Yellow Nails, Lymphedema and Pleural Effusion: DISCUSSION
Pleural effusions in the yellow nail syndrome are thought to be secondary to dysfunction of pleural lymphatics. Once present, they tend to persist and may recur rapidly after therapeutic thoracentesis, making this an impractical option in many symptomatic patients. Chemical pleurodesis using quinacrine (Atabrine) and tetracycline has been successful in two patients. Nine patients have been treated successfully with open pleural abrasion, pleurectomy or decortication. Unfortunately, chemical pleurodesis causes pain and discomfort and has an appreciable failure rate, and open pleural abrasion and pleurectomy, while very effective, are major surgical procedures associated with a perioperative morbidity of up to 10 percent.
The pleuroperitoneal shunt is a modification of the Denver peritoneovenous shunt and may be inserted under local or general anesthesia in a procedure taking approximately 30 min. After insertion, the patient is required to compress the pumping chamber, which rests on the chest wall, for approximately 5 min four times per day, a frequency which results in fluid transfer of up to 1 L/24 h.
Pleuroperitoneal shunting is an effective mode of palliation of symptoms in patients with malignant pleural effusion. Little et al reported 17 patients with malignant effusion treated with pleuroperitoneal shunting. Twelve achieved effective palliation, with subjective relief of dyspnea in all, and decrease in the volume of pleural effusion on chest x-ray by greater than 50 percent in eight. Only one shunt became obstructed. The five patients who did not achieve palliation were either moribund or unable to compress the pumping chamber effectively. Cimochowski et al reported successful palliative use of pleuroperitoneal shunting in five patients with malignant effusion. The use of the pleuroperitoneal shunt in benign effusion in adults has been described in only two instances: an effusion secondary to mediastinal fibrosis and an effusion associated with amyloidosis. The temporary (less than three months) use of the pleuroperitoneal shunt also has been reported in the management of chylothorax in infants.
Our patient represents the first report of the use of the pleuroperitoneal shunt in the treatment of pleural effusion associated with the yellow nail syndrome. This procedure avoids the need for lengthy hospitalization and is associated with lower morbidity than chemical pleurodesis or open pleural procedures. It may also ameliorate the negative nitrogen balance which may result from repeated large volume thoracentesis in chronically ill patients. Pleuroperitoneal shunting should be considered as an option in the management of any symptomatic patient with chronic pleural effusion, benign or malignant.