DEXTRA MASSIVE PDEXTRA MASSIVE PLEURAL EFFUSION LEURAL EFFUSION ET ET CAUSA SUSPECT RELAPSE TB + MILD ANEMIACAUSA SUSPECT RELAPSE TB + MILD ANEMIA

CLINICAL WORK CLINICAL WORK DEPARTMENT OF INTERNAL MEDICINEDEPARTMENT OF INTERNAL MEDICINEREGIONAL GENERAL HOSPITALREGIONAL GENERAL HOSPITAL Dr. Hi. ABDUL MOELOEK Dr. Hi. ABDUL MOELOEK

MEDICAL FACULTY LAMPUNG UNIVERSITYMEDICAL FACULTY LAMPUNG UNIVERSITY

BANDAR LAMPUNGBANDAR LAMPUNG

June June 2929thth 2013 2013

(Case Report) 

 By Adi Sutriwanto Pasaribu, S. Ked (0718011039)Ayu Kesuma Wardhani W, S.Ked (0718011008)Ricky Pebriansyah, S. Ked (0818011091) 

Preceptor dr. Dedi Zairus, Sp.P

 

I. PATIENT STATUSI. PATIENT STATUS

PATIENT IDENTITYInitial Name : Mr. MSex : MaleAge : 80 years oldNationality : JawaMarital status : MarriedReligion : IslamOccupation : FarmerEducational background : -Address : Kota Gajah, Lampung Tengah

ANAMNESIS Taken From : Auto & alloanamnesis June 18th 2013

03.30 p.m. Chief complain : breathlessnessAdditional complains : chest pain dextra, sputum

cough

History of the Illness : Patient came to the RSAM hospital with breathlessness since 3 months ago and got worse in 5 days before he came to the hospital. Patient felt breathlessness when he was cough, decreased if slept on the right sideway and sit down. His cough products thick white phlegm, since 3 months ago too, no blood. Patient felt breathlessness almost every day. Patient also complain that he has right chest pain.  He claimed that he has ever get ATD (Anti Tuberculosis Drug) treatment during 9 months two years ago and he has recovered, always taken drugs routinly. He also said that he had ever been sweaty night, fever, low appetite, and weight loss. His weight is decreased since he has illness. History of asthma is denied. He was also a smoker since 35 years ago, every day he smoked 3 cigarettes. No history of thorax trauma. No history of hypertension, diabetes Melitus, or heart disease. No edema palpebra, leg, or abdomen. Mixtion and defecation no complaint. Patient has been treated at RSAY Metro, post WSD 1 times 3 months ago.

General Check upHeight : 162 cm.Weight : 55 kgBlood Pressure : 120/70 mmHgPulse : 90 x/minute, regulerTemperature : 37,5 °CBreath (frequence&type) : 32 x/minute,

rapid&shallowNutrition condition : EnoughConsciousness : Compos mentis

Conjungtiva : anemic/ anemic (+/+) Neck : Trachea deviation to the left  Chest : Shape Hemithorax dextra looks convex

  Lung Lung

InspectionInspection

Left : hemithorax movement Left : hemithorax movement normalnormal, re, rettraction (-)raction (-)

Right : hemithorax movement Right : hemithorax movement more slow, more slow, rerettractionraction IC IC (+) (+)

PalpationPalpation

Left and rightLeft and right : tactil fremitus asimetris, dextra weaker : tactil fremitus asimetris, dextra weaker than sinistrathan sinistra

PercussionPercussion :: Left Left : Sonor: Sonor ; ; Right : dullnessRight : dullness

AuscultationAuscultation

Left Left : Vesiculer: Vesiculer (+) (+) , Ronchi , Ronchi ( (--)), Wheezing (-), Wheezing (-)

Right : Vesiculer Right : Vesiculer (-)(-), Ronchi , Ronchi ((--)), Wheezing (-), Wheezing (-)

Roentgen ThoraxRoentgen Thorax AP AP : :

PPulmo dextra shows radioulmo dextra shows radioopaopaqueque massive, not look dextra massive, not look dextra contophrenicus angle, trachea contophrenicus angle, trachea deviation and cor to the left side deviation and cor to the left side Dextra Massive Pleural Effusion.Dextra Massive Pleural Effusion.

