Abstract

A 74-year-old with burnt out autoimmune hepatitis, portal hypertension with thrombocytopenia, oesophageal varices and previous hepatic encephalopathy has presented with a recurrence of a left sided pleural effusion. She was very breathless at rest and therapeutic aspiration of 1.1 litres of straw coloured fluid has good symptomatic benefit. However, this is her sixth presentation in as many months and on top of four previous therapeutic aspirations, she has had one 12 French Seldinger drain inserted for fluid removal accompanied by an attempt at medical pleurodesis using 4 g of talc. She is very frail and has a low body mass index (18.6) and doses of diuretics beyond 80 mg of furosemide and 25 mg of spironolactone cause systemic hypotension with dizziness on standing and renal dysfunction. Even removing more than 1 L from her pleural space causes hemodynamic compromise and needs concomitant albumin replacement. The pleural fluid has always been a transudate with an average fluid protein of 9 g/l. The ascitic fluid is also a transudate with a fluid protein of 7 g/l. The patient thus has a Hepatic Hydrothorax (HH), which is a transudative pleural effusion which occurs in patients with liver cirrhosis in the absence of cardiac or pleural disease [1]. Repeated cytological examinations of both ascitic and pleural fluid have been negative. She has had a normal echocardiogram and has never smoked. She has had previous hypo-albuminaemia but this is now normal. A Magnetic Resonance (MR) scan of her liver has confirmed extensive cirrhosis, large amount of ascites and no hepatocellular carcinoma. This patient is well known to the gastroenterological services. She has had autoimmune hepatitis for many years now and has become very frail recently with development of ascites and significant weight loss. She has been admitted on a few occasions with worsening confusion and ammonia levels have been raised suggesting hepatic encephalopathy. No obvious cause was found for this and she was treated conservatively. She has also had repeated abdominal paracenteses to try control her ascites.

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