Annals of Tropical Paediatrics International Child Health
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Right diaphragmatic eventration simulating neonatal pleural effusion: a case report A. G. Falade To cite this article: A. G. Falade (1992) Right diaphragmatic eventration simulating neonatal pleural effusion: a case report, Annals of Tropical Paediatrics, 12:2, 221-223, DOI: 10.1080/02724936.1992.11747572 To link to this article: http://dx.doi.org/10.1080/02724936.1992.11747572
Published online: 13 Jul 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19 Download by: [Australian Catholic University]
Date: 29 August 2017, At: 12:15
Annals of Tro#cal Paediatrics (1992) 12, 221-223
Right diaphragmatic eventration simula ting neonatal pleural effusion: a case report A.G.FALADE
Downloaded by [Australian Catholic University] at 12:15 29 August 2017
Department of Paediatrics, University Co/lege Hospital, Ibadan, Nigeria (Received 4 September 1991)
Summary This is a report of a 10-day-old term female infant with right diaphragmatic eventration in whom the initial diagnosis was right pleural effusion with probable ipsilateral lung hypoplasia. The diagnostic pitfalls in such a case and suggestions ofhow to avoid them are discussed.
Introduction Diaphragmatic eventration is described as an abnormal elevation or smooth upward arching of ali or a portion of one diaphragmatic leaf. 1 It may be partial or complete, congenital 1 or acquired. 2 Classical definitions of diaphragmatic hernia and eventration are different, 3 but congenital eventration may present as congenital diaphragma tic hernia. 4 Although radiological differentiation of diaphragmatic eventration from pleural effusion is usually straightforward, difficulty might be encountered when the eventration is accompanied by peritoneal reaction, as this may be mis-diagnosed as an effusion. Such a case, the first in our centre, is presented and ways to avoid the diagnostic pitfall which was observed are suggested. Case report A 10-day-old female term infant developed respiratory distress shortly after an uneventful delivery. Initially, she fed weil on breast milk but subsequently started vomiting and Reprint requests to: Dr A. G. Falade, MRC Laboratories Fajara, PO Box 273, Banjul, The Gambia, West Africa.
refusing feeds. The stools were normal and she was apyrexial. On the 8th day of life co-trimoxazole suspension was prescribed. She showed no improvement and was referred to the paediatric department of University College Hospital (UCH), Ibadan. Physical examination revealed an acutely ill infant in extreme respiratory but acyanotic distress. Her weight was 3 kg, temperature 37°C and respiratory rate 108/minute. Percussion note was dull and the breath sounds rouch reduced over the right hemithorax. No crepitations or bowel sounds were heard. The abdomen was full and the liver just tipped below the right costal margin. Chest radiograph (Fig. 1) showed a shift of the mediastinum to the left with a positive right silhouette sign and an almost complete uniform opacification of the right hemithorax. Right-sided diagnostic chest tap yielded 7 ml of serosanguinous ftuid. Right closed thoracostomy tube drainage (CTTD) was done. A further amount of 15 ml of serosanguinous ftuid was drained but repeat chest radiograph showed no expansion of the right lung. This state of affairs persisted despite re-insertion of the chest drain, which appeared to be kinked. Intravenous cloxacillin and intramuscular gentamicin were given. Other supportive measures included
Downloaded by [Australian Catholic University] at 12:15 29 August 2017
222
A. G. Falade
eventration is on the right side, the dislocated liver in the right hemithorax often gives rise to dullness on percussion and absent breath sound which, taken together with radiological opacity, may be indistinguishable from pleural effusion. The small amount of serosanguinous fl.uid withdrawn on diagnostic tap in our patient compounded our error. The fl.uid probably came from the peritoneal cavity. Sorne important elues to diagnosis were overlooked in this case and it is important to note these in order to avoid such an error in future. First, the non-expansion of the lung, despite repeated CTTD, should have excluded pleural effusion even though this may occasionally occur with concomiFIG. 