PMC5648088_01
The serial chest X-ray findings during the observation period. The accumulation of fluid in the right thoracic space was shown in mid-March 2015 (A). After switching to a reduced dwell time, the blunting of the right lateral costophrenic angle disappeared in early April 2015 (B). However, the effusion recurred about 3 weeks later (C). Approximately 2 months after the surgical intervention for PPC, fluid collection was no longer detected (D). Note that there is slight tethering of the right hemidiaphragm (arrow), probably manifesting as an anatomical sequela of the surgery.
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Chest X-ray at the presentation revealed a blunting of the right lateral costophrenic angle, which is suggestive of right-sided pleural effusion (Figure 1A), but she had neither hypoalbuminemia nor any features for congestive heart failure and/or fluid overload. Her urine output was maintained at about 1000 to 1200 mL/day, but the daily ultrafiltration volume gradually decreased from approximately 400 to 200 mL despite a prompt but transient decline in the thoracic fluid accumulation (Figure 1B). At the end of April 2015, the recurrence of pleural effusion (Figure 1C) with an increased serum Cr level of 12.59 mg/dL was confirmed when she complained of general fatigue and appetite loss as well as dyspnea. Despite terminating HD in mid-August 2015, there was no recurrence of right hydrothorax (Figure 1D), and her serum Cr levels settled around 9.82 mg/dL with PD using 5 daily exchanges (1.2 L of Midperiq  135 x5 [total dwell time of 14 hours]).
Findings of peritoneal scintigraphy (A) and SPECT/CT (B to E). An abnormal uptake in the right hemithorax is demonstrated after instilling the tracer into abdomen through the PD catheter (A). Select axial (B and C), coronal (D), and sagittal (E) images of SPECT/CT allow us to confirm precisely the abnormal radioactivity in the region corresponding to the fluid accumulation in the right thoracic cavity (arrows).
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In addition, Technetium-99m-labeled macro-aggregated albumin scintigraphy combined with single-photon emission computed tomography and computed tomography (SPECT/CT) successfully demonstrated the entry of the radiotracer into the right pleural space (Figure 2), encouraging us to make a diagnosis of PPC.