American Journal of Medical Case Reports, 2017, Vol. 5, No. 4, 104-106 Available online at http://pubs.sciepub.com/ajmcr/5/4/7 ©Science and Education Publishing DOI:10.12691/ajmcr-5-4-7 A Rare Presentation of Hepatic Hydrothorax in a Patient with Alcohol induced Liver Cirrhosis Ganesh Kasinathan 1,* , Naganathan Pillai 2 1 Department of Internal Medicine, Segamat Hospital, KM 6 Jalan Genuang, 85000 Segamat, Johor, Malaysia 2 Department of Internal Medicine, Monash University Malaysia, Bandar Sunway, Malaysia *Corresponding author: ganeshkasinathan11@hotmail.com Abstract Hepatic hydrothorax is defined as significant pleural effusion greater than 500 ml in a patient with liver cirrhosis without any underlying pulmonary, cardiac and pleural disease. This case report describes a 47 year old Indian gentleman who was diagnosed as alcohol induced liver cirrhosis, Child-Turcotte-Pugh score B, with gross ascites. He presented with recurrent right sided pleural effusion. Pleural fluid analysis revealed transudative pleural effusion. A diagnosis of hepatic hydrothorax was made after excluding other causes of pleural effusion. He did not respond to medical therapy and sodium restriction. His recurrent pleural effusion was treated with tube thoracostomy and chemical talc pleurodesis. He was referred to the tertiary hepatology unit for transjugular intrahepatic portosystemic shunt (TIPSS) and liver transplantation. Hepatic hydrothorax should always be suspected in a patient who presents with liver cirrhosis with portal hypertension and transudative pleural effusion. Keywords: hepatic hydrothorax, cirrhosis, thoracostomy, transplantation, portal hypertension Cite This Article: Ganesh Kasinathan, and Naganathan Pillai, “A Rare Presentation of Hepatic Hydrothorax in a Patient with Alcohol induced Liver Cirrhosis.” American Journal of Medical Case Reports, vol. 5, no. 4 (2017): 104-106. doi: 10.12691/ajmcr-5-4-7. 1. Introduction Hepatic hydrothorax is defined as transudative pleural effusion due to portal hypertension without any evidence of pulmonary, cardiac and pleural disease. The presence of portal hypertension but not end-stage liver disease is a requirement for the development of hepatic hydrothorax. [1] In most cases (85%) hepatic hydrothorax develops on the right side, with 13% of cases occurring on the left side and 2% bilateral. [2] Ascites is usually present. Hepatic hydrothorax accounts for 2–3% of all pleural effusions. [3] Patients with ascites are able to tolerate a much greater amount of fluid amounting to 5-10 liters due to the large capacity of the peritoneal cavity. Those with pleural effusion are frequently symptomatic with fluid as little as 1-2 liters. 2. Case Presentation A 47 year old Indian gentleman presented with worsening dyspnoea for the past 2 weeks associated with pleuritic chest pain. He denied any fever. No history of recent chest trauma or travel. His significant medical history includes alcohol induced liver cirrhosis with gross ascites and recurrent pleural effusion. His previous pleural effusion was treated with needle thoracocentesis. He was compliant to his diuretics and other medications. He works as a labourer with the local council. He has a long history of consumption of illicit liquor with high alcohol content. He is also a chronic smoker with no significant family history. On examination, he was alert and well orientated in space and time. He had obvious abdominal distension with fluid thrill. Stigmata of chronic liver disease were present including bilateral palmar erythema, jaundice and gynaecomastia. His respiratory examination revealed reduced chest wall expansion, stony dullness and absent breath sounds over the entire right lung. There was bilateral pitting edema till the knees. The other examination systems were unremarkable. His blood pressure was 120/60 with a heart rate of 88 beats per minute. His Child-Turcotte-Pugh score was B. An urgent chest radiograph (Figure 1) showed massive right pleural effusion. He was anaemic with a haemoglobin of 8.4 g/dL. The other blood parameters are as shown in Table 1. The ultrasound of the abdomen showed an enlarged liver with coarse echotexture, splenomegaly and gross ascites.Abdominal paracentesis and thoracocentesis were performed which revealed transudative ascites and pleural effusion. The pleural fluid analysis is as shown in Table 2 which was similar in composition to his ascites. A CECT of the thorax showed right pleural effusion with no obvious lung or pleural mass. A 2D- transthoracic echocardiogram depicted a left ventricular ejection fraction of 65% with normal chamber sizes. His medications were further optimized and he was placed on a strict sodium restriction diet. He was on oral furosemide, spironolactone, propranolol, omeprazole and folate. A chemical talc plurodesis was performed via tube thoracostomy in the ward. He was referred to the tertiary