Thoracosentesis :1500 cc.Brownish red, muddy (Serohemorragic)pH : 8. LDH : 2259 mg/dl.Cell total : 100 cell/ul (0-5 cell/ul)Glucosa : 13 mg/dl (50-80 mg/dl)Protein : 3,5 g/dl (1-2 g/dl)Clorida : - (720-750mg Cl/dl)PMN : 27 %MN : 73 %Rivalta test: (+)Cytology : no malignancy. Just limfosit cells and degeneratif mesothel.

Working diagnoseDextra massive pleural effusion ec suspect relapse TB + mild anemia Differential diagnosisDextra massive pleural effusion ec malignancy Supporting Examination•Sputum and pleura fluid culture and resistance test•Acid-fast Bacillus (AFB) Sputum at the time - at the morning – at the time

Therapy Therapy Management :Management : OO2 2 22-3-3 L/minute L/minute

Bed rest Bed rest High calory and protein dietHigh calory and protein diet IVFD RL 20 gtt/mntIVFD RL 20 gtt/mnt Salbutamol Salbutamol 0,50,5 mg/Metyl Prednisolon mg/Metyl Prednisolon 11 mg/ mg/Cetirizine ½ tab/Cetirizine ½ tab/GG 1 tab GG 1 tab 3 x 1 cap 3 x 1 cap Ceftriaxone 1 gr vial/ 12 hCeftriaxone 1 gr vial/ 12 h Ranitidin amp/12 hRanitidin amp/12 h WSD planningWSD planning Second category TB therapy planningSecond category TB therapy planning

PrognoseQuo ad vitam : dubia ad bonamQuo ad functionam : dubia ad malamQuo ad sanationam : dubia ad malam

II. DISCUSSIONII. DISCUSSION

1.1. Is the patient diagnosis has been correct ?Is the patient diagnosis has been correct ? The anamnesisThe anamnesis : :

BBreathlessnessreathlessness and and productive cough since 3 monthproductive cough since 3 monthss ago ago. . He He claimed that he claimed that he has everhas ever get ATD (Anti Tuberculosis Drug) get ATD (Anti Tuberculosis Drug) treatment during 9 treatment during 9 months two yearsmonths two years ago ago and he has and he has recovered, always taken drugs routinly. recovered, always taken drugs routinly. He also said that he He also said that he had had ever ever been been sweaty night, sweaty night, fever, lowfever, low appetite appetite, and weight , and weight lossloss. . Suspect relapse TB.Suspect relapse TB.

Right Right chest pain when coughchest pain when cough and breathing and breathing, feel full in right , feel full in right thoraxthorax. B. Breathlessnessreathlessness decreased if slept on the right sideway decreased if slept on the right sideway and sit down and sit down Suspect dextra pleura effusionSuspect dextra pleura effusion

Physical examinationPhysical examination Conjungtiva : anemic/ anemic (Conjungtiva : anemic/ anemic (++//++)) NeckNeck : : Trachea deviation to the left Trachea deviation to the left ChestChest : : Shape Shape Hemithorax dextra looks convex Hemithorax dextra looks convex

Lung Lung InspectionInspection :: Left : hemithorax movement Left : hemithorax movement normalnormal, ,

rerettraction (-)raction (-) Right : hemithorax movement Right : hemithorax movement more slow, more slow, rerettractionraction IC IC (+) (+) PalpationPalpation : : tactil fremitus asimetris, dextra weaker than tactil fremitus asimetris, dextra weaker than

sinistrasinistra PercussionPercussion : : Dullnes/Dullnes/SonorSonor AuscultationAuscultation : : VesiculerVesiculer (-/+) (-/+) , Ronchi , Ronchi (-/ (-/--)), Wheezing (, Wheezing (-/-/-)-)

Suspect massive dextra pleura effusion.Suspect massive dextra pleura effusion.

Supporting examinationSupporting examination

Routine blood Routine blood HbHb : 8,1 gr % : 8,1 gr % mild anemia. mild anemia. LEDLED, segment neutrofil, and monosit increased , segment neutrofil, and monosit increased commonly on commonly on

TB.TB.

