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PEDIATRIC RADIOLOGY Table of Contents   
Year : 2007  |  Volume : 17  |  Issue : 2  |  Page : 71-73
Spontaneous neonatal pleural effusion


1 Department of Radiodiagnosis and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110 029, India
2 Incharge Neonatal Division, Department of Paediatric Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110 029, India
3 Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110 029, India

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Keywords: Neonatal respiratory distress, spontaneous neonatal pleural effusion

How to cite this article:
Grover SB, Gupta P, Chellani H, Bharti LK, Vinayak R. Spontaneous neonatal pleural effusion. Indian J Radiol Imaging 2007;17:71-3

How to cite this URL:
Grover SB, Gupta P, Chellani H, Bharti LK, Vinayak R. Spontaneous neonatal pleural effusion. Indian J Radiol Imaging [serial online] 2007 [cited 2020 Aug 15];17:71-3. Available from: http://www.ijri.org/text.asp?2007/17/2/71/33612
Respiratory distress is a leading cause of neonatal mortality worldwide and has various causes; the usual ones being those warranting medical treatment, such as hyaline membrane disease, transient tachypnea of new born and neonatal pneumonia and those warranting urgent surgical intervention, such as congenital diaphragmatic hernia and congenital cystic adenomatoid malformation. Pleural effusion is rare. [1],[2],[3] A Medline search revealed approximately 55 cases documented in the indexed literature with frequent mortality. [2],[3],[4],[5],[6],[7] Early recognition of neonatal pleural effusion is crucial not only for lowering mortality and morbidity known to be associated with this entity, but also because, it has an excellent prognosis following timely diagnosis and treatment. [1],[2],[3] Radiological diagnosis is critical in differentiating various etiologies of respiratory distress. We report a case of neonatal hydrothorax, which was diagnosed as "spontaneous" after exclusion of all possible etiologies. Furthermore, our infant recovered due to timely diagnosis and management.


   Case Report Top


A baby girl weighing 2225 grams was delivered vaginally in breech presentation to an unbooked, immunized, full-term, primigravid mother, 22 years of age, presenting in labor with footling presentation. The baby had an Apgar score of 6, 8 and 8 at 1, 3 and 5 minutes, respectively. The heart rate was 166 beats per minute and the respiratory rate was 76 breaths per min. There were signs of severe respiratory distress with subcostal and intercostal retraction and the breath sounds were poorly audible in the left hemithorax. Arterial blood gas analysis revealed respiratory acidosis. The baby was administered 100% oxygen via nasal hood and 10% intra venous dextrose as a maintenance drip.

A bedside chest radiograph obtained within one hour of birth, revealed a left-sided hydrothorax [Figure - 1]. An attempt at intercostal needle drainage was unsuccessful. A repeat radiograph obtained immediately after needle drainage showed a hyperlucent left hemithorax with contralateral mediastinal shift, along with masking of the pleural fluid [Figure - 2]. A diagnosis of left-sided hydropneumothorax was made and reconfirmed by ultrasound (USG). The USG showed clear fluid without septae or loculi, in the left lung base. A size 22 Fr intercostal tube drained clear fluid. Following pleural fluid drainage, gradual clinical improvement occurred around the sixth hour of life. At this stage, a plain CT scan was performed (at six hours of life) to exclude mediastinal and thoracic duct abnormalities, which were found to be absent [Figure - 3]. The baby passed urine at eight hours of life and meconium at 12 hours. A total of 50 ml of clear fluid was drained from the left pleural cavity over the next six days, during which period the infant was maintained only on intravenous fluids.

The pleural aspirate was found to be a transudate, with proteins < 2.4 g and normal sugars, triglycerides, cholesterol, lactate dehydrogenase and culture. The VDRL was negative and karyotype was normal. A diagnosis of "spontaneous unilateral neonatal pleural effusion with iatrogenic conversion into hydropneumothorax" was made.

On day seven of life, the chest radiograph showed significant resolution of the hydropneumothorax and the intercostal drainage tube was removed [Figure - 4]. The following period was uneventful with gradual recovery. The baby was finally discharged on day 12, with a weight of 2.25 kilograms and the mother was advised breast- feeding. Follow-up of the case at one month of age revealed a healthy infant with a normal growth pattern, accepting feeds actively.


