Discussion
Eventration of diaphragm is a relatively rare entity. Depending on the severity, the condition can range from asymptomatic incidentally diagnosed ones to severe dyspnoea[4]. Severe respiratory distress, recurrent infections, and lack of response to conservative management warrant a need for surgical intervention.[3]
It is more common in males, more on the left diaphragm. [5][6] [7][8]. The condition can be congenital or acquired but not much symptomatic distinction exists between the two. Congenital causes are due to abnormalities in the development of the muscular portion of the diaphragm[7], whereas acquired cases most commonly occur due to traumatic phrenic nerve damage, but can also be attributed to infectious, inflammatory, or idiopathic causes[4]. Congenital cases occur in association with congenital syndromes and developmental anomalies[7], which was not seen in our case. Neither was there a history of recurrent chest infections in childhood as seen in congenital eventration[9]. It is also rare that congenital cases present in adulthood [6], making our case likely to be an acquired one.
Our patient denies past history of trauma or any cardiac, thoracic, and pulmonary surgeries in the past. Ruling out all other possibilities, a high index of suspicion of an infectious etiology was made in our case as the patient gave a history of Tuberculous infection 25 years back, and there were also multiple calcified lesions in the hemithorax as seen on present CT imaging. The presence of calcified lesions in the vicinity of the phrenic nerve might have led to diaphragmatic paralysis.
Similar cases of eventration in tuberculous patients have been reported and a possible association with Tuberculosis has been reported earlier[10]. Even a successful tuberculosis treatment in terms of bacteriological clearance or completion of drug doses does not guarantee a halt in the progression of structural and functional organ changes in the long haul.[11] Residual radiological sequelae, lung function impairment, and other long-term complications like airway stenosis, lung scarring, fistulae formation in successfully treated Tb cases have also been seen[12] [13] A case of diaphragmatic eventration in association with enteric fever has been previously reported in Nepal.[10] Apart from these, association with mumps [10], polio, influenza, diphtheria, have also been mentioned in literature[14]
Imaging modalities play a chief role in the diagnosis. Management, depending on the severity of the case, can be done conservatively with supportive care and periodic follow-up visits in asymptomatics and those with mild symptoms, whereas a definitive surgical intervention is required in those with severe and persistent respiratory distress.[5]
Diaphragmatic plication, which is the surgical fixation of the diaphragm is the surgical intervention of choice, conventionally done via thoracotomy or laparotomy, but recent advances allow minimally invasive approaches too[5]. The aim of surgery is to position the diaphragm at the position of maximum inspiration, allowing re-expansion of the lung.[6]
Substantial elevation resulting from respiratory distress impairing daily life activities is the most common indication of surgery[15]. Yet, the exact timing of surgery is a matter of contention, a variable period of observation ranging from 6 to 24 months is advocated in literature[16].
While on observation, careful follow-up surveillance is very crucial to examine, analyze and judge the need for surgical operation depending upon the patient’s clinical condition.
Selective, patient-centered, and tactful decisions should be taken while considering surgical interventions, especially in unilateral and low-level eventration in the elderly age group.[17]
Diaphragm plication has been widely practiced to treat elevated diaphragm and studies have shown improved diaphragm function in operated cases[18] but the long-term benefits of plication are yet uncertain.[6][17]
In our case, considering the age and the mildness of symptoms, a nonsurgical approach was pursued. Breathing exercises were taught and efforts for smoking cessation were made. In a 3 monthly follow-up visit, the patient was clinically stable. No progression of condition was noted in the chest X-Ray.
CONCLUSION
Late presentation in a female patient with a right-sided eventration and a probable association with tuberculosis infection are the distinctive features of this case. We focus on refraining the patent from avoidable operative intervention in view of the mild nature of the symptoms and no progression of the disease.
CONFLICT OF INTEREST
None
AUTHOR CONTRIBUTIONS
KP designed, reviewed and edited the original manuscript. SD reviewed and edited the manuscript.
ETHICAL APPROVAL
Written informed consent was obtained from the patient for publication of the case report.
ACKNOWLEDGMENTS
Dr. Robin man Karmacharya (Dhulikhel hospital), Dr. Satish Vaidya (Dhulikhel Hospital)
Consent: Informed and Written consent was obtained from the patient in her local language (Nepali).