Case Presentation - Malignant Pleural Effusion Edited
Case Presentation - Malignant Pleural Effusion Edited
Case Presentation - Malignant Pleural Effusion Edited
Christian Gallardo, MD
Objectives
• To discuss a case of Pleural effusion and
its approach.
• To discuss the approach to Transudative
and Exudative Pleural Effusion using the
Light’s Criteria.
• To discuss the Diagnosis and Treatment
strategies for Malignant Mesothelioma
General Data
• F.E.
• 74/M
• Las Pinas
• Roman Catholic
Chief Complaint
Difficulty of
Breathing
History of Present Illness
2 ●
●
Cough, non productive
No Hemoptysis
No Colds
weeks
●
No Fever
●
No Chest Pain
●
No DOB
●
No Orthopnea, No PND
PTA
●
No Consult done
●
No Medications taken
History of Present Illness
●
Still with non productive cough
●
Chest pain, G4/10
1 week
●
pricking in character,
●
radiating to the shoulder, < 1 minute,
precipitated by breathing
●
No Orthopnea, No PND
●
No Hemoptysis
PTA
●
No swelling of the legs
●
Consulted
●
Medications:
●
Cefixime 200mg BID
●
Ambroxol 75mg OD
History of Present Illness
C
Few ●
Persistence of increased
severity of chest pain and non
productive coughing
O
N
Hours Difficulty of Breathing
●
●
Fever, One episode, Low S
Grade (38C)
U
PTA
●
No chills
●
No colds
L
T
Past Medical History
• Hypertension Stage II
• Maintained on Losartan 50mg/tab 1 tab OD
• Type 2 DM
• Maintained on Metformin 500mg/ tab 1 tab OD
• CAD
• Maintained on Clopidogrel 75mg/tab 1 tab OD
Trimetazidine 35mg 1 tab TID
Simvastatin 40mg OD HS
• S/P Coronary Angiogram (7/26/2008) - UPHR
• S/P PTCA of LAD (7/26/2008) - UPHR
• S/P IABP Insertion R Femoral Artery (7/26/2008) -UPHR
• S/P ORIF Right Forearm (1994) - UPHR
• S/P Cholecystectomy (1982) - ?
Family Medical History
• (-) Hypertension
• (-) DM
• (-) Bronchial Asthma
• (-) Heart Disease
• (-) Thyroid disease
• (-) Blood Dyscrasia
• (-) Cancer
Personal and Social History
• (-) Non smoker
• (-) Alcoholic beverage drinker
• Retired Office Employee
Review of Systems
• General: (+) Weight Loss 20% for 2 months
• HEENT: (-) blurring of visions, (-) sorethroat
• Gastroenterology: (-) abdominal pain, (-) diarrhea, (-)
constipation, (-) melena, (-) hematochazia
• GUT: (-) dysuria, (-) oliguria (-)anuria
• Endocrinology: (-) polyuria, polydipsia, polyphagia,
• Musculoskeletal: (-) myalgia
• Hematology: (-)easy brusability
• Neurology: (-) neuropathy, (-)seizures
Physical Examination
• General:
• conscious, coherent, not in respiratory distress
• Vital Signs:
• BP: 110/70mmHg RR:24 cpm
• CR: 101 bpm, regular T: 38. 1 C
• Skin:
• Good skin turgor, no rashes, no jaundice
• HEENT:
• Anicteric sclera, pink palpebral conjunctivae, no
tonsillopharyngeal congestion, no nasoaural
discharge, no cervicolymphadenopathy, JVP at
9 cm
Physical Examination
• Chest and Lung:
• Symmetrical chest expansion, no lagging, no
retractions, dull at percussion at left base,
decreased breath sounds at left base,
decreased tactile and vocal fremitus at left
base, fine crackles at left base
• Heart:
• Adynamic precordium, normal rate, regular rhythm, PMI at 6 th
ICS at MCL, normal S1 and S2, (-) S3 and S4, no murmurs.
• Abdomen:
• Flat, soft, normoactive bowel sounds, non-tender. Liver span:
8 cm, Intact Traube’s space, No Organomegaly
• Extremities:
• Full pulses, no edema, extremities with full range of motion
Neurological Examination
• Oriented to time, person and place, (-) dysmetria
• (-) dysdiadochokinesia, can do FTNT, (-) nystagmus
• Cranial Nerves:
• I: can smell
• II: 2-3mm PERTL, Fundoscopy: (+) ROR, Clear
Media, Distinct Cup borders, CDR: 1:3, AVR: 2:3, No
exudates, No Hemorrhage
• III, IV, VI: Full EOM
• V: (+) bilateral corneal reflex, good masseter tone
• VII: (-) facial asymmetry
• VIII: can hear
• IX, X: (+) gag Reflex
• XI: can equally shrug shoulder
• XII: no tongue deviation
Neurological Examination
100% ++ ++
5/5 5/5 100%
5/5 5/5
100% 100%
++ ++
100%
5/5 5/5
100%
++ ++
Dyspnea
Pleural Effusion
• Patient’s Meds:
• 1. Essentiale Forte 1 Tab TID
• 2. Losartan 50mg 1 tab OD
• 3. Clopidogrel 75mg 1 tab OD
• 4. Digoxin 0.25 mg 1 tab OD
• 5. Metformin 500mg 1 tab OD
• 6. Simvastatin 40mg 1 tab OD
HS
• 7. Vit B Complex 1 Tab OD
• 8. Trimetazidine 35mg 1 tab OD
Course in the Wards
• 02 saturation: 97%-98% at 2
lpm via nasal cannula
• Sputum AFB for 3 collection
Sputum AFB x 3 Collection Negative for Acid Fast
• Sputum
BacilliGS/CS
Sputum GS/CS Gram Stain:
Pus Cells: < 25/OIF
Epithelial: < 25/OIF
Gram Positive cocci single
and Pair
Gram Negative Short Rods:
Few
Couse in the Wards
2nd Hospital Day
• Levodropropizine (Levopront)
1 tspFree
Chest Mapping Ultrasound TIDfluid
POin both pleural
cavities, more in the left.
