Pleural effusion after Nuss procedure: a case series

Introduction: Pleural effusion is an underreported and poorly understood complication of the Nuss procedure. Cases presentation: Case 1: A 16-year-old female presented five weeks postoperatively with dyspnea (CRP 258 mg/L), left-sided pleural and pericardial effusion. Drainage and treatment with amoxicillin/clavulanic acid, gentamicin, diuretics, ibuprofen, and prednisolone led to improvement. After steroid discontinuation, effusion recurred despite treatment with amoxicillin/clavulanic acid and gentamicin. Cultures remained negative. She required thoracic drainage and received oral clindamycin, later switched to ciprofloxacin, with eventual recovery. Case 2: A 17-year-old male presented with right-sided chest pain and pleural effusion two weeks after a complicated Nuss procedure (due to extensive adhesiolysis for pneumonia-related lung adhesions. Despite antibiotics, symptoms progressed, and he was admitted (CRP 240 mg/L). Chest drainage yielded 1300 mL clear fluid; cultures were negative. Recurrent effusion eventually required video-assisted thoracoscopic surgery. He was treated with amoxicillin/clavulanic acid after surgery. Case 3: A 14-year-old female developed fever one week postoperatively (CRP 123 mg/L), with no abnormalities on imaging. Three weeks later, she developed right-sided effusion; 600 mL was drained, and she received ceftriaxone and clindamycin. Recurrence occurred within two weeks; oral prednisolone was added, resulting in rapid improvement. She was discharged on cotrimoxazole and tapered steroids. Two months later, imaging for persistent fatigue revealed Nuss bar dislocation and pneumothorax, requiring bar repositioning. Conclusion: Pleural effusion after the Nuss procedure can be caused by a reactive inflammatory response, triggered by pleural or mechanical irritation. If an infection and bar displacement are ruled out, a course of corticosteroid therapy may be effective.