PEDIATRICS Vol. 112 No. 6 December 2003, pp. e487-e490
Diaphragmatic Hernia Simulating a Left Pleural Effusion
Jamie L. Wooldridge, MD*,
David A. Partrick, MD
,
Denis D. Bensard, MD and
Robin R. Deterding, MD*
* Departments of Pediatrics
Surgery, Children’s Hospital, Denver, Colorado
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ABSTRACT
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We review a case of a diaphragmatic hernia simulating on chest
radiograph left lower lobe pneumonia and associated pleural
effusion. We also characterize the atypical chest radiographic
findings of this patient and recommend further imaging with
computed tomography in unusual patient presentations.
Key Words: Bochdalek hernia • pneumonia • parapneumonic effusion • empyema • thoracentesis
Congenital diaphragmatic hernias occur rarely with an estimated incidence of 1:3600 live births. Most of these patients present in infancy, but 5% to 25% are discovered from 1 month of life up to adulthood.1 These late-presenting patients often complain of a wide variety of symptoms, and diagnosis can be difficult. Acquired diaphragmatic hernias can also occur in children, usually after a trauma. We discuss a patient with chest radiographic findings consistent with left lower lobe pneumonia and associated pleural effusion that subsequently proved to be a diaphragmatic hernia.
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CASE REPORT
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A previously healthy, well-nourished, 11-year-old male presented
to our emergency department with complaints of intermittent,
sharp, left upper quadrant pain, constipation, malaise, headache,
and 1 episode of vomiting. On review of symptoms, he had a 1-
to 2-day history of a slightly productive cough without fever.
His medical history was noncontributory. He had recently vacationed
in Mexico but otherwise had no known exposures and no recent
trauma. Vital signs were normal, with oxygen saturations of
93% on room air. On physical examination, his abdomen was soft
and nontender with normal bowel sounds. He had absent breath
sounds in the left lower lobe. Electrolytes, amylase, lipase,
lactate dehydrogenase, uric acid, hemoglobin, and hematocrit
were normal. The white blood cell count was 7100 with a differential
of 12% bands, 71% neutrophils, 12% lymphocytes, and 1% monocytes.
Abdominal films revealed a possible left lower lobe pneumonia
but were otherwise normal. A chest radiograph was consistent
with a left lower lobe consolidation and associated pleural
effusion (Fig
1). A left lateral decubitus chest film revealed
layering of a moderate amount of pleural fluid (Fig
1). Thoracentesis
was attempted in the emergency department, but no fluid was
drained. The patient was admitted for observation and started
on cefotaxime for presumed pneumonia with parapneumonic effusion.
He remained stable with continued intermittent complaints of
abdominal pain and no fever during the next 24 hours. Sputum
cultures showed heavy mixed upper respiratory flora. An acid-fast
bacteria stain on the sputum was negative, and a subsequent
mycobacteria culture was also negative.
Mycobacteria pneumoniae immunoglobulin M was nonreactive.
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Fig 1. Initial chest radiograph shows consolidation in left lower lobe on posterior-anterior film (A), upsloping layering density (arrow) on lateral film (B), and layering of mesenteric fat (arrow) simulating pleural effusion on left lateral decubitus film (C).
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Because the child’s symptoms persisted despite 24 hours
of antibiotics, an ultrasound of the chest was completed to
further evaluate the pleural space and guide needle placement
for thoracentesis. Ultrasound findings suggested unusual echogenic
material in the left pleural space. Because a clear pocket of
free-flowing fluid was not seen, and the pleural space appeared
unusual, a thoracentesis was not attempted. A chest computed
tomography was obtained to better understand the pleural space
and revealed posterior layering of mesenteric fat in the left
pleural space and intestine within the fat. No fluid or pneumonia
was seen (Fig
2). The patient was taken to the operating room,
and a small Bochdalek hernia defect was found containing omentum
and a portion of the splenic flexure of the colon. After reduction
of the hernia contents, the posterolateral defect was primarily
closed laparoscopically (Fig
3). The patient did well postoperatively
with resolution of his symptoms and was discharged from the
hospital the next day.
