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CASE REPORT
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 1154-1156

Late-onset congenital diaphragmatic hernia, misdiagnosed as hydropneumothorax: a case report


Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India

Date of Submission13-Dec-2017
Date of Acceptance10-Feb-2018
Date of Web Publication17-Oct-2019

Correspondence Address:
Aditya P Singh
Near The Mali Hostel, Main Bali Road, Falna, Dist-Pali, Rajasthan 306116
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_831_17

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  Abstract 

Congenital diaphragmatic hernia (CDH) is herniation of bowels and abdominal solid organs in the thoracic cavity, causing pulmonary hypoplasia with decreased pulmonary vasculature and dysfunction of the surfactant system. In severe cases, left ventricular hypoplasia is also observed. Usually CDH present in the neonatal period. Late-onset CDH is a rare anomaly with misleading symptoms and signs. We present here a case of late presentation of congenital diaphragmatic hernia misdiagnosed as hydropneumothorax in an 11-month-old male child.

Keywords: chest tube, congenital diaphragmatic hernia, hydropneumothorax, late


How to cite this article:
Singh AP, Gupta AK, Tanger R, Barolia DK. Late-onset congenital diaphragmatic hernia, misdiagnosed as hydropneumothorax: a case report. Menoufia Med J 2019;32:1154-6

How to cite this URL:
Singh AP, Gupta AK, Tanger R, Barolia DK. Late-onset congenital diaphragmatic hernia, misdiagnosed as hydropneumothorax: a case report. Menoufia Med J [serial online] 2019 [cited 2019 Nov 19];32:1154-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/1154/268853




  Introduction Top


Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly that usually presents antenatally or soon after birth [1]. Most newborn infants present with severe respiratory compromise in the neonatal period [2]. Late presentation is rare and variable leading to misleading radiologic assessment, delay in treatment, and fatal consequences [2],[3]. We report the case of a patient with a rare presentation of late-onset CDH resembling hydropneumothorax and review the literature.


  Case Report Top


An 11-month-old male child presented to us with mild respiratory distress with cough since last 10 days. The patient was first seen by the pediatric department at our institute. He had a history of mild respiratory distress with cough since the last 4 months. The patient was managed conservatively by a pediatrician. Contrast-enhanced computed tomography (CECT) of the chest showed bronchiectatic cavitary changes in the left lower lobe causing mediastinal shift towards the right side with left pleural effusion and collapse consolidation of the lung parenchyma 4 months before. Pediatrician even started antitubercular treatment. Pediatrician diagnosed it as a case of hydropneumothorax after looking at chest radiography after 4 months. Patients managed with intercostal drainage insertion [Figure 1]a. But the respiratory distress could not be relieved after around 50 ml of the purulent drainage and referred to us for further management. His routine blood investigations were within normal limits including renal function and serum electrolytes except hemoglobin, 8.6 g% and total leucocyte counts of 18 100/cm. Radiography of the chest showed bowel loops in the left hemithorax [Figure 2]a. Ultrasonography of the chest showed consolidation with bowel loops on the left side of the thorax. CECT chest showed herniation of bowel loops in the left hemithorax with consolidation and atelectasis and contralateral mediastinal shift [Figure 2]b. We explored the patient with left subcostal incision. There was a small defect on the left side of the diaphragm posteriorly [Figure 3]a. The content was the whole small bowel without sac. There was pus in the left hemithorax. After reduction of the content and drainage of the pus, defect was closed with prolene 2–0 with drain in situ [Figure 1]b. The drain was removed after 48 h [Figure 3]b. The patient was discharged after 7 days uneventfully.
Figure 1: (a) Radiography of the chest shows Intercostal drainage tube (ICDT) in the chest for hydropneumothorax and (b) radiography chest after 48 h show full lung expansion with drain in situ.

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Figure 2: (a) Radiography of the chest shows bowel loops in the left hemithorax, (b) contrast-enhanced computed tomography of the chest shows bowel loops in the left hemithorax.

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Figure 3: (a) Photograph showing defect in the left hemidiaphragm and (b) postoperative photograph.

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  Discussion Top


In 1848, Bochdalek first described a CDH case which resulted from developmental failure of posterolateral foramina to fuse properly. Its exact pathogenesis is not well understood.

Incidence of CDH is 1 : 2000 to 1 : 5000 with equal sex preference [4]. Incidence of herniation is 78–90% posterolaterally through foramen of Bochdalek, 1.5–6% retrosternally via foramen of Morgagni and 14–24% via oesophageal hiatus. Left-sided herniation is common, as the right hemidiaphragm develops earlier and the liver prevents hollow viscus from herniation [5]. There is right to left shunting of blood on the affected side. Also 70–95% cases are diagnosed in the neonatal period and only 5% of diaphragmatic hernias occur beyond the neonatal period [3]. Later diagnosis becomes difficult due to vague cardiorespiratory and gastrointestinal symptoms [5]. Emergency correction is required in most cases.

