Year: 2014
Type: article
Abstract: End-stage renal disease (ESRD) is a common condition in older adults and poses difficult management decisions for patients and clinicians.1 Renal replacement therapy in the form of dialysis is often considered, and complications from hemodialysis or peritoneal dialysis should be part of the decision-making process.2 Herein is presented a case of “sweet syndrome” in an individual undergoing continuous ambulatory peritoneal dialysis (CAPD). The subject was an 84-year-old woman with a history significant for pacemaker implantation for sick-sinus syndrome, diet-controlled diabetes mellitus, and CAPD for ESRD. She had been a member of a Program of All-inclusive Care for the Elderly (PACE) for 3 years and had been managing her CAPD independently since switching from hemodialysis in January 2013. She was cognitively intact and lived independently. She presented to the PACE clinic with 1 day of increasing dyspnea, nonproductive cough, and wheezing. She denied missing any recent CAPD exchanges. On examination, she was afebrile, with a heart rate of 84 beats per minute, a respiratory rate of 26 breaths per minute, oxygen saturation of 98% on 2 L of oxygen, and blood pressure of 161/61 mmHg. She had bilateral wheezing but no evidence of pulmonary edema on lung examination. Although she had gained 20 pounds, there were no peripheral signs of volume overload (no peripheral edema, hepatojugular reflux, or rales). An electrocardiogram was unchanged from baseline and demonstrated no new ST changes or tachydysrhythmia. Because patients can be seen daily in PACE, she was treated with nebulizers and azithromycin for presumed community-acquired pneumonia, and a follow-up telephone call was scheduled for the next day. Because her symptoms improved with the nebulizer, she was already on antibiotics, and she had close follow-up, no chest X-ray was obtained. She had no oxygen requirement when she left the clinic. Her wheezing and shortness of breath initially improved and then rapidly deteriorated 48 hours later during her CAPD. She presented to the emergency department with significant shortness of breath and wheezing, which required biphasic positive airway pressure support. She denied all retrosternal or pleuritic chest pain, palpitations, or calf pain. Her physical examination revealed rales and decreased breath sounds on the right and bilateral expiratory wheezes. Her laboratory test results were remarkable for a creatinine of 7.2 mg/dL (her baseline), blood glucose of 95 mg/dL, and white blood cell count of 12,300 cells/mL. Her electrocardiogram was unchanged, troponin I was 0.02 mg/dL, and chest X-ray demonstrated a 50%, right pleural effusion (Figure 1). She was admitted to the medical intensive care unit for respiratory support and started on moxifloxacin for a presumed infectious process. The diagnostic and therapeutic thoracentesis produced 1.6 L of clear fluid, white blood cells of 35/mL, red blood cells 45/mL, total protein of 0.3 g/dL, lactate dehydrogenase of 20 U/L, and glucose of 302 mg/dL, consistent with a transudate. Pleural fluid glucose was significantly greater than blood glucose, which is consistent with dialysate fluid.3 Her respiratory status improved after the thoracentesis, and she was discharged on hospital day 3. Her CAPD was discontinued, and she was started on hemodialysis. As an outpatient, she will remain on hemodialysis until imaging and treatment of a possible pleuroperitoneal communication is complete. A “sweet” hydrothorax is the result of pleuroperitoneal communications in an individual undergoing CAPD. This is a rare cause of a pleural effusion, and it is has been infrequently reported.4, 5 The dialysate migrates into the pleural space and can cause life-threatening respiratory distress from the resulting effusion. A review of one case series found the incidence of “sweet” hydrothoraxes to be 1.9% of individuals undergoing CAPD.6 The diagnosis is confirmed through analysis of the pleural fluid, which will have a glucose measurement significantly greater than the blood glucose. A difference of more than 50 mg/dL was found to be 100% specific and sensitive for identifying a “sweet” hydrothorax.3 Acute treatment is thoracentesis and conversion to hemodialysis. For individuals who wish to return to CAPD, pleuroperitoneal communication can sometimes be visualized using technetium-99 m peritoneal scintigraphy or video-assisted thoracic surgery, and the opening can be closed using pleurodesis.3, 7, 8 In one series, talc pleurodesis was successful in six of seven individuals.7 Some older adults with ESRD choose CAPD for long-term management because it allows greater personal autonomy. Acute presentation with respiratory symptoms in these individuals should prompt clinicians to consider sweet syndrome (effusion due to pleuroperitoneal communications) as a possible etiology. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: conception, writing, and editing letter. Sponsor's Role: There was no sponsorship of this work.
DOI: 10.1111/jgs.12663
Institution: Johns Hopkins University
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1994246641