5/4/18 Intern Morning Report – Shortness of Breath, Cough, Unintentional Weight Loss, Bloody Pleural Effusion, Asbestosis, Malginancy

CC: Shortness of breath and cough for 2 weeks

HPI: This is a 65-year old female with no past medical history presenting with two weeks of shortness of breath and cough as well as three weeks of generalized malaise.  She received a five day course of azithromycin prescribed by her primary care physician with no improvement in symptoms.  She is from Northeastern China and moved to Los Angeles in the 1990s.  She works at and owns a pencil manufacturing factory for ten years . She denies any smoking or alcohol use. Review of systems is pertinent for unintentional weight loss of 10 lbs over the last month.  Physical exam shows the patient to be afebrile, heart rate in the 130s, tachypneic to 22, and sat’ing 96% on room air.  Her rhythm is regular and pulmonary exam demonstrates evidence of a pleural effusion (decreased breath sounds in left lung base, dullness to percussion in the left lung field with decreased tactile fremitus).

Labs/Diagnostics:

 

CT Chest: Bilateral calcified pleural plaques are present with left pleural thickening.

 

Pleural fluid is grossly bloody with the following studies:

  • Glucose 72
  • LDH 1100
  • Protein 5.3
  • Color: Red
  • Markedly bloody
  • 902 nucleated cells
  • 84% segmented neutrophils
  • 16% lymphocytes
  • Pathology did not show malignant cells

Body Fluid Comparison

  • Glucose 90
  • LDH 161
  • Protein 6.6

Initial cytology is negative, so the favored diagnosis at the time is BAPE.  However repeat cytology done, showing atypical cells most consistent with Invasive Ductal Carcinoma primary site likely breast.  Patient is eventually diagnosed with breast cancer that is ER+/PR+/HER2 negative.


Morning Report Pearls:

Grossly bloody pleural effusions can narrow your differential to: Malignancy, Trauma, Asbestos, Pulmonary infarct, and Infection

 

Hemothorax is when the Hct in the pleural fluid is >50% of serum.  Important to know because chest tube placement would be indicated.

 

Benign Asbestos Pleural Effusion came up on this differential given the fluid being bloody, exudative and with a CT showing calcified pleural plaques.  Just remember that BAPE is a diagnosis of exclusion!  Malignancy should be ruled out first particularly given the elevated risk with asbestos exposure.

 

Risk Factors to know with regards to asbestos exposure include construction, automotive servicing, mining workers and shipbuilding industries.  When exposed the shorter fibers are typically cleared from the lungs however the longer fibers are transported to the interstitium or to the lymphatics where they can reach the pleura.  Most common finding in asbestos related pleural diseases is parietal plaques followed by pleural fibrosis and pleural effusion.  Pleural fibrosis can cause a restrictive disease if diffuse.  BAPE is almost always hemorrhagic as mentioned above and eosinophils can be elevated in 1/3.  Mesothelioma is a potential cancer that can be difficult to exclude in cases suspicious for BAPE given the low sensitivity of cytology so pleuroscopy may be needed.

 

Lung cancer is the most common malignancy to cause a pleural effusion and asbestos exposure does increase the risk of lung cancer.  Other cancers that can commonly lead to pleural effusion to consider are breast cancer and lymphoma.

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