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Case Report

Massive transudative pleural effusion due to CSFfistula e A case report

V. Vinod Kumar

Consultant Pulmonologist, Apollo First Med Hospital, India

a r t i c l e i n f o

Article history:

Received 17 October 2013

Accepted 1 May 2014

Available online xxx

Keywords:

CSF

Massive

Pleural effusion

E-mail address: drvinodkumar_v@yahoo.

Please cite this article in press as: VinodApollo Medicine (2014), http://dx.doi.org/

http://dx.doi.org/10.1016/j.apme.2014.05.0010976-0016/Copyright ª 2014, Indraprastha M

a b s t r a c t

A 33-year-old paraplegic female patient presented with a massive pleural effusion a few

years after two spinal surgeries. She was evaluated and found to have pleural effusion due

to CSF leak into pleural cavity.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Patients presenting with massive pleural effusions are a

common presentation in clinical practice. The usual causes of

such massive pleural effusions include malignancy, para-

pneumonic effusions and empyemas, occasionally tubercu-

losis and chylothorax. Most of the massive effusions are

exudative in nature.

Transudative effusions are seldom massive in nature. The

commonest causes of transudative effusions being congestive

cardiac failure and hepatic hydrothorax.

Here is presented an unusual patient presenting with a

massive transudative pleural effusion.

2. Case report

A 33-year-old female with paraplegia was referred with

breathlessness at rest and CXR suggestive of a massive right-

sided pleural effusion (Fig. 1).

com.

Kumar V, Massive tran10.1016/j.apme.2014.05.

edical Corporation Ltd. A

In view of her severe dyspnoea, an ICD right was done and

a pleural fluid drained to relieve her breathlessness. The

appearance of pleural fluid was clear, non viscous, colourless

and odourless. Biochemical analysis of the same confirmed

the presence of a transudative pleural effusion.

This patient has a history of two surgeries for detethering

of corde the first 4 years earlier for post arachnoiditis tethered

cord at D6 D7. Two years after the first surgery this patient

again developed progressive weakness of her lower limbs and

urinary incontinence and reedetethering of cord at D6 D7

level was done using a lateral extra cavitary approach. For one

month prior to her current admission this patient developed

progressively increasing breathlessness and was very dysp-

noic at the time of admission.

Though the patient became symptomatically better after

drainage of the pleural effusion, she continued to have

drainage of about 800 ml of pleural fluid daily.

An MRI dorsal spine was done which revealed post-

operative changes in the right side of D6 D7 vertebral bodies

and posterior elements and adjacent ribs. Focal CSF collection

was seen in the postoperative region communicating with the

sudative pleural effusion due to CSF fistula e A case report,001

ll rights reserved.

Fig. 2 e MRI of the patient demonstrating the CSF fistula.

Fig. 1 e Chest radiograph of the patient at presentation

showing large right-sided pleural effusion.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e32

right lateral spinal canal CSF spaces at D6 vertebral level and

communicating with the pleural spaces at D7 level. Focal

altered signal intensity was also noted in the D6 D7 vertebra

levels suggestive of myelomalacic changes. Clumping of

cauda equinae and lumbosacral nerve roots was noted sug-

gestive of chronic arachnoiditis (Figs. 2 and 3).

Fig. 3 e MRI of the patient demonstrating the CSF fistula.

Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report,Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3 3

This patient was referred to our neurosurgery colleagues

for further management and subsequently a flap closure of

the duropleural fistula was done.

3. Discussion

The accumulation of cerebrospinal fluid in the pleural cavity is

a rare occurrence and usually follows migration of ven-

triculoperitoneal shunt to pleural cavity or following a ven-

triculopleural shunting.1

Traumatic CSF fistulas can develop following penetrating

injuries and fractures of the thoracic spine. Iatrogenic CSF

leaks into pleural cavity have been reported after spinal sur-

geries especially diskectomies using an anterolateral

approach.2

The diagnosis is suggested by the appearance of pleural

fluid, which is clear and colourless and has low protein like

the CSF.1 Detection of beta 2 transferrin, a protein found only

in CSF and perilymph, in the pleural fluid has been reported as

Please cite this article in press as: Vinod Kumar V, Massive tranApollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.

a useful test in detecting such CSF leaks.3 Due to lack of lab

facilities this test could not be done in our patient.

This case is presented here due to its rarity and several

unique features namely the onset of symptoms 2 years after

spinal surgery, a transudative effusion presenting as a

massive pleural effusion and diagnosis confirmed by MRI.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Light RW. Pleural Diseases. 4th ed. Lippincott Williams andWilkins; 2001.

2. Monla hassan J. Duropleural fistula manifested as a largepleural effusion. Chest. 1998;114:1786e1789.

3. Haft GF. Use of beta 2 transferrin to diagnose csf leakagefollowing spinal surgery. Iowa Orthop J. 2004;24:115e118.

sudative pleural effusion due to CSF fistula e A case report,001

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