Aslamzai et al.
Journal of Medical Case Reports
(2023) 17:183
https://doi.org/10.1186/s13256-023-03910-4
Journal of
Medical Case Reports
Open Access
CASE REPORT
Right-side diaphragmatic eventration
with atrial septa defect and cleft palate
in an infant: a case report
Mansoor Aslamzai1* , Fazal Rahman Rahmani2, Turyalai Hakimi3, Abdul Hakim Mukhlis1 and
Basir Ahmad Froogh1
Abstract
Background Congenital right-side diaphragmatic eventration with atrial septal defect and cleft palate is a rare congenital anomaly.
Case presentation We present a rare case of congenital right-sided diaphragmatic eventration along with atrial
septal defect, cleft palate, pneumonia, and undernutrition in a 3-month-old Asian and Afghan girl. The clinical features
were observed in the third month of life, and the diagnosis of these anomalies was established by the patient’s history, physical examination, chest X-ray, thoracic computed tomography, and echocardiography. Her condition was
good after supportive treatment. Since the index case of diaphragmatic eventration was associated with congenital
heart disease, cleft palate, and parental consanguinity, a genetic basis may have played an important role in the
pathogenesis of this anomaly.
Conclusion Eventration of the diaphragm may be diagnosed in early infancy, and genetic factors may contribute to
its pathogenesis.
Keywords Diaphragmatic eventration, ASD and cleft palate
Background
Diaphragmatic eventration is characterized by an abnormal partial or total elevation of an intact diaphragm
due to the abnormality of its musculature. This anomaly
can be congenital or acquired, with an estimated prevalence of 1 per 10,000 live births, and usually occurs on
the left side [1–3]. Congenital eventration is caused by
*Correspondence:
Mansoor Aslamzai
mansooraslamzai@gmail.com
1
Department of Neonatology, Kabul University of Medical Sciences, 3rd
District, Kabul 1003, Afghanistan
2
Department of Abdominal Surgery, Kabul University of Medical
Sciences, 3rd District, Kabul 1003, Afghanistan
3
Department of Pediatrics Surgery, Kabul University of Medical Sciences,
3rd District, Kabul 1003, Afghanistan
an underdeveloped diaphragmatic muscle or a lack of
the phrenic nerve. The most common cause of acquired
eventration is phrenic nerve injury, which can result from
either a traumatic birth or thoracic surgery for congenital
heart disease [4]. Focal diaphragm elevation is very rare
and has generally been observed on the anteromedial
right hemidiaphragm, while complete elevation has been
found on the left hemidiaphragm [5]. The manifestation
of diaphragmatic eventration can be ranged from asymptomatic, respiratory, and gastrointestinal discomforts to
a potentially fatal rupture [2, 4–7]. Radiographic imaging
such as chest X-ray and computed tomography is used to
confirm the diagnosis, and treatment usually consists of
supportive care and, in rare situations, surgical management [4].
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Aslamzai et al. Journal of Medical Case Reports
(2023) 17:183
Case report
A 3-month-old female infant weighing 3.5 kg was born
normally at 38 weeks of gestation to a 39-year-old Asian
and Afghan multigravida mother by cesarean delivery at
a local hospital. The mother was in good health during
pregnancy and did not receive any teratogenic drugs or
radiation. The baby had no history of trauma or surgery.
The parents were third-degree relatives, which denotes
parental consanguinity. The infant was admitted to the
intensive care unit (ICU) of the pediatric department
due to respiratory difficulty, poor sucking, and fever. On
physical examination, lethargy, a length of 55 cm, rectal
temperature of 40 °C, respiratory rate of 95/minute, heart
rate of 190/minute, subcostal and intercostal retraction,
nasal flaring, and central cyanosis with oxygen saturation of 74% were detected. Chest auscultation revealed
crackles, diminished breathing sounds, and bowel sound
in the lower right thorax. Furthermore, a cleft palate was
also found during physical examination (Fig. 1). Blood
investigations revealed hemoglobin of 12.8 gm/dl, total
leukocyte count of 16,500/mm3 (polymorphs 79.9%, lymphocytes 16.1%, eosinophils 0.2%, monocytes 3.3%, and
basophil 0.5), platelet count of 559,000/mm3, and C-reactive protein of 12 mg/dl. Arterial blood gas analysis
showed pH (7.39), pCO2 (32 mmHg), pO2 (59.4 mmHg),
and bicarbonate (20 meq/l). The liver and renal function
tests were within normal limits. The chest X-ray demonstrated prominent elevation on the right side of the diaphragm with infiltration in the right lung (Fig. 2). The
above mentioned abnormal respiratory findings, fever,
leukocytosis, elevated C-reactive protein level, and the
radiographic findings were used to diagnose bacterial
pneumonia and right-sided diaphragmatic eventration.
