A 33-year-old paraplegic female patient presented with a massive pleural effusion a few years after two spinal surgeries. She was evaluated and found to have pleural effusion due to CSF leak into pleural cavity.

1.
Massi
ive trans
sudative
fistula -
pleural e
A case r
effusion d
report
due to CCSF

2. Case Report
Massive transudative pleural effusion due to CSF
fistula e A case report
V. Vinod Kumar
Consultant Pulmonologist, Apollo First Med Hospital, India
a r t i c l e i n f o
Article history:
Received 17 October 2013
Accepted 1 May 2014
Available online xxx
Keywords:
CSF
Massive
Pleural effusion
a b s t r a c t
A 33-year-old paraplegic female patient presented with a massive pleural effusion a few
years after two spinal surgeries. She was evaluated and found to have pleural effusion due
to CSF leak into pleural cavity.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Patients presenting with massive pleural effusions are a
common presentation in clinical practice. The usual causes of
such massive pleural effusions include malignancy, para-
pneumonic effusions and empyemas, occasionally tubercu-
losis and chylothorax. Most of the massive effusions are
exudative in nature.
Transudative effusions are seldom massive in nature. The
commonest causes of transudative effusions being congestive
cardiac failure and hepatic hydrothorax.
Here is presented an unusual patient presenting with a
massive transudative pleural effusion.
2. Case report
A 33-year-old female with paraplegia was referred with
breathlessness at rest and CXR suggestive of a massive right-
sided pleural effusion (Fig. 1).
In view of her severe dyspnoea, an ICD right was done and
a pleural fluid drained to relieve her breathlessness. The
appearance of pleural fluid was clear, non viscous, colourless
and odourless. Biochemical analysis of the same confirmed
the presence of a transudative pleural effusion.
This patient has a history of two surgeries for detethering
of cord e the first 4 years earlier for post arachnoiditis tethered
cord at D6 D7. Two years after the first surgery this patient
again developed progressive weakness of her lower limbs and
urinary incontinence and reedetethering of cord at D6 D7
level was done using a lateral extra cavitary approach. For one
month prior to her current admission this patient developed
progressively increasing breathlessness and was very dysp-
noic at the time of admission.
Though the patient became symptomatically better after
drainage of the pleural effusion, she continued to have
drainage of about 800 ml of pleural fluid daily.
An MRI dorsal spine was done which revealed post-
operative changes in the right side of D6 D7 vertebral bodies
and posterior elements and adjacent ribs. Focal CSF collection
was seen in the postoperative region communicating with the
E-mail address: drvinodkumar_v@yahoo.com.
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a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report,
Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001
http://dx.doi.org/10.1016/j.apme.2014.05.001
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. right lateral spinal canal CSF spaces at D6 vertebral level and
communicating with the pleural spaces at D7 level. Focal
altered signal intensity was also noted in the D6 D7 vertebra
levels suggestive of myelomalacic changes. Clumping of
cauda equinae and lumbosacral nerve roots was noted sug-
gestive of chronic arachnoiditis (Figs. 2 and 3).
Fig. 2 e MRI of the patient demonstrating the CSF fistula.
Fig. 3 e MRI of the patient demonstrating the CSF fistula.
Fig. 1 e Chest radiograph of the patient at presentation
showing large right-sided pleural effusion.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e32
Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report,
Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001

4. This patient was referred to our neurosurgery colleagues
for further management and subsequently a flap closure of
the duropleural fistula was done.
3. Discussion
The accumulation of cerebrospinal fluid in the pleural cavity is
a rare occurrence and usually follows migration of ven-
triculoperitoneal shunt to pleural cavity or following a ven-
triculopleural shunting.1
Traumatic CSF fistulas can develop following penetrating
injuries and fractures of the thoracic spine. Iatrogenic CSF
leaks into pleural cavity have been reported after spinal sur-
geries especially diskectomies using an anterolateral
approach.2
The diagnosis is suggested by the appearance of pleural
fluid, which is clear and colourless and has low protein like
the CSF.1
Detection of beta 2 transferrin, a protein found only
in CSF and perilymph, in the pleural fluid has been reported as
a useful test in detecting such CSF leaks.3
Due to lack of lab
facilities this test could not be done in our patient.
This case is presented here due to its rarity and several
unique features namely the onset of symptoms 2 years after
spinal surgery, a transudative effusion presenting as a
massive pleural effusion and diagnosis confirmed by MRI.
Conflicts of interest
The author has none to declare.
r e f e r e n c e s
1. Light RW. Pleural Diseases. 4th ed. Lippincott Williams and
Wilkins; 2001.
2. Monla hassan J. Duropleural fistula manifested as a large
pleural effusion. Chest. 1998;114:1786e1789.
3. Haft GF. Use of beta 2 transferrin to diagnose csf leakage
following spinal surgery. Iowa Orthop J. 2004;24:115e118.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 3
Please cite this article in press as: Vinod Kumar V, Massive transudative pleural effusion due to CSF fistula e A case report,
Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.001

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