Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies

Abstract

Introduction: Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches.

Presentation of case: A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day.

Discussion: Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches.

Conclusion: Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Keywords: Acquired eventration; Case report; Eventration; Nepal; Phrenic nerve palsy.

Fig. 1

Chest X-ray showing elevated left hemidiaphragm up to 4th rib with normal gas shadow of bowel underneath and mediastinal shift towards the right side.

Fig. 2

CECT Abdomen-Eventration of left hemidiahragm with minimal peripheral left basal atelectasis.

Fig. 3

Lax diaphragm without any adhesion to underlying bowel.

Fig. 4

Plication of eventrated diaphragm done in three layer.

Fig. 5

1st post operative day - flat left hemidiaphragm with opacity of the plicated part of the diaphrgm.