Diaphragmatic hernia: an unexpected cause of pseudopleural effusion

摘要

A previously well 38-year-old man presented to theemergency department with acute shortness of breathlasting 2 days. He denied chest pain, cough, or fever.There was no history of trauma. He did not have anymedical history of note and was not on any long-termmedications. On arrival, the vital signs were temperature 36.5uC (97.7uF), heart rate 130 beats/min,respiratory rate 30 breaths/min, blood pressure 135/80 mm Hg, and oxygen saturation of 85% on room air.He was in moderate respiratory distress. The jugularvenous pressure was raised, and there were bilateralcoarse lung crackles. Heart sounds appeared to belouder on the right. There was no pitting pedal edema.Laboratory investigations, including complete bloodcount, serum electrolytes, and cardiac enzymes, werenormal. The electrocardiogram was unremarkable.The pro–brain natriuretic peptide (pro-BNP) levelwas elevated at 2,256 ng/L. A chest radiograph showeda massive left pleural effusion causing tracheal deviation and mediastinal shift (Figure 1). An arterial bloodgas taken on high-flow oxygen showed a pH of 7.24,carbon dioxide partial pressure of 84 mm Hg, oxygenpartial pressure of 86 mm Hg, bicarbonate of35 mmol/L, and oxygen saturation of 94% consistentwith type 2 respiratory failure, for which the patientwas put on noninvasive ventilation. The initialdiagnosis based on the clinical findings and investigations was heart failure, and the patient receivedintravenous glyceryl trinitrate and diuretics.