Work

Hepatic hydrothorax in the absence of ascites with mixed bacterial and fungal infection: a case report

Year: 2025

Type: article

Abstract: BACKGROUND: Hepatic hydrothorax (HH) is a rare complication of cirrhosis, typically caused by the transdiaphragmatic migration of ascitic fluid. However, HH can also occur without ascites, complicating both diagnosis and treatment. Infections in HH, particularly with pathogens such as Enterococcus faecium and Candida parapsilosis, are uncommon but present significant clinical challenges. CASE PRESENTATION: We report a 49-year-old male with hepatitis B cirrhosis, presenting with isolated right-sided pleural effusion that was unresponsive to diuretic therapy. Thoracentesis confirmed HH without bacterial infection initially. However, secondary infection was identified when cultures revealed Pseudomonas luteola, Enterococcus faecium, and Candida parapsilosis. Despite in vitro sensitivity, voriconazole was ineffective against Candida parapsilosis, necessitating a switch to caspofungin, which successfully resolved the infection. DISCUSSION: This case highlights potential mechanisms for HH without ascites, such as increased pleural capillary permeability and impaired lymphatic drainage. The presence of Enterococcus faecium and Candida parapsilosis indicates an increased risk of opportunistic infections in cirrhotic patients, particularly those undergoing thoracentesis or pleural drainage. The failure of voriconazole, despite in vitro sensitivity, may be due to biofilm formation or poor pleural penetration, suggesting the need for antifungal agents like caspofungin. Management options for patients who do not respond to sodium restriction and diuretics include serial thoracentesis, transjugular intrahepatic portosystemic shunt (TIPS), pleurodesis, thoracoscopic surgery to repair diaphragmatic defects, and liver transplantation. CONCLUSION: This case underscores the diagnostic and therapeutic challenges of HH without ascites, emphasizing the need for individualized infection management and surgical interventions in refractory cases. Further research is needed to clarify the mechanisms of HH and improve treatment strategies.

Source: BMC Infectious Diseases

DOI: 10.1186/s12879-025-11715-7