1. Chest radiograph of the patient showing right tant congenitallung hypoplasia. Secondly, in hemithorax opacity. Note the convex meniscus. neonates the li ver is usually easily palpable at about 2 cm below the right costal margin and in our patient it could only just be 'tipped'. oxygen by head box, incubator care and in- This should have given pause for thought. travenous glucose/electrolyte solutions. The Finally, the convex meniscus of the right clinical state of the patient continued to hemithorax (Fig. 1) and the absence of the deteriorate and she died on the 4th day of normal triangular liver shadow on chest and abdominal radiograph should have raised a admission. Post mortem examination confirmed a shift suspicion of congenital malformation. Given the nature of our patient's congeniof the mediastinum to the left with bilateral compression collapse of the lungs (due to the tal defect, the prognosis was intrinsically displacement of the liver into the right poor. Earl y recognition of the diagnosis and hemithorax) more pronounced on the right surgical intervention offer the only chance of side. There was no excess fl.uid in the pleural survival in these circumstances. 5' 6 cavities. The li ver had an abnormal S-shaped Respiratory distress in neonates requires configuration in situ, the right lobe, sur- urgent accurate diagnosis to determine rounded by a limiting fibrous membrane, whether surgical operation is indicated. occupying much of the right hemithorax. Failure of drainage with persistence of 'mass' The diaphragm was intact but its right half and mediastinal shift may indicate a spacewas replaced by fibrous tissue covering the occupying lesion requiring excision. An inenlarged eventrating liver. fant who recently presented with features Anatomical diagnosis of diaphragmatic similar to our patient was found to have a eventration with abnormal liver configur- large intrapulmonary branchial cyst (0. A. ation was made. Adebo, personal communication). Discussion
Acknowledgements
A diagnosis of diaphragmatic eventration is suggested when bowel sounds are beard in the chest of an infant in acute respiratory distress with radiological evidence of abnormal elevation of the diaphragm. But, when the
1 am grateful to Drs Aghadiuno and Akang for doing the post mortem on this patient. The secretarial assistance of Mrs Fatou Coker is much appreciated. My thanks also go to Drs O. A. Adebo and O. Sodeinde for making
Right diaphragmatic eventration
useful criticisms during the preparation of this work. References
Downloaded by [Australian Catholic University] at 12:15 29 August 2017
1 Bisgard JD. Congenital eventration of the diaphragrn. J Thorac Surg 1947; 16:489-91. 2 Nath J, Jain VK, Mohan S. Eventration of diaphragrn with pleural effusion. J Indian Med Assoc 1979; 73: 39-40.
223
3 Kirklin BR, Hodgson JR. Roentgenological characteristics of diaphragrnatic hernia. Am J Roentgenol 1947; 58:77-101. 4 Marks JH. Diaphragrnatic hernia and associated conditions. Am J Roentgenol1937; 37:613-32. 5 Bishop HC, Koop CE. Acquired eventration of the diaphragrn in infancy. Pediatries 1958; 22:1088-96. 6 Symbas PN, Hatcher Jr CR, Waldo WD. Diaphragmatic eventration in infancy and childhood. Ann Thorac Surg 1977; 24:113-9.
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Right diaphragmatic eventration simulating neonatal pleural effusion: a case report A. G. Falade To cite this article: A. G. Falade (1992) Right diaphragmatic eventration simulating neonatal pleural effusion: a case report, Annals of Tropical Paediatrics, 12:2, 221-223, DOI: 10.1080/02724936.1992.11747572 To link to this article: http://dx.doi.org/10.1080/02724936.1992.11747572
Published online: 13 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19 Download by: [Australian Catholic University]
Date: 29 August 2017, At: 12:15
Annals of Tro#cal Paediatrics (1992) 12, 221-223
Right diaphragmatic eventration simula ting neonatal pleural effusion: a case report A.G.FALADE
Downloaded by [Australian Catholic University] at 12:15 29 August 2017
Department of Paediatrics, University Co/lege Hospital, Ibadan, Nigeria (Received 4 September 1991)
Summary This is a report of a 10-day-old term female infant with right diaphragmatic eventration in whom the initial diagnosis was right pleural effusion with probable ipsilateral lung hypoplasia. The diagnostic pitfalls in such a case and suggestions ofhow to avoid them are discussed.
Introduction Diaphragmatic eventration is described as an abnormal elevation or smooth upward arching of ali or a portion of one diaphragmatic leaf. 1 It may be partial or complete, congenital 1 or acquired. 2 Classical definitions of diaphragmatic hernia and eventration are different, 3 but congenital eventration may present as congenital diaphragma tic hernia. 4 Although radiological differentiation of diaphragmatic eventration from pleural effusion is usually straightforward, difficulty might be encountered when the eventration is accompanied by peritoneal reaction, as this may be mis-diagnosed as an effusion. Such a case, the first in our centre, is presented and ways to avoid the diagnostic pitfall which was observed are suggested. Case report A 10-day-old female term infant developed respiratory distress shortly after an uneventful delivery. Initially, she fed weil on breast milk but subsequently started vomiting and Reprint requests to: Dr A. G. Falade, MRC Laboratories Fajara, PO Box 273, Banjul, The Gambia, West Africa.