Based on the weight-for-length reference card, this infant
of 3.5 kg weight and 55 cm length classified as moderate
acute malnutrition. The patient was put on intravenous
fluids, electrolytes, oxygen, and antibiotics, consisting of ceftriaxone intravenously. On the fourth day of
Fig. 1 Cleft palate is obviously visible in the index infant
Page 2 of 5
Fig. 2 Before the management of bacterial pneumonia, chest
radiography shows an elevation of right hemidiaphragm at the
medial part and right lung infiltration in the index baby
admission, the baby became stable with a rectal temperature of 37.5 °C, respiratory rate of 60/minute, heart rate
of 140/minute, and no intercostal retraction. Therefore,
we started high protein and calorie feeding via a nasogastric tube and advised computed tomography (CT) of the
chest for the confirmation of diaphragmatic eventration.
The contrast-enhanced CT scan revealed focal elevation
at the anteromedial portion of the right hemidiaphragm,
including parts of the liver and transverse colon (Figs. 3,
Fig. 3 Front view of the thorax on contrast-enhanced computed
tomography demonstrates focal elevation at the medial portion of
right hemidiaphragm containing abdominal viscera
Aslamzai et al. Journal of Medical Case Reports
(2023) 17:183
Page 3 of 5
diagnosed as a case of congenital right-side diaphragmatic eventration, a small ostium secundum type of ASD,
cleft palate, bacterial pneumonia, and moderate acute
malnutrition. Bacterial pneumonia was treated by intravenous antibiotic for 10 days. The mother’s breast milk
and a high protein and calorie formula were used to treat
moderate acute malnutrition. A pulmonary to systemic
blood flow ratio (Qp/Qs) of less than 1.5 was accompanied by a small-size ASD, hence no surgical management
was necessary. Palatoplasty or surgical repair for cleft palate is usually performed at 9–12 months of age. On the
ninth day of admission, she was stable with full enteral
feeding and no need for respiratory support. The lung
infiltration was decreased as shown in the second chest
X-ray (Fig. 6). The indications of surgical intervention for
diaphragmatic eventration are the presence of respiratory
distress despite medical management or respiratory failure. Therefore, such management was not performed for
the index case.
Fig. 4 Lateral view of the thorax on contrast-enhanced computed
tomography shows elevation at the anterior portion of right
hemidiaphragm containing abdominal viscera
4), all of which are diagnostic of congenital right-side
diaphragmatic eventration. On the fifth day of admission, Doppler echocardiography revealed an ostium
secundum type of atrial septal defect (ASD) with a 4 mm
diameter (Fig. 5) and a pulmonary to systemic blood flow
ratio (Qp/Qs) of less than 1.5. Finally, the patient was
Discussion
Eventration of the diaphragm is a rare malformation
that usually develops unilaterally on the left side [1–
3]. It was identified for the first time in 1774 by Jean
Louis Petit during a postmortem investigation, and
the term was first used by Beclard in 1829 [6, 7]. Congenital eventration can be caused by either a lack of
diaphragmatic muscle or a phrenic nerve deficit, and
replacement of the diaphragmatic muscle with fibroelastic tissue [4]. The indications for surgical intervention for diaphragmatic eventration are the presence of
respiratory distress despite medical management or
respiratory failure [8, 9]. Persistent interatrial communication is called an atrial septal defect (ASD) and has
three types: ostium secundum, ostium primum, and
sinus venosus. The pulmonary to systemic blood flow
Fig. 5 Doppler echocardiography reveals an atrial septal defect in the index infant
Aslamzai et al. Journal of Medical Case Reports
(2023) 17:183
Fig. 6 After the treatment of bacterial pneumonia, chest radiography
shows elevation of right hemidiaphragm at the medial part and
decrease of right lung infiltration in infant
ratio (Qp/Qs) needs to be greater than 2.0 to indicate
surgical intervention for ASD [10, 11]. Cleft palate is
defined as a congenital abnormal gap in the upper palate. The etiology is complex including genetic factors
[12]. Palatoplasty is performed at about 9–12 months of
age [10]. Bacterial pneumonia is the infectious inflammation of lung parenchyma leading to cough, fever,
tachypnea, chest retraction, leukocytosis, hypoxia, elevated C-reactive protein, and lung infiltration on chest
X-ray. Respiratory support and antibiotic therapy are
the mainstays of management [14]. Acute malnutrition
is defined as low weight-for-height and is classified as
moderate and severe types. A high protein and calorie
diet is the treatment of choice [15].