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Fig 2. Chest computed tomography shows layering of mesenteric fat (arrow) in pleural space (A), which has the same optic density as chest wall fat, and loops of intestine within mesenteric fat (arrow) in pleural space (B).
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DISCUSSION
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Patients who present with late diaphragmatic hernias may have
diverse complaints including acute gastrointestinal symptoms
such as recurrent abdominal pain, vomiting, anorexia, and constipation;
pulmonary symptoms including cough, dyspnea, and respiratory
distress; or nonspecific complaints such as failure to thrive
and fever. Plain chest films often show the presence of bowel
in the thorax, leading to the diagnosis. However, plain films
have been misinterpreted as pneumatoceles, tension pneumothorax,
congenital lung cysts, and gastric volvulus.
1 If the bowel is
incarcerated and necrotic, reactive pleural effusion has been
reported in a few children.
2,3 All of these children had symptoms
consistent with necrotic bowel including vomiting, fever, and
severe abdominal pain. In comparison, our patient had minimal
symptoms and no surgical evidence of necrotic bowel.
Haines and Collins4 reported an asymptomatic adult diagnosed with a diaphragmatic hernia after a chest radiograph was interpreted as showing a left pleural effusion that layered in the left lateral decubitus position. At thoracotomy, a large mass of omentum was seen without pleural fluid. Our pediatric patient is very similar to this adult patient. Retrospectively, both cases demonstrated scalloping on the superior surface of the layered pleural density, which is uncharacteristic of free-flowing fluid. Furthermore, our patient’s lateral plain film showed a density layering in an upsloping direction parallel with the diaphragm instead of the characteristic downsloping direction of fluid under the effects of gravity (Fig 1 B). The recognition of these 2 subtle radiographic findings, although not diagnostic for a diaphragmatic hernia, and the mild clinical symptoms of the patient may have led to earlier further radiographic workup, diagnosis of the hernia, and avoidance of a potentially dangerous thoracentesis.
Observing the thoracic position of a nasogastric tube on a plain chest film has been a common maneuver to diagnose diaphragmatic hernias. This maneuver would not have provided the diagnosis in our patient, because he did not have herniation of the stomach and therefore would have had a normal nasogastric tube placement. Instead, ultrasonography of the chest was used to further characterize the pleural space in our patient and provided important clues. Siegel et al5 showed that ultrasonography was useful in establishing the nature of fluid in the pleural space and may show the presence of an air-containing mass in the thorax. In our patient, the definitive diagnosis of diaphragmatic hernia was made based on computed tomography of the chest. Wilbur et al6 encouraged computed tomography of the chest in adults for direct visualization of the focal defect and definitive diagnosis of either a hernia or other chest masses. Another diagnostic imaging choice available is to give the patient oral contrast and then do an abdominal plain film 24 hours later, looking for contrast in the intestines above the diaphragm. The study would have worked well in our patient, because he was not seriously ill or in severe pain. If, however, the patient had necrotic bowel present in the hernia, causing high fever, vomiting, and severe abdominal pain, waiting 24 hours for the follow-up film would not have been possible. In children with pleural effusions and clinical symptoms atypical for pneumonia, we recommend careful observation of the effusion on the lateral chest radiograph and further imaging with ultrasound or computed tomography in unusual patient presentations before instrumentation of the thorax.
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ACKNOWLEDGMENTS
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We thank John Strain, MD, for help with the radiographic interpretation
of the plain films and CT scans.
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FOOTNOTES
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Received for publication Apr 18, 2003; Accepted Jul 14, 2003.
Reprint requests to (J.L.W.) Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: jamie.wooldridge{at}cchmc.org
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REFERENCES
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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ABSTRACT
CASE REPORT
