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).