A rare cause of chronic cough: Diaphragmatic eventration with splenic migration

Dear Editor,

We report the case of a 38-year-old woman who presented with an 8-month history of chronic dry cough with occasional scanty expectoration, without fever, dyspnea, chest pain, weight loss, or appetite loss. She had no comorbidities and had previously received symptomatic treatment from local clinics, with minimal improvement. Her general and respiratory examinations were unremarkable. A chest radiograph showed a well-defined homogeneous opacity in the left lower zone arising from the diaphragm, prompting further evaluation [Figure 1]. Contrast-enhanced computed tomography of the chest revealed eventration of the left hemidiaphragm with migration of the spleen into the thoracic cavity [Figure 2]. Cardiothoracic surgery consultation recommended operative repair; however, the patient declined surgical intervention and opted for conservative management with regular follow-up.

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Figure 1:

Chest X-ray showing the left side diaphragmatic eventration. Red circle highlights a well-defined homogeneous opacity in the left lower zone arising from the diaphragm.

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Figure 2:

Contrast-enhanced computed tomography images, red circles highlights eventration of the left hemidiaphragm with migration of the spleen into the thoracic cavity.

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Diaphragmatic eventration is defined as abnormal elevation of an intact hemidiaphragm due to congenital maldevelopment or acquired causes such as phrenic nerve injury. It is rare, with an incidence of 0.05% and a noted male predominance.^[1] Right-sided involvement is less common, likely owing to earlier closure of the right pleuroperitoneal canal and protective support from the liver.^[2,3] Many patients remain asymptomatic, but when symptoms occur, they may include chest pain, orthopnea, recurrent respiratory infections, or nonspecific gastrointestinal complaints such as nausea or dyspepsia. Imaging plays a pivotal role, and features may include mediastinal shift, air–fluid levels, or herniation of abdominal organs into the thorax. Chronic cases may mimic a homogeneous opacity, as seen in our patient.

Splenic migration through an eventrated diaphragm is exceedingly uncommon and carries risks such as torsion or infarction, underscoring the need for timely identification. Surgical plication is considered the definitive therapy in symptomatic patients, and minimally invasive thoracoscopic or laparoscopic techniques offer advantages, including reduced postoperative pain, rapid recovery, and better cosmetic outcomes.^[4] Nonetheless, management must be individualized, balancing symptom severity, potential complications, and the patient’s preferences. In this case, the patient was clinically stable and chose conservative care.

This case highlights a rare but important cause of chronic cough and emphasizes the need for clinicians to consider diaphragmatic abnormalities when evaluating persistent, unexplained respiratory symptoms. Early imaging facilitates prompt diagnosis and helps avert serious complications associated with organ migration.