Because most diaphragmatic hernias occur on the left side of the chest, most frequently Bochdalek hernia, a large number of them allow the stomach to enter into the chest cavity [6]. Although the diaphragmatic defect is present in foetal life, the occurrence of postnatal diaphragmatic hernia has been reported after months or years of normal chest radiographs. Probably it is due to the effect of liver protection on the right side and spleen protection on the left side and the presence of a thin hernia sac which contains both pleura and peritoneum [7]. It was same as in our case where the previous CECT chest did not show any diaphragmatic hernia.

Increase in abdominal pressure can precipitate the protrusion of the abdominal content into the thoracic cavity [3],[7], which we believe happened to our patient, as the previous history of chronic cough may cause an increase in abdominal cavity pressure.

Radiologically CDH can mimic congenital lung cysts, infective lung diseases, and pneumothoraces [3]. The main diagnostic modality for detection of pneumothorax or hydropneumothorax is plain radiography and computed tomography [6]. The radiologic signs that establish the diagnosis of hydropneumothorax include the horizontal line of an air-fluid level, fluid effusion, and collapse of the lung [6]. Careful attention should be paid to intestinal gas shadow patterns especially in the upper abdomen before reporting them as normal. Usually plain chest radiograph done after passing a nasogastric tube gives the diagnosis of CDH. However, it may be misinterpreted and diagnosed as pleural effusion/pneumothorax, and hence there is a possible risk of chest tube perforating herniated viscus [8].

Coren et al. [9] as well as a recent publication in Hong Kong Journal of Paediatrics [10] described a case of CDH misdiagnosed as pneumothorax, resulting in Intercostal tube (ICT) insertion. Hence, investigations like chest radiography (with or without nasogastric tube insertion), contrast studies, computed tomography scan, and laparoscopy are to be done to exclude diaphragmatic herniation [11]. Most patients with late-onset CDH do well after surgical repair with apparently normal ipsilateral lung volume [7].


  Conclusion Top


Late-onset CDH is a tricky diagnosis with misleading symptoms and signs with a wide range of differential diagnoses. A careful examination of any initial abdominal radiography that shows a sign of gastric and intestinal gas shadow connection with the chest cavity will help dramatically in the diagnosis of suspected diaphragmatic hernia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Javier AA, Bindi NM, Oluyinka OO. Delayed presentation of congenital diaphragmatic hernia manifesting as combined-type acute gastric volvulus: a case report and review of the literature. J Ped Surg 2008; 43:35-39.  Back to cited text no. 1
    
2.
Thomas RW, Tom TJ, Patrick VBJ, Eugene L, Susan W. Congenital diaphragmatic hernia beyond infancy. Am J Surg1991; 162:643-646.  Back to cited text no. 2
    
3.
Lawrence B, David S, Sigmund H, Barry S. The late-presenting pediatric Bochdalek hernia: a 20-year review. J Ped Surg 1988; 23:735-739.  Back to cited text no. 3
    
4.
FJ, Hayden JD, Guthrie A, Smith AM. Right-sided Bochdalek hernia obstructing in an adult: Case report and review of the literature. Hernia 2007; 11:359-62.  Back to cited text no. 4
    
5.
Bhardwaj M, Taxak S, Rattan KN, Goyal P, Aggarwal M. Late presentation of congenital diaphragmatic hernia-anaesthetic considerations. Internet J Anesthesiol 2008; 16:2.  Back to cited text no. 5
    
6.
Joel AF, John L, Samuel E, James F, Louis MB. Diaphragmatic hernia masquerading as pneumothorax in two toddlers case report. Ann Emerg Med1993; 22:1221-1224.  Back to cited text no. 6
    
7.
Robinson PD, Fitzgerald DA. Congenital diaphragmatic hernia. Paediatr Respir Rev 2007; 8:323-335.  Back to cited text no. 7
    
8.
Remi T, Jean MB, Roseline C, Christiane MD, Pierre B. Ultrasonographic approach to diagnosing hydropneumothorax. Chest 1992; 101:931-934.  Back to cited text no. 8
    
9.
Coren ME, Rosenthal M, Bush A. Congenital diaphragmatic hernia misdiagnosed as tension pnemothorax. Pediatr Pulmonol 1997; 24:119-21.  Back to cited text no. 9
    
10.
Tsui KP, Chan KW, Lee KH. Acute complications of late-presenting congenital diaphragmatic hernia in children. HK J Paediatr (New Series) 2010; 15:157-60.  Back to cited text no. 10
    
11.
Cigdem MK, Onen A, Otcu S, Okur H. Late presentation of Bochdalek-type congenital diaphragmatic hernia in children: A 23 year experience at a single center. Surg Today 2007; 37:642-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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