A 51-year-old male presented with increasing dyspnoea, pleuritic chest pain and pain in the right shoulder tip. Clinical examination revealed stony dull percussion and absent breath sounds on the right mid and lower zones of the chest. He had no clinical evidence of heart failure or systemic volume overload, the main differential diagnoses in this case. His background history was significant for end stage renal disease due to focal segmental glomerulosclerosis with failed renal allograft. A Tenchkoff catheter had recently been sited and he had commenced peritoneal dialysis. Chest radiograph showed evidence of a large right pleural effusion (figure 1). A peritoneal dialysis drainage bag was immediately attached which drained 1.5 litres with immediate symptomatic relief, followed by further intermittent drainages. Peritoneal dialysis was immediately discontinued and the patient was transitioned to haemodialysis. Follow-up chest radiograph showed resolution of the pleural effusion (figure 2). There was no evidence of a localised pleural process.
Dialysate leakage occurs in approximately 5% of chronic ambulatory peritoneal dialysis (CAPD) patients, is more commonly right sided and occurs due to the presence of a diaphragmatic hernia. Pleural aspiration will reveal a high glucose content in the fluid, due to the presence of dialysate. Peritoneal scintigraphy can be used for diagnosis.1 Treatment options include pleural sclerotherapy (talc or tetracycline) or discontinuation of CAPD. A minority of patients may require thoracotomy.2 This is an uncommon cause of a pleural effusion and we suggest vigilance in the peritoneal dialysis population.