According to the evidence of clinical, chest X-ray,
and thoracic computed tomography findings, the index
case is a congenital right-sided diaphragmatic eventration along with a small-sized ASD, cleft palate, bacterial
pneumonia, and moderate acute malnutrition. The cleft
palate was clearly visible at the upper palate of the baby
(Fig. 1). Diagnostic findings of diaphragmatic eventration
on chest radiography and thoracic computed tomography were the focal elevation at the anteromedial section
of right hemidiaphragm containing components of liver
and transverse colon (Figs. 2, 3, 4). The eventration of
diaphragm was identified during early infancy, without
a history of trauma or surgical intervention, hence it
is a congenital type. A small size of ASD (Fig. 5) with a
pulmonary to systemic blood flow ratio (Qp/Qs) of less
than 1.5 was diagnosed by Doppler echocardiography.
The presence of ASD and cleft palate with diaphragmatic
eventration in our case highlights a significant difference
from previously reported cases [2, 4–7].
Page 4 of 5
The current case demonstrated triple congenital
anomalies and positive parental consanguinity, suggesting a possible role of genetics in the development
of diaphragmatic eventration. According to the study
Wynn et al. multiple genetic variants are attributed to
the development of diaphragmatic hernia [16]. Wojcik
and Agrawal concluded that congenital abnormalities
can result from a range of genetic variations [17]. These
findings support our hypothesis regarding the genetic
basis in the pathogenesis of diaphragmatic eventration. The clinical features of the infant presented in this
case report were respiratory distress, signs of respiratory infection, and slow weight gain, which are consistent with the literature [2, 4–7]. The patient had a stable
condition on full enteral feeding without any respiratory support after 8 days of hospitalization. These findings are similar to the study of Groth and Andrade [18].
Conclusions
The manifestations of diaphragmatic eventration may
be observed during the first few months of life. The
index case of congenital right-side diaphragmatic eventration was associated with atrial septal defect and cleft
palate and had parental consanguinity. Therefore, in the
pathogenesis of this anomaly, a genetic basis may be
implicated. Further analytic studies are needed to evaluate this issue. Since bacterial pneumonia and undernutrition accompanied the current case, the proper
evaluation and management of pulmonary infection
and nutritional disorder are suggested for infants with
diaphragmatic eventration.
Abbreviations
ASD
Atrial septal defect
CT
Computed tomography
ICU
Intensive care unit
Acknowledgements
We gratefully acknowledge the staff of ICU of Maiwand Teaching Hospital, particularly Dr. Aman Zaland, Dr. Basir Rahimzai, and Dr. Mesbahullah Mushoud
for their cooperation in this study.
Author contributions
MA assessed the patient clinical feature, chest radiography, and CT scan to
make a final diagnosis, as well as prepared the manuscript. FRR and TH evaluated the infant for surgical management and reviewed the manuscript. AHM
performed the Doppler echocardiography and detected the ASD in the infant.
BAF reviewed the literature and collected the documents. All authors read and
approved the final manuscript.
Funding
The authors received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
Availability of data and materials
The documents used during the current study are available from the corresponding author on reasonable request.
Aslamzai et al. Journal of Medical Case Reports
(2023) 17:183
Declarations
Ethics approval and consent to participate
This study was approved by the Department of Neonatology (Protocol no 6
dates 27/10/2022), Kabul University of Medical Sciences.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian for
publication of this case report and any accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Page 5 of 5
16. Wynn J, Yu L, Chung WK. Genetic causes of congenital diaphragmatic
hernia. Semin Fetal Neonatal Med. 2014;19(6):324–30. https://doi.org/10.
1016/j.siny.2014.09.003.
17. Wojcik MH, Agrawal PB. Deciphering congenital anomalies for the next
generation. Cold Spring Harb Mol Case Stud. 2020. https://doi.org/10.
1101/mcs.a005504.
18. Groth SS, Andrade RS. Diaphragmatic eventration. Thorac Surg Clinic.
2009. https://doi.org/10.1016/j.thorsurg.2009.08.003.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Received: 29 October 2022 Accepted: 20 March 2023
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