Approximate Volume in
24cc in the right and 818cc
• Chestin UTZ with Mapping
the left
Ultrasound
• Ultrasound is more accurate than plain
chest radiography for estimating pleural
fluid volume and aids thoracentesis.
• In a series of 320 patients, Yang et al
found that pleural effusions with complex
septated, complex non-septated, or
homogeneously echogenic patterns are
always exudates, whereas hypoechoic
effusions can be either transudates or
exudates.
●
Systemic factors influencing
the formation or absorption of
Trans pleural fluid are altered so
that pleural fluid accumulates
udativ ●
Left ventricular failure,
ascites, and decreased
e serum oncotic pressure with
hypoproteinemia.
●
Pleural surfaces or the
capillaries in the location
Algorithm for
distinguishing
transudative
from exudative
pleural effusions
Turbid pleural
the •diagnosis fluid
of haemothorax.
• increased cellular content or increased
BTS guidelines for the investigation of a unilateral pleural
lipid contenteffusion in adults, Thorax 2003;58(Suppl II):ii8–ii17
ICU Transfer
Pneumothorax
• Air in the pleural space, that is, air
between the lung and the chest wall
• Spontaneous pneumothoraces
• Ooccur without antecedent trauma or
other obvious cause
• Traumatic pneumothoraces
• Occur from direct or indirect trauma to
the chest.
• Iatrogenic pneumothorax
• An intended or inadvertent consequence of
a diagnostic or therapeutic maneuver
Clopidogrel Resumed
Decreased O2 at 2 lpm
Chronic Inflammatory
Cell Cytology
Pattern with Reactive
Mesothelial Hyperplasia
Immunohistochemical Staining
CEA, CK 7, Calretenin, CK
20
Course in the Wards
13th Hospital Day (-) DOB, comfortable
VS Stable
Decreased Breath Sounds at L
Contemplated Pleurodesis if
CTT output is < 100cc/day
Course in the Wards
Non-Contrast and Bilateral Pleural Effusion,
Contrast CT
15th Hospital Day Larger Amount on the Left
(-) DOB, comfortable
side
VS Stable
The Tip
Decreased of theSounds at L
Breath
Thoracotomy Tube is in
the Left Major Fissure
CTT output: 0cc/day
Small Amount of Fluid
Collections in the
Pericardial Sac
CT Scan of Chest
Ground Glass Opacity in
the Left
Pleurodesis <Lower Lobe
done
Secondary to Compressive
Doxurubicin
Atelectasis or infiltrates
Prerequisites for Pleurodesis
• Significant symptoms that are relieved when
pleural fluid is evacuated
• Evidence of complete re-expansion of the
lung without evidence of bronchial
obstruction or fibrotic-trapped lung
• Daily tube drainage is less than 150 mL/day
• Reserved for those cases where there is no
other therapeutic alternative, or when this
has already failed
• If the patient undergoing pleurodesis is
receiving corticosteroid therapy
Light, Richard. Pleural Diseases.
5th Edition. 2007©
CT Scan
CT Scan • Useful in distinguishing empyema with air
fluid levels from lung abscess
CT scans• for pleural
Identify effusion
pleural shouldwhich
thickening, be suggests
performed with contrast
that the enhancement.
patient has an exudative [C]
effusion.
• In one study, 36 of 59 exudative effusions
In cases of difficult
(61%) drainage, CT scanning
had associated pleural thickening,
should be used to delineate
whereas only 1 the size
of 27 and
transudates (4%)
had associated
position of loculated pleural
effusions. [C]thickening (45).
• An added bonus with CT is the clear
CT scanning demonstration
can usuallyofdifferentiate
bone pathology such as
between
benign andmetastases
malignantorpleural
tuberculosis.
thickening.
BTS guidelines for the investigation of a unilateral pleural
effusion in adults, Thorax 2003;58(Suppl II):ii8–ii17
Light, Richard. Pleural Diseases.
5th Edition. 2007©
Course in the Wards
17th Hospital Day (-) DOB, comfortable
VS Stable
Decreased Breath Sounds at L
CTT removed
Course in the Wards
21th Hospital Day (-) DOB, comfortable
VS Stable
Discharged
Home Medications:
HR (Rimactactazid) 300mg/tab 1
tablet OD
E 400mg/tab 1 tablet BID before
meals
Ipratropium + Salbutamol beulization
every 8 hrs.
Lactulose 15 ml OD HS