Diagnosis of a pleural hernia using ultrasounds

Introduction: The assessment and study of the diaphragm is rarely done with ultrasound, and it is usually used other imaging techniques as Computed Tomography (CT). The image is an hyperechoic structure over abdominal viscera without any rupture.

The pleural hernia is an uncommon pathology. Usually related with trauma and studied with CT.

Clinical case: 73 years old patient sent to the Emergency Department (ED) by the cardiologist because of the presence of a pleural effusion which has been increasing over the last 4 months. The patient has dyspnea without progression from diagnosis of the pleural effussion (NYHA grade I) without other symptoms.

Additionally, mass relates in the upper abdomen and left side, soft, not painfully, pulsatile or unrelated to previous disease.

During the study in the ED is performed blood tests and electrocardiogram wich are normal. The X-ray shows a left pleural effusion. Thoracentesis is performed by ultrasound-guided technique. During the technique is seen as the pleural effusion is penetrating in the lateral abdominal mass presented in the lateral region. In addition, ultrasound shows the disruption of the diaphragm. The injury is confirmed by CT study where rib fracture is seen in the area.

After a deep anamnesis, the patient recalls a respiratory infection with important cough component some months before.

Comments: In this case, the X-ray was not sufficient for the evaluation of the process, and the diagnosis was better guided when the ultrasound was used.

This case shows the importance of ultrasound for evaluation before the puncture of any effusion to display elements that contraindicate or help during the technique or for the diagnosis.

For pleural hernia, CT is choice modality for diagnosis, but ultrasound helps in patient management.