Chemical bloodChemical blood Total proteinTotal protein : 5,0 : 5,0 decreased decreased AlbuminAlbumin : : 2,3 2,3 hipoalbumin hipoalbumin

Roentgen ThoraxRoentgen Thorax AP AP : : PPulmo dextra shows radioulmo dextra shows radioopaopaqueque massive, not look dextra massive, not look dextra

contophrenicus angle, trachea deviation and cor to the left side contophrenicus angle, trachea deviation and cor to the left side Dextra Massive Pleural Effusion.Dextra Massive Pleural Effusion.

Thoracosentesis Serohemorragic DD : TB, Malignancy, Trauma.LDH increasedCell total increasedProtein increased (>3 g/dl)Glucose decreased (<60 mg/dl)Rivalta test: (+)Cytology: no malignancy. Just limfosit cells and

degeneratif mesothel.

So, pleura fluid is exudate the pathologics derived from pulmo ( not ekstrapulmo). Example : TB, Pulmo malignancy, pneumonia, bronciectacsis, pulmo abses, etc.Cytology: no malignancy malignancy could be removed in differential diagnosis.Definite diagnosis is found acid-fast bacillus (AFB) on sputum or culture.

Inhalation of TB Bacilli

Tubercle Formation (Primary Infection)

Exposure to Air Pollutants

Exposure to TB

Formation of Granuloma

Living in Poorly-lighted and

overcrowded house

PTB

Productive cough, Fever 39C, Anorexia,

weight loss, easy fatigability

AFB (+)

2. How the pathogenesis pleura effusion from this patient ?

Vigorous inflammatory response associated with an exudation of white blood cells and proteins.

Increase WBC count(16.6 x 10^9 mm/ L)

Increase Monocyte count(0.13 g/L)

Mycobacterial antigens enter the pleural space

Not early detected

subpleural caseous focus in the lung ruptures into the pleural space

PTB

Vigorous inflammatory response associated with an exudation of white blood cells and proteins.

Increase pulmonary interstitial fluid

PLEURAL EFFUSION(Accumulation of fluid in the

pleural cavity)

Low serum albumin level:

25 g/LChanges in

permeability of capillaries

Intense inflammation obstructs the lymphatic pores in the parietal

pleura

Decrease in lymphatic drainage

3. Is the patient treatment has been correct ?• O2 2-3 L/minute suplly oxygen based on tidal volume.BB = 55 kg. Tidal volume = 7-10 cc/kgBB. So TV = 550 cc 600ccRR = 30x/mnt. 600cc/30 =2 L/mnt• Bed rest preventing worse breathlessness.• High calory and protein diet for supply energy and protein because of his hipoalbumin.• IVFD RL 20 gtt/mnt the patient has been decreasing appetite preventing dehidration.• Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine ½ tab/GG 1 tab 3 x 1 cap for reducing breathlessness.and cough.

• Ceftriaxone 1 gr vial/ 12 h for temporary treatment for 1 week for evaluation whether because of TB or the others bacterial. Beside that, because of thoracosentesis for preventing infection from it.• Ranitidin amp/12 h preventing gaster acid refluks because of decreasing appetite.• WSD planning because massive pleura effusion so that not enough just for thoracosentesis. Setting up WSD until no undulation that means fluid is discharged and lung tissue have developed. • Second category TB therapy planning because relapse TB is the basic of pleura effusion from this patient.

4. How the prognosis from this patient ?•Quo ad vitam : dubia ad bonam because vital signs are still good.•Quo ad functionam : dubia ad malam because it would indicate repeated pleura effusion again because of relapse TB. Of course the function of pulmo is still bad. Pleurodesis is the definitif treatment of malignant pleural effusion. •Quo ad sanationam: dubia ad malam it can always interfere with daily activities of the patient.

III. PLEURA EFFUSIONIII. PLEURA EFFUSION

What is Pleural Effusion?

It is the abnormal It is the abnormal accumulation of fluid accumulation of fluid in the pleural space in the pleural space resulting from resulting from excess fluid excess fluid production or production or decreased decreased absorption .absorption .