   Discussion Top


Spontaneous or idiopathic neonatal pleural effusion is defined as any effusion in a newborn of age less than thirty days, without any obvious explanation. [2] Intrapartum and postpartum causes of neonatal pleural effusion could be either a continuum of the antenatal causes or may occur due to congenital malformations of the peripheral lymphatics or thoracic duct trauma. It may also follow infections, surgical interventions or may be due to chromosomal or systemic disorders. [1],[2],[3],[4],[5],[6],[7]

The leading clinical presentation of spontaneous pleural effusion in the newborn is respiratory distress ranging from mild to severe asphyxia, presenting in the first day of life in 50% cases and within the first one week in the remainder. [1] Spontaneous neonatal pleural effusion due to intra or postpartum causes is frequently chylous in nature. Simple effusions are known to turn chylous after establishment of external fat feeds. [1],[2],[3] However, in our baby, external feeds had not been initiated and the effusion was non-chylous.

A chest radiograph is the modality of choice for screening cases of neonatal respiratory distress. If the radiograph reveals a pleural effusion, USG confirmation and grading should be done, in order to decide the management options. A low-grade effusion has clear non-echogenic fluid, without septae or loculi. A high-grade effusion is one with fronds or septae or loculi or thickened pleural surfaces or evidence of organization. [8] CT scan has a supplementary role in differentiating neonatal pleural effusion from other conditions, which may present radiographically as a lucent / and or opaque hemithorax with contralateral mediastinal shift. In our patient once a radiological diagnosis of pleural effusion was made, USG confirmed and classified it as low-grade and guided therapeutic drainage. CT scan excluded mediastinal and thoracic duct abnormalities. In our patient, there was iatrogenic conversion of pleural effusion to a hydropneumothorax.

Hydropneumothorax in newborn is mostly due to rupture of staphylococcal pneumatoceles, congenital bullae or cysts or due to surgical interventions. In the neonate, a mild pleural effusion is mostly self-limiting. A low-grade effusion causing respiratory distress needs pleural drainage, as was undertaken in our patient. A high-grade effusion mandates surgical intervention. In chylothoraces, maintenance of fat nutrition and vigilant surveillance of lymphocyte count is integral to prevent secondary sepsis. Recently some investigators have advocated the use of intravenous octreotide infusion to control chylothorax. [1],[2],[6],[7]

Neonatal respiratory distress remains one of the leading emergencies in neonatal units. Although spontaneous neonatal pleural effusion remains a rare cause, the awareness of this entity is vital for timely diagnosis and management and can be life saving. The role of imaging modalities in aiding rapid diagnosis and guiding therapeutic intervention and monitoring resolution has also been illustrated in our report and should be kept in mind while managing similar clinical situations.

 
   References Top

1.Wadhwa S, Verma M, Kaur J. Pleural effusion in neonatal period: A case report. Indian Pediatr 1976;13:729-31.  Back to cited text no. 1  [PUBMED]  
2.Depp DA, Atherton SO, McGough EC. Spontaneous neonatal pleural effusion. J Pediatr Surg 1974;9:809-12.  Back to cited text no. 2  [PUBMED]  
3.Rao SS, Karan S. Neonatal pleural effusion due to chylothorax. Indian J Pediatr 1982;49:149-50.  Back to cited text no. 3    
4.Martinez Tallo E, Hernandez Rastrollo R, Agulla Rodino E, Sanjuan Rodriguez S, Campello Escudero E. Neonatal chylothorax and conservative treatment. An Esp Pediatr 2002;56:448-51.  Back to cited text no. 4    
5.Hwang JY, Yoo JH, Suh JS, Rhee CS. Isolated nonchylous pleural effusion in two neonates. J Korean Med Sci 2003;18:603-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Sivasli E, Dogru D, Aslan AT, Yurdakok M, Tekinalp G. Spontaneous neonatal chylothorax treated with octreotide in Turkey: A case report. J Perinatol 2004;24:261-2.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Lauterbach R, Sczaniecka B, Koziol J, Knapczyk M. Somatostatin treatment of spontaneous chylothorax in an extremely low birth infant. Eur J Pediatr 2005;164:195-6.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Ramnath RR, Hellar RM, Ben-Ami T, Miller MA, Campbell P, Neblett WW 3 rd , et al . Implications of Early Sonographic Evaluation of parapneumonic effusions in children with pneumonia. Pediatrics 1998;101:68-71.  Back to cited text no. 8    

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Correspondence Address:
Shabnam Bhandari Grover
E-81, Kalkaji New Delhi -110 019
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.33612

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

This article has been cited by
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