Unusual Cause of Pleural Effusion Dr. Mazen Badawi Dr. Abdulrahman Al-Demerdash Prof. Omer...
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Unusual Cause of Pleural Effusion
Dr. Mazen Badawi
Dr. Abdulrahman Al-Demerdash
Prof. Omer Al-Amoudi
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Week 1
63 yrs old Saudi gentleman,Presented to ENT clinic with 1 wk
history of:
Sore throat, low grade fever, generalized fatigue
Diagnosed as URTI, received antibiotics
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Week 2
Partial improvement Having heaviness in Rt side of chest Received 2nd course of antibiotics for
suspected pneumonia
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Week 3
Patient developed shortness of breathSeen in our OPDAdmitted
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Week 3 : History
Cough, pleuritic chest painSmoker for 35 years, DM and HTN on
oral medicationsOther systemic review was
unremarkable
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Week 3 : Examination
Signs of Rt. Sided moderate pleural effusion
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Week 3 : Examination
Incidental findings Left small breast mass Goiter
Otherwise, normal
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Week 3 : Investigations
CBC, U&E , LFT normalCXR= moderate Rt sided pleural
effusion
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Diagnosis so far ?…
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Week 3 : Management
Initial DX Parapneumonic effusion
Pleural tapping done light yellowish fluid sent for diagnostics IV antibiotics were started Chest tube inserted
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Analysis Pleural fluidSerumRatio
Protein427060%
LDH12114880%
Glucose8.814.860%
Cell count
WBC5333 cells/cc81% Lymph3% Mono/Macro
RBC833
AFB + PCR-ve
Bacterial stain + cult.-ve
CytologyAbundant lymphocytes
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Week 3 : Work up
CT chest = LN
• Mediastinal • Rt hilar • Para aortic
Multiloculated, nodular soft tissue mass at left breast,
Goiter No parynchymal lung lesion
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Week 4
Chest tube drainage turned to be more whitish
Daily drainage = 300cc for more than 2 weeks
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?
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Analysis Pleural fluidSerumRatio
Protein427060%
LDH12114880%
Glucose8.814.860%
Cell count
WBC5333 cells/cc81% Lymph3% Mono/Macro
RBC833
AFB + PCR-ve
Bacterial stain + cult.-ve
CytologyAbundant lymphocytes
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Week 4 : The lab story
pleural TG sample
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Surprisingly …
TG =450 mg/dl
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Diagnosis :
TG > 110 mg/dl chylothorax
Possibly ruptured thoracic duct, due to : Lymphoma : HD, NHL Lung CA Mets.
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Week 5
Surgeons were hesitant for immediate mediastinoscopy
Breast and thyroid lesion were biopsied
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Week 6
Thyroid FNA Follicular growth, no malignant cells
Breast biopsy hemangioma
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Week 7
Patient admitted under surgical care, underwent mediastinoscopy.
LN histopathology : Invasive keratinizing squamous carcinoma, well differentiated
1ry is ? : Lungs, larynx, nasopharynx, esophagus
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Plan
Localizing primary site, stagingTreating
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Thank You…