Pleural effusion is a common encounter in renal failure patients and frequently possess a diagnostic challenge to clinician especially when it was exudative. Fortunately, transudative pleural effusion secondary to fluid overload remains the commonest cause of pleural effusion in haemodialysis patients. Frequent thoracocentesis enhance pleural inflammation and potentially complicate further this challenging clinical presentation. We report a middle-aged gentleman with advanced chronic kidney disease presented with dyspnea and new right upper lobe consolidation on chest roentograph. He had a history of recurrent bilateral pleural effusion secondary to fluid overload and hence multiple attempts of thoracocentesis were performed. Medical thoracoscopy performed previously yielded non-specific pleuritis. Flexible bronchoscopy demonstrates normal airway with negative microbiological studies. Computed tomography (CT) of the thorax shown a loculated hypodense pleural effusion at the apical region of the right upper lobe. Ultrasound guided thoracocentesis anteriorly yield 400 mL of clear straw color fluid which was transudative by Light's criteria. Post tapping chest X-ray shown complete resolution of right upper lobe consolidation and patient reports immediate relieve of dyspnea. Patient was started on regular effective haemodialysis and pleural effusion did not recur during follow up. Loculated pleural effusion masquerading as mediastinal tumour had been reported but pleural effusion that conformed to the contour of a lung lobe is rare. This case highlights the atypical but unique presentation of a transudative pleural effusion and demonstrates the risk of repeated thoracocentesis complicating a simple clinical presentation.
This study was undertaken to determine whether an infusion of local anesthetic (LA) delivered through an extrapleural tunnel could provide satisfactory control of pain in the postthoracotomy period. Twelve patients undergoing thoracotomy were studied. A T-shaped tunnel was created by elevating the parietal pleura at the posteromedial end of the thoracotomy wound. An irrigation catheter was then inserted and an infusion of bupivacaine commenced, initially at 5 mg/kg/24 h and subsequently at 3 mg/kg/24 h. Pain was well controlled in eight patients and satisfactory in four patients. The latter required one dose of opiate analgesia each in the 48-h postoperative period. We conclude that an infusion of bupivacaine into the extrapleural space is an effective means of control of pain after thoracotomy.