Normally, the pleural Normally, the pleural space approximately space approximately contains 1mL of fluidcontains 1mL of fluid

Classifications of Pleural Classifications of Pleural Effusion:Effusion:

1. Transudative Effusion1. Transudative Effusion

2. Exudative Effusion2. Exudative Effusion

Clear, pale yellow, watery substanceClear, pale yellow, watery substance Influenced by systemic factors that alter Influenced by systemic factors that alter

the formation or absorption of fluidthe formation or absorption of fluid Contains few protein cellsContains few protein cells Common causes: CHF and liver or Common causes: CHF and liver or

kidney diseasekidney disease

Transudative effusions

Pale yellow and cloudy substancePale yellow and cloudy substance Influenced by local factors where fluid absorption is Influenced by local factors where fluid absorption is

altered (inflammation, infection, cancer) altered (inflammation, infection, cancer) Rich in protein (serum protein greater than 0.5)Rich in protein (serum protein greater than 0.5) Ratio of pleural fluid LDH and serum LDH is >0.6Ratio of pleural fluid LDH and serum LDH is >0.6 Pleural fluid LDH is more the two-thirds normal upper Pleural fluid LDH is more the two-thirds normal upper

limit for serumlimit for serum Rich in white blood cells and immune cellsRich in white blood cells and immune cells Always has a low pHAlways has a low pH Common causes: tuberculosis, pneumonia, cancer, Common causes: tuberculosis, pneumonia, cancer,

and traumaand trauma

Exudative effusions

Light’s criteriaLight’s criteria (exudate) (exudate)

Pleural fluid protein divided by serum protein is greater than 0.5. Pleural fluid protein divided by serum protein is greater than 0.5. Pleural fluid LDH divided by serum LDH is greater than 0.6. Pleural fluid LDH divided by serum LDH is greater than 0.6. Pleural fluid LDH is greater than two-thirds the upper limit of Pleural fluid LDH is greater than two-thirds the upper limit of

normal for the serum LDH.normal for the serum LDH. If none of these criteria is met, the patient has a transudative If none of these criteria is met, the patient has a transudative

pleural effusionpleural effusion

EtiologiEtiologi

PLEURAL EFFUSION(Accumulation of fluid in the

pleural cavity)

Irritation of sensory nerves in the parietal pleura during deep

inspiration

Increase in intra-alveolar & intra-pleural pressure

Dyspnea, Pleuritic chest pain, Orthopnea, Paroxysmal

nocturnal dyspnea

Decrease lung expansion

Decrease breath sounds, stony dull sound when

percussed

Dyspnea, Increase RR

Decrease respiratory excursion

Lung collapse

CXR: Opaque densities on the right

lower lobe& blunting of

costophrenic angle

Prolonged pleural effusion

Risk for infection of pleural fluid

Empyema

Thorax and Lungs InspectionPalpation

AuscultationPercussion

(-) Chest wall retractionsasymmetric Tactile fremitus

(absent on the right thorax)

asymmetric respiratory excursion (movement only

on the left thorax)asymmetric breathsounds

(absent breathsounds on the right)

(-) adventitious breath sounddull, flat sound over the right

thorax

NormalAbnormalAbnormalAbnormalNormal

Abnormal

Heart Auscultation (-) heart murmur Normal

Abdomen InspectionAuscultation

Flat abdomen(+) ascites

Normal bowel soundsNo bruit heard

NormalAbnormalNormalnormal

Extremities InspectionPalpation

Arms bilaterally symmetric(-) edema

(-) lesions or ulcerations(+) palpable distal pulse

NormalNormalNormalNormal

ORGAN/ BODY PART(S)

METHODS USED

FINDINGS SIGNIFICANCE

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Complete Blood CountComplete Blood CountProcedure/Item Abnormal

flagsResult Units Reference

Range

Hemoglobin 16 g/DL ( 13.0 – 18.0 )

Hematocrit 45 % ( 40.0 – 52.0 )

RBC 5 Mil/mm^3 ( 4.70 – 5.40 )

WBC *High 16.6 /mm^3 (4-11 x 10^9)

Neutrophils 0.77 g/L (0.50-0.70)

Lymphocytes 0.39 g/L (0.20-0.40)

Monocytes *High 0.13 g/L ( 0.02 – 0.05 )

Eosinophils 0.03 g/L ( 0.02-0.04 )

Basophils -- /mm^3 ( 10 – 100 )

Arterial Blood GasesArterial Blood Gases

Result Normal Range

pH 7.48 7.35-7.45

PCO2 47 35-45mmHg

HCO3 23 22-26mmHg

PaO2 88 80-100%

Significance: The patient has respiratory alkalosis. This may be due to rapid & shallow breathing.

