Hepatic Hydrothorax in the Absence of Ascites: A Diagnostic Challenge

Hepatic hydrothorax is a rare complication of chronic liver disease. It usually occurs in patients with advanced liver disease, portal hypertension, and ascites. On a rare instance, it may be the index presentation of chronic liver disease. Hepatic hydrothorax occurs in approximately 5-6% of patients with cirrhosis. The exact mechanism has not been well defined, but it is frequently thought to be due to the direct passage of ascitic fluid from the peritoneal cavity through the diaphragmatic defects. Treatment involves salt and water restriction and diuretics. Therapeutic thoracocentesis is required in case of respiratory distress. In resistant cases, indwelling pleural catheter (IPC) like PleurX catheter system (Franklin Lakes, NJ: BD) is placed and patients manage their symptoms through intermittent drainage of the pleural fluid. Here we describe an unusual case of hepatic hydrothorax in a patient with rheumatoid arthritis and liver cirrhosis without any ascites, a scenario that has rarely been reported in the literature. The patient underwent thoracentesis thrice but in view of re-accumulating pleural effusion, a pig-tail catheter with underwater seal was inserted. She was then referred to a hepatology center for transjugular intrahepatic portosystemic shunt (TIPS) or liver transplant.