An uncommon cause of pleural effusions in a dialysis patient

A 42-year-old woman presented in October, 2011, describing dyspnoea, a non-productive cough, left-sided pleuritic chest discomfort, and 10 kg weight loss over 2 months. She had been receiving maintenance haemodialysis via a right brachiocephalic arteriovenous fi stula (fi gure) for 2 years having reached end-stage renal failure (ESRF) due to glomerulonephritis. She had smoked heavily for many years. Clinical examination showed cachexia with a body-mass index of 17 kg/m2, fl uctuating pyrexia, and persistent tachycardia of 120 bpm. Blood pressure was 124/78 mm Hg. Heart sounds were normal and no murmurs were audible. There was a large left pleural eff usion. Blood tests showed a low haemoglobin of 84 g/L, a white cell count of 8∙0×109/L, and a high C-reactive protein (CRP) concentration of 249 mg/L. Serum albumin was low at 18 g/L. Chest radi ography confi rmed a large left pleural eff usion. ECG showed sinus tachycardia, and echocardiography showed an undilated left ventricle with moderate systolic impairment, mild left atrial dilatation, and moderate mitral regurgitation (MR). The right heart was normal. Of note, a year earlier the left atrium and ventricle had been normal with mild MR on echocardiography. CT showed no evidence of thromboembolism or malignancy. The pleural eff usion was drained and found to be an exudate. Despite serially negative microbiology, the patient was treated with broad-spectrum antibiotics, for presumed infection, with little improvement. 3 weeks into her hospital stay, the left pleural eff usion re-accumulated with a new right eff usion. At 6 weeks there was a marked deterioration with the patient developing worsening tachycardia and MR alongside a gallop rhythm. Blood pressure was maintained. Echocardiography (see webvideo 1 and 2) now showed a dilated left ventricle with severe systolic dysfunction, moderate MR, and new pulmonary hypertension (pul monary arterial pressure about 48 mm Hg). We noted that the patient’s fi stula seemed large for her body size, with a