Subpulmonic effusion.

摘要

A 50-year-old man with cirrhosis and hypothyroidism underwent routine posteroanterior chest radiograph as part of the work-up to qualify for liver transplantation. He had no pulmonary complaints. Three different experienced pulmonologists gave the same reading for the posteroanterior view: 'elevated righ the midiaphragm' (Fig. 1). The lateral and right lateral decubitus views, however, showed a significant right-sided pleural effusion (Fig. 2 and 3). For unclear reasons, pleural effusion can accumulate in a subpulmonic location rather than into the general pleural cavity. Without any clear explanation, transudates (e.g. congestive heart failure, cirrhosis, nephrotic syndrome) are more often associated with subpulmonic effusions. When unilateral, subpulmonic effusions are more commonly right sided. A subpulmonic effusion should besuspected whenever the right hemidiaphragm is slightly higher than usual, along with a more lateral presentation of the highest portion of the dome. The right hemidiaphragm'shighest portion of the dome is generally in the midclavicular line or even more medial to this. These chest radiographs illustrate the importance of always obtaining a lateral projection of the chest along with the frontal view, unless patient mobility is a problem. As this patient had considerably increased thyroid-stimulating hormone, his pleural effusion was attributed to a combination of hypothyroidism and hepatic hydrothorax. He underwent liver transplantation without complications.