Procedure/Item

Abnormal flags

Result Units Reference Range

Albumin *Low 25 g/L ( 34 - 50 )

AST (SGOT) 35 u/L ( 15 - 37 )

ALT (SGPT) 33 u/L ( 30 - 65 )

Alkaline Phospha

tase

143 u/L (50-165)

Acid-fast Bacillus (AFB)Acid-fast Bacillus (AFB)

Specimen: SputumSpecimen: Sputum ResultResult: : AFB (+)AFB (+)

Gram StainGram Stain

Specimen: Pleural FluidSpecimen: Pleural Fluid Result: Smear shows no presence of gram Result: Smear shows no presence of gram

(-) bacilli.(-) bacilli.

CYTOPATHOLOGYCYTOPATHOLOGY

Specimen: Pleural FluidSpecimen: Pleural Fluid Pathologic Diagnosis: Negative for Pathologic Diagnosis: Negative for

malignant cellsmalignant cells

Chest X-rayChest X-ray

Impression: Consider Impression: Consider moderate pleural moderate pleural effusion; righteffusion; right

Right Lateral Right Lateral Decubitus: Evidence of Decubitus: Evidence of minimal pleural fluidminimal pleural fluid

Chest X-rayChest X-ray

Right Lateral DecubitusRight Lateral Decubitus

Normal CXRNormal CXR Right Pleural Effusion Right Pleural Effusion

CT-SCAN of ChestCT-SCAN of Chest

Result: PTB with Result: PTB with organizing Pneumonia, organizing Pneumonia, Superior and postero-Superior and postero-medial right lower lobe medial right lower lobe with right hilar with right hilar lymphadenopathies and lymphadenopathies and right pleural effusion. right pleural effusion.

CT – MRICT – MRI

Findings:Findings: Mediastinal lymphadenopathiesMediastinal lymphadenopathies Right pleural effusion with thick pleural Right pleural effusion with thick pleural

densitydensity Heart not enlargedHeart not enlarged Pulmonary Fibrosis in Left Lower LobesPulmonary Fibrosis in Left Lower Lobes

ThoracentesisThoracentesis

CONCLUSIONCONCLUSION

Treating the underlying disease is the Treating the underlying disease is the definitif treatment of pleura effusion. So, it definitif treatment of pleura effusion. So, it must be found the etiology.must be found the etiology.

Massive pleura effusion can be removed Massive pleura effusion can be removed through the thoracosentesis, WSD, or through the thoracosentesis, WSD, or pleurodesis.pleurodesis.

BIBLIOGRAPHYBIBLIOGRAPHY

W, Aru. Sudoyo, et all. 2006. W, Aru. Sudoyo, et all. 2006. Ilmu Peyakit Dalam Ed IV Jilid Ilmu Peyakit Dalam Ed IV Jilid II. Department of Internal Medicine Medical Faculty of . Department of Internal Medicine Medical Faculty of Indonesian University. Jakarta.Indonesian University. Jakarta.

Arun Gopi, Sethu M. Madhavan, Surendra K. Sharma and Arun Gopi, Sethu M. Madhavan, Surendra K. Sharma and Steven A.Sahn. 2007.Steven A.Sahn. 2007. Diagnosis and Treatment of Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006Tuberculous Pleural Effusion in 2006. American College of . American College of Chest Physicians.Chest Physicians.

Halim, Hadi. 2007. Halim, Hadi. 2007. Penyaki-Penyakit Pleura dalam Buku Ajar Penyaki-Penyakit Pleura dalam Buku Ajar Ilmu Penyakit Dalam, Jilid II, Edisi IVIlmu Penyakit Dalam, Jilid II, Edisi IV. . Department of Internal Department of Internal Medicine Medical Faculty of Indonesian UniversityMedicine Medical Faculty of Indonesian University. . Jakarta.Jakarta.