Tension Hydrothorax from Pleuroperitoneal Leak in Peritoneal Dialysis

Introduction: The reported prevalence of pleuroperitoneal leak (PPL) with continuous cycling peritoneal dialysis (CCPD) is only 2%, but the true frequency may be higher as PPL can be asymptomatic. Undiagnosed PPL may rarely produce devastating results. Case Description: A 62-year-old man with muscular dystrophy, diabetes, and ESKD on CCPD for 4 years presents with 2 weeks of dyspnea, dizziness, and anasarca. Chest CT shows large right > left pleural effusions without diaphragmatic defect. CCPD is continued, but symptoms worsen. Thoracentesis yields 1.6 L of transudative fluid with pleural glucose 131 mg/dL vs. serum 107 mg/dL. Though volume overload is felt more likely than PPL, he is trialed on intermittent hemodialysis (IHD), but severe intradialytic hypotension despite midodrine and IV albumin precludes ultrafiltration. After 2 weeks, repeat CT shows recurrent large effusions. PD is reattempted but is stopped within minutes due to respiratory distress, cyanosis, and rapidly worsening shock requiring ICU transfer. Chest x-ray shows large left > right effusions with worsening tracheal shift. A left thoracostomy tube drains 1 L with immediate improvement in hypotension. He stabilizes and is weaned off noninvasive ventilation, vasopressors, and CRRT over 4 days. IHD is restarted but again is poorly tolerated. He ultimately chose comfort care. Discussion: Diagnosis of PPL may be challenging. Pleural fluid analysis classically shows a transudate with high glucose relative to serum. Peritoneal scintigraphy, if available, can be diagnostic. Atypical features in this case include delayed onset, CCPD use, bilateral effusions, and rather low pleural glucose. Leak of hypertonic dialysate may acutely worsen respiratory status, but tension hydrothorax—suspected in this case given the immediate improvement in shock with drainage—has not been reported before. PPL treatment ranges from temporary IHD—with return to PD possible in roughly 50% after 2 months—to invasive options (e.g., pleurodesis, VATS, or thoracotomy).Serial X-ray, obtained (A) hours before restarting PD, (B) immediately after restarting, and (C) after chest tube placement.