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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 10-12

Delayed diaphragmatic rupture an unusual differential diagnosis for a pleural effusion


1 Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of General Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication27-Apr-2018

Correspondence Address:
Ramya Iyyadurai
Department of Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_2_18

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  Abstract 

Delayed diaphragmatic rupture is usually seen after blunt trauma. The diagnosis is often missed since the symptoms are often nonspecific.The radiograph findings are also nonspecific, and high index of suspicion is necessary for diagnosis. We report a patient who presented to us 7 years after blunt trauma with delayed diaphragmatic rupture and was successfully diagnosed and treated surgically.

Keywords: Delayed, diaphragmatic rupture, pleural effusion


How to cite this article:
Iyyadurai R, Satyendra S, Chandran S. Delayed diaphragmatic rupture an unusual differential diagnosis for a pleural effusion. Curr Med Issues 2018;16:10-2

How to cite this URL:
Iyyadurai R, Satyendra S, Chandran S. Delayed diaphragmatic rupture an unusual differential diagnosis for a pleural effusion. Curr Med Issues [serial online] 2018 [cited 2018 May 25];16:10-2. Available from: http://www.cmijournal.org/text.asp?2018/16/1/10/231368


  Introduction Top


Delayed diaphragmatic rupture is seen following blunt injury to the abdomen. It presents a unique diagnostic dilemma to the treating physician because traumatic diaphragmatic rupture is often missed at initial presentation.[1] We present an individual who was asymptomatic for a prolonged period after blunt trauma and who presented with clinical features suggestive of a pleural effusion. The diagnosis was made with a CT scan and successfully treated by surgical repair.


  Case Report Top


A 24-year-old male under treatment for depression was referred from the Department of Psychiatry with a history of cough, right-sided pleuritic chest pain, and breathlessness for 1 month. The patient had a significant history of fall from the first floor of a building 3 years ago and had sustained right-sided rib fractures and fractures of the superior and inferior pubic rami. The injuries had been treated conservatively, and he had been well subsequently. Clinical evaluation revealed findings suggestive of a right pleural effusion. A chest radiograph and lateral chest radiograph were done [Figure 1] and [Figure 2]. A careful examination of the films showed that the opacity was not homogeneous this was clearer in the lateral view which revealed the presence of air bubbles within the opacity. A computed tomogram of the chest was done for further characterization of the opacity which showed diaphragmatic rupture with herniation of abdominal contents including the large and small intestine, the right lobe of the liver and the gallbladder into the right hemithorax [Figure 3].
Figure 1: Chest radiograph posteroanterior view showing homogeneous opacity in the right lower zone suggestive of a pleural effusion.

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Figure 2: Chest radiograph lateral view showing elevated right dome of diaphragm and air bubbles within the opacity.

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Figure 3: Computed tomogram showing herniation of abdominal contents right lobe of liver, gallbladder, small and large intestine.

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  Discussion Top


Latent diaphragmatic rupture is a diagnostic challenge. The diagnosis can be delayed by months or even years. The incidence of diaphragmatic rupture and diaphragmatic hernia is more common in males (male:female 4:1), in the third decade of life and is often associated with blunt trauma (25% of patients with abdominal and chest trauma). The protective effect of the liver increased the strength of the right hemidiaphragm and underdiagnosis are proposed to be the causes of rarity of right-sided diaphragmatic rupture.[2] The diagnosis is often missed in the acute stage due to overwhelming concurrent injuries. The most common clinical presentation of delayed diaphragmatic rupture is asymptomatic. A high index of suspicion is required for diagnosis. Chest X-ray has low sensitivity for detection of delayed diaphragmatic rupture (DDR) but repeating the chest X-ray is associated with increased sensitivity.[3],[4] Pathognomonic chest X-ray findings include gas bubbles in the chest and nasogastric tube in the chest. More often only an elevated hemidiaphragm or blunting of the costophrenic angle is seen as in our patient [Figure 4]. Other findings on the chest X-ray include an irregular diaphragmatic outline, compression atelectasis of the lower lobe, elevated diaphragm, and mediastinal shift without pulmonary or intrapleural cause. Computed tomography (CT) is a useful diagnostic tool.[2] The sensitivity of the CT scan is variable in the diagnosis of DDR between 14% and 82%, and specificity of CT scan is very high 86%–100%.[5] Management is by surgical repair. The patient was transferred to surgery after surgical repair is doing well.
Figure 4: Postoperative chest radiograph posteroanterior view showing minimal blunting of the right costophrenic angle.

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
De Blasio R, Maione P, Avallone U, Rossi M, Pigna F, Napolitano C, et al. Late posttraumatic diaphragmatic hernia. A clinical case report. Minerva Chir 1994;49:481-7.  Back to cited text no. 1
    
2.
Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444-9.  Back to cited text no. 2
    
3.
Scharff JR, Naunheim KS. Traumatic diaphragmatic injuries. Thorac Surg Clin 2007;17:81-5.  Back to cited text no. 3
    
4.
Goh BK, Wong AS, Tay KH, Hoe MN. Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma. CJEM 2004;6:277-80.  Back to cited text no. 4
    
5.
Ganie FA, Lone H, Lone GN, Wani ML, Ganie SA, Wani NU, et al. Delayed presentation of traumatic diaphragmatic hernia: A diagnosis of suspicion with increased morbidity and mortality. Trauma Mon 2013;18:12-6.  Back to cited text no. 5
    


    Figures

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



 

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