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The mysterious pleural effusion …

Inês Simão1, João Farela Neves1, Rute Neves2, Gabriela Pereira1, Eugenia Soares3, Paolo Casella4, Lurdes Ventura1

1Pediatric Intensive Care Unit – Department of Paediatrics
2 Nutritional and Respiratory Care Special Unit – Department of Paediatrics
3 Department of Radiology;
4 Department of Pediatric Surgery
Hospital de Dona Estefânia, Centro Hospitalar Lisboa Central, EPE, Lisbon, Portugal

- Artigo aceite para publicação no Annals of Pediatric Surgery

Central venous catheter placement for long term total parenteral nutrition is a well established practice. Considering the number of placed lines, serious complications are rare, but may be life threatening. We report the case of a 6 months-old infant on total parenteral nutrition since neonatal period, as a consequence of severe intestinal insufficiency secondary to extensive intestinal resection for necrotizing enterocolitis. The child was admitted to the intensive care unit with respiratory failure due to bilateral milky pleural effusion seventeen days after placement of a left internal saphenous line. Pleural effusion analysis was suggestive of chylothorax, with high triglyceride (722mg/dL) and low cholesterol (<20mg/dL). Persistence of pleural effusion, despite adequate treatment, drew attention to other diagnostic hypothesis. Considering that parenteral nutrition solution used is cholesterol-free and the child complained of pain when administered bolus through the catheter, the hypothesis of misplacement of the central venous catheter became more likely. Computed tomography scan after contrast administration through the catheter, revealed its presence in the epidural space and the ascending route reaching the pleural space. When parenteral nutrition was stopped the pleural effusion resolved. At the present time, with two years of follow up, the child does not have any complication of this event.
This is, to our knowledge, the first reported case of an infant developing bilateral pleural effusion secondary to misplacement of a left internal saphenous catheter.