refusing feeds. The stools were normal and she was apyrexial. On the 8th day of life co-trimoxazole suspension was prescribed. She showed no improvement and was referred to the paediatric department of University College Hospital (UCH), Ibadan. Physical examination revealed an acutely ill infant in extreme respiratory but acyanotic distress. Her weight was 3 kg, temperature 37°C and respiratory rate 108/minute. Percussion note was dull and the breath sounds rouch reduced over the right hemithorax. No crepitations or bowel sounds were heard. The abdomen was full and the liver just tipped below the right costal margin. Chest radiograph (Fig. 1) showed a shift of the mediastinum to the left with a positive right silhouette sign and an almost complete uniform opacification of the right hemithorax. Right-sided diagnostic chest tap yielded 7 ml of serosanguinous ftuid. Right closed thoracostomy tube drainage (CTTD) was done. A further amount of 15 ml of serosanguinous ftuid was drained but repeat chest radiograph showed no expansion of the right lung. This state of affairs persisted despite re-insertion of the chest drain, which appeared to be kinked. Intravenous cloxacillin and intramuscular gentamicin were given. Other supportive measures included
Downloaded by [Australian Catholic University] at 12:15 29 August 2017
222
A. G. Falade
eventration is on the right side, the dislocated liver in the right hemithorax often gives rise to dullness on percussion and absent breath sound which, taken together with radiological opacity, may be indistinguishable from pleural effusion. The small amount of serosanguinous fl.uid withdrawn on diagnostic tap in our patient compounded our error. The fl.uid probably came from the peritoneal cavity. Sorne important elues to diagnosis were overlooked in this case and it is important to note these in order to avoid such an error in future. First, the non-expansion of the lung, despite repeated CTTD, should have excluded pleural effusion even though this may occasionally occur with concomiFIG. 1. Chest radiograph of the patient showing right tant congenitallung hypoplasia. Secondly, in hemithorax opacity. Note the convex meniscus. neonates the li ver is usually easily palpable at about 2 cm below the right costal margin and in our patient it could only just be 'tipped'. oxygen by head box, incubator care and in- This should have given pause for thought. travenous glucose/electrolyte solutions. The Finally, the convex meniscus of the right clinical state of the patient continued to hemithorax (Fig. 1) and the absence of the deteriorate and she died on the 4th day of normal triangular liver shadow on chest and abdominal radiograph should have raised a admission. Post mortem examination confirmed a shift suspicion of congenital malformation. Given the nature of our patient's congeniof the mediastinum to the left with bilateral compression collapse of the lungs (due to the tal defect, the prognosis was intrinsically displacement of the liver into the right poor. Earl y recognition of the diagnosis and hemithorax) more pronounced on the right surgical intervention offer the only chance of side. There was no excess fl.uid in the pleural survival in these circumstances. 5' 6 cavities. The li ver had an abnormal S-shaped Respiratory distress in neonates requires configuration in situ, the right lobe, sur- urgent accurate diagnosis to determine rounded by a limiting fibrous membrane, whether surgical operation is indicated. occupying much of the right hemithorax. Failure of drainage with persistence of 'mass' The diaphragm was intact but its right half and mediastinal shift may indicate a spacewas replaced by fibrous tissue covering the occupying lesion requiring excision. An inenlarged eventrating liver. fant who recently presented with features Anatomical diagnosis of diaphragmatic similar to our patient was found to have a eventration with abnormal liver configur- large intrapulmonary branchial cyst (0. A. ation was made. Adebo, personal communication). Discussion
Acknowledgements
A diagnosis of diaphragmatic eventration is suggested when bowel sounds are beard in the chest of an infant in acute respiratory distress with radiological evidence of abnormal elevation of the diaphragm. But, when the
1 am grateful to Drs Aghadiuno and Akang for doing the post mortem on this patient. The secretarial assistance of Mrs Fatou Coker is much appreciated. My thanks also go to Drs O. A. Adebo and O. Sodeinde for making
Right diaphragmatic eventration
useful criticisms during the preparation of this work. References
Downloaded by [Australian Catholic University] at 12:15 29 August 2017
1 Bisgard JD. Congenital eventration of the diaphragrn. J Thorac Surg 1947; 16:489-91. 2 Nath J, Jain VK, Mohan S. Eventration of diaphragrn with pleural effusion. J Indian Med Assoc 1979; 73: 39-40.
223
3 Kirklin BR, Hodgson JR. Roentgenological characteristics of diaphragrnatic hernia. Am J Roentgenol 1947; 58:77-101. 4 Marks JH. Diaphragrnatic hernia and associated conditions. Am J Roentgenol1937; 37:613-32. 5 Bishop HC, Koop CE. Acquired eventration of the diaphragrn in infancy. Pediatries 1958; 22:1088-96. 6 Symbas PN, Hatcher Jr CR, Waldo WD. Diaphragmatic eventration in infancy and childhood. Ann Thorac Surg 1977; 24:113-9.
