CHEST Guidelines-A-26-Year-Old-Man-With-a-Pleural-Effusion-and-Head

A-26-Year-Old-Man-With-a-Pleural-Effusion-and-Head

Pdf Summary

A 26-year-old man presented to the emergency department with symptoms of dizziness, gait imbalance, nausea, vomiting, and "wobbly legs," worsening over the last three weeks. He also reported subjective fevers and chills but no respiratory symptoms. Notably, he had a history of brain surgery four years prior. Neurological examination was largely normal except for disorientation to time. There was an absence of breath sounds in the right lower lung field and dullness to percussion. <br /><br />Diagnostic imaging revealed chronic hydrocephalus and a large right-sided pleural effusion. The pleural fluid was transudative with elevated levels of β2-transferrin, indicative of a cerebrospinal fluid (CSF) effusion. The diagnosis was a CSF pleural effusion resulting from ventriculopleural (VPL) shunt failure, which had been placed for chronic hydrocephalus but without an antisiphon valve.<br /><br />The primary concern was that large-volume thoracentesis could cause brain herniation due to pressure changes transmitted to the central nervous system via the VPL shunt. Antisiphon valves regulate CSF flow and prevent the "siphon" effect, reducing complications such as CSF hydrothorax. The patient subsequently underwent placement of an antisiphon valve, and 1 liter of pleural fluid was safely removed. With external shunt drainage and antibiotics, the patient improved, and his shunt was later replaced by a ventriculoatrial shunt.<br /><br />Key clinical takeaways include recognizing the risk of brain herniation from thoracentesis in CSF pleural effusions, the utility of β2-transferrin to confirm CSF presence, and management strategies such as antisiphon valve use to regulate CSF flow and allow safe effusion drainage.

Keywords

CSF pleural effusion

ventriculopleural shunt

antisiphon valve

hydrocephalus

β2-transferrin

thoracentesis

brain herniation

ventriculoatrial shunt

neurological examination

transudative pleural fluid