was removed, and left frontal VP shunt placed without complications. Respiratory symptoms improved thus chest tube was removed. Patient was discharged home.

DISCUSSION: CSF pleural effusions are rare, most commonly caused by VP shunt migration. Three types of mechanisms such complications exist: intrathoracic trauma during placement of shunt, migration of peritoneal catheter into thoracic cavity, and pleural effusion accompanying CSF ascites without tip migration. Two types of tip migration into the chest: supradiaphragmatic & transdiaphragmatic. Supradiaphragmatic migration occurs when the site of entry into pleural cavity passes into and out of pleural cavity during distal tunneling procedure; negative pressure during inspiration draws catheter upward. Transdiaphragmatic migration occurs when part of the catheter remains in peritoneal cavity, with tip entering the thorax via congenital diaphragmatic hiatuses.

CONCLUSIONS: CSF pleural effusion caused by VP shunt migration into thoracic cavity is rare but potentially serious complication often presents with respiratory distress. Removal of VP catheter and treatment of pleural effusion with resolution of respiratory symptoms is paramount for management of such a complication.

Reference #1: Gupta AK, Berry M. VP shunt presenting with recurrent pleural effusion: report of a new complication. Pediatr Radiol. 1994;24:147

Reference #2: Taub E, Lavyne MH. Thoracic complications of VP shunts: case report and review of the literature. Neurosurgery. 1994;34:181Y183

DISCLOSURE: The following authors have nothing to disclose: Anupam Gupta, Jessica Gupta, Terence Mc Garry

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