Massive pleural effusion post-emergency cesarean in undiagnosed congenital diaphragmatic hernia

Abstract

Introduction: Bochdalek’s hernia is a congenital diaphragmatic hernia (CDH) resulting from inadequate closure of the membrane over the left side of the hemidiaphragm. Patients will start to develop symptoms upon displacement of abdominal contents into the thoracic cavity. This case report highlights the radiological modality findings that can be used in diagnosing a late-presentation CDH in adults. Case Report: A 35-year-old postpartum woman developed shortness of breath, left-sided chest pain, episodes of vomiting and epigastric tenderness within 24 hours post-emergency cesarean section. An initial diagnosis of left tension hydrothorax was made based on the clinical and radiological findings. Left diagnostic and therapeutic thoracocentesis using landmark technique was performed and brownish fluid was obtained upon aspiration. Post-procedural chest X-ray (CXR) reported cystic-like features over the left hemithorax. Therefore, computed tomography (CT) thorax was proceeded and confirmed the left diaphragmatic hernia with a mediastinal shift to the right. However, the patient’s condition worsened and required emergency open thoracotomy with left diaphragmatic hernia repair. Intraoperative findings showed left Bochdalek’s hernia complicated by multiple visceral organ perforations secondary to previous thoracocentesis. The patient was discharged well after a few weeks of hospital stays. Conclusion: The diagnosis of late-presentation Bochdalek’s diaphragmatic hernia remained challenging and can be easily missed. Therefore, a comprehensive evaluation is required prior to performing an invasive diagnostic procedure. Chest X-ray and ultrasound are useful diagnostic aid in the absence of CT thorax and magnetic resonance imaging (MRI) modalities.