Neonatal pleural effusion and insertion of intercostal drain into the liver.

Dichorionic twins, a girl (twin 1) and a boy (twin 2), were born at 37 weeks by emergency caesarean section for prolonged rupture of membranes and fetal tachycardia in twin 1. At first they were in good condition but at ten hours of age twin 2 developed signs of respiratory distress with mild hypercapnia (pCO2 7–8 kPa) but no significant acidosis. A chest radiograph showed infiltrative changes in the right middle and lower lobes with the diaphragm apparently normal (Figure 1). Because the infant was irritable on handling, lumbar puncture was performed in addition to a partial sepsis screen. Antibiotics were given and the respiratory distress settled in forty-eight hours without respiratory support. C-reactive protein peaked at 89 mg/L on day 4 and was normal by day 7; all cultures were subsequently reported negative. Twin 1, who likewise received antibiotics, had a raised C-reactive protein and group B streptococcus was grown from surface swabs. On day 9 twin 2 became severely distressed with tachypnoea and a respiratory acidosis (pCO2 10 kPa). The chest radiograph (Figure 2) showed complete opacification of the right hemithorax consistent with a pleural effusion. In addition the nasogastric tube was noted to deviate to the left at the level of the mid-oesophagus. The infant was placed on continuous positive airway pressure with supplemental oxygen. An intercostal drain was inserted at the fourth intercostal space in the mid-axillary line and 27 mL clear serous fluid was obtained. When the drain ceased to show respiratory swings but clinical signs persisted, 20 mL of clear fluid was removed by thoracocentesis. The chest radiograph now revealed a liver shadow and bowel gas in the right hemithorax (Figure 2). An ultrasound scan, likewise indicating that the liver was in the right hemithorax, suggested that the intercostal drain was embedded in the right lobe of the liver. The infant was then transferred to the regional neonatal surgical centre with the chest drain in situ. On arrival he was intubated and mechanically ventilated. CT confirmed that the intercostal