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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Hydrothorax is a peritoneal dialysis complication&#44; associated with an increase in intra-abdominal pressure&#44;<span class="elsevierStyleSup">1</span>&#160;which on very rare occasions has been reported to be related with peritonitis episodes&#46;<span class="elsevierStyleSup">2&#44;3</span>&#160;We present the case of a patient who&#44; after having had other complications related with an increase in intra-abdominal pressure&#44; developed hydrothorax during the course of a peritonitis episode&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">She is a 76-year-old woman&#44; with stage 5 chronic kidney disease with interstitial nephropathy&#46; Over the past three years&#44; she has been receiving continuous ambulatory peritoneal dialysis&#44; with three daily 2&#44;000ml refills&#46; Over this period&#44; she has not suffered peritonitis nor has she undergone surgery&#46; In a routine check-up&#44; a small non-incarcerated umbilical hernia and an abdominal hernia were detected&#44; the latter measuring approximately 6cm in diameter in the left paramedian line and confirmed by CT scan and ultrasound&#46; The peritoneal dialysis was not affected by these anatomical alterations&#44; so after surgical evaluation a conservative stance was maintained&#44; modifying the dialysis rate to four daily 1&#44;500ml refills&#46; She returned to the hospital six months later with cloudy fluid&#44; fever and mild abdominal pain&#44; with a 5 hour evolution&#46; In the days before&#44; she had suffered mild diarrhoea&#46; The peritoneal effluent cell count was 4&#44;570cells&#47;ml &#40;98&#37; PMN&#41;&#46; Diagnosed with bacterial peritonitis in peritoneal dialysis&#44; she was admitted and put on intraperitoneal antibiotic therapy&#44; following our centre&#8217;s protocol&#58; vancomycin&#44; ampicillin and tobramycin&#46; On the following day&#44; the fluid was still cloudy and cell count was 9&#44;850cells&#47;ml &#40;94&#37; PMN&#41;&#59; the peritoneal dialysis balance showed a gain of 1&#44;200ml and the abdominal pain persisted&#46; Thirty-six hours after admittance&#44; she suffered sudden dyspnoea&#46; The patient presented a generally poor state&#58; she was pale&#44; sweaty&#44; tachypneic and had difficulty breathing&#46; Oxygen saturation was 90&#37;&#46; The respiratory auscultation displayed a reduced breath sounds in the right hemithorax&#46; The chest X-ray displays a moderate right pleural effusion &#40;Figure 1&#41;&#46; A short hypertonic refill is administered with no improvement&#46; Due to paroxysmal breathing difficulty and the X-ray results&#44; thoracocentesis was performed&#44; which drained 2&#44;000ml&#46; The pleural fluid was a glucose concentration of 269mg&#47;dl&#44; much higher than the plasmatic concentration &#40;110mg&#47;dl&#41;&#44; which confirmed hydrothorax&#46; Improvement was significant after the pleural tap&#46; The peritoneal dialysis was suspended and on receiving the peritoneal fluid culture&#44; positive for <span class="elsevierStyleItalic">Bacteroides</span><span class="elsevierStyleItalic">fragilis</span>&#44; intravenous antibiotic therapy was started with meropenem and metronidazole&#46; The abdominal CT scan ruled out perforation and other intra-abdominal pathologies&#46; After two weeks of treatment&#44; she was discharged and is currently on regular haemodialysis&#46;</p><p class="elsevierStylePara">Hydrothorax consists of peritoneal fluid passing to the pleural space through a peritoneal-pleural structural defect&#44; and can be either congenital or acquired&#46;<span class="elsevierStyleSup">1-3&#44;5-8</span>&#160;Its prevalence is hard to estimate and varies from 1&#46;6&#37; and 2&#46;9&#37; to 10&#37;&#44; according to studies&#46;<span class="elsevierStyleSup">3&#44;5&#44;6</span>&#160;It appears more commonly in females and in the right hemithorax&#44;<span class="elsevierStyleSup">5</span>&#160;with a tendency to manifest at the start of the peritoneal dialysis technique&#44; although it is not unusual for it to appear months or even years later&#46; There are two factors that are combined in its aetiology and pathogenesis&#58; on the one hand&#44; the increase in intra-abdominal pressure and&#44; on the other&#44; the existence of continuity solutions in the pleuro-peritoneum&#44; either congenital or acquired&#46;<span class="elsevierStyleSup">7&#44;8</span>&#160;Peritonitis episodes can also worsen congenital diaphragmatic defects&#44; although we have only found two reported cases and both are quite old&#44; confirming the scarceness of this possibility&#46;<span class="elsevierStyleSup">2&#44;3</span>&#160;Clinical results are diverse&#44; depending on the amount of pleural effusion&#46; In some studies&#44; up to 25&#37; of the cases go unnoticed&#46;<span class="elsevierStyleSup">5</span>&#160;In others&#44; there may be paroxysmal dyspnoea&#44; thoracic pain and coughing&#44; together with a decrease in ultrafiltration&#46; The examination showed abolition of breath sounds&#44; dullness on percussion and no transmission of vocal vibrations&#46; Diagnosis was via chest X-ray and pleural fluid analysis &#40;with higher glucose concentration than plasmatic&#41;&#46; Stainings can be used &#40;methylene blue&#41; and peritoneography with contrast medium to reveal the existence of pleuro-peritoneal communications&#44; although these methods can cause peritoneal irritation&#46; Currently&#44; the most common technique applied is peritoneal scintigraphy with technetium-99&#46;<span class="elsevierStyleSup">4&#44;7</span>&#160;Several therapeutic options have been reported&#58; transitory haemodialysis with a return to peritoneal dialysis with low volumes or with a cycler&#44; pleural tap&#44; pleurodesis with chemical substances or autologous blood transfusion and direct surgical repair or thoracoscopy&#46;<span class="elsevierStyleSup">3&#44;5-8</span>&#160;Nonetheless&#44; treatment results are not very encouraging and in a high proportion of cases&#44; the patient is definitively transferred to dialysis&#46;<span class="elsevierStyleSup">3&#44;5-7</span></p><p class="elsevierStylePara">In our patient&#44; advanced in age&#44; the increase in intra-abdominal pressure due to the peritoneal dialysis gave rise to&#44; firstly&#44; a hernia&#46; This increase in pressure with the structural weakness of the diaphragmatic parietal peritoneum caused by peritonitis generated pleuro-peritoneal communication&#44; giving rise to hydrothorax&#46; Given these complications haemodialysis was chosen as the most appropriate extrarenal purification technique&#44; although it was against the patient&#8217;s will&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10435&#95;108&#95;9217&#95;en&#95;10435&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10435_108_9217_en_10435_f1.jpg" alt="Hydrothorax"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Hydrothorax</p>"
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