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.

12/5/17 Resident Morning Report – Flank pain, Shortness of breath, Kidney Injury, Bilateral Hydronephrosis, Pleural Effusion, Retroperitoneal Fibrosis, Adenocarcinoma

CC: flank pain

HPI: 56 year old Korean man with no past medical history reports 2 months of worsening bilateral flank pain. He states it was of sudden onset with gradual worsening of the pain over 2 months.  It radiates to upper back, but there is no radiation to groin.  Intensity is 10/10 at its worst, intermittent, sharp in quality, and worse when lying down. In addition, he complains of subjective fevers, abdominal swelling, shortness of breath and decreased exercise tolerance. He is only able to walk up 1 flight of stairs when he previously could walk multiple flights. He denies chest pain, palpitations, lower extremity swelling, and orthopnea. He also denies any changes to urination, dysuria, frequency, gross hematuria or difficulty urinating. The patient has been seen at several outside emergency departments, however, he has not had further work up due to lack of funding. He reports he has always been healthy and has never been hospitalized, never had surgeries, and never been treated for any diseases. Exam is pertinent for decrease breath sounds at the bilateral lung bases with dullness to percussion.  The patient also has moderate tenderness to palpation to bilateral flanks.

 

Labs/Studies:

BUN/Cr: 19/1.61

K: 5.3

Pro-BNP: 277

UA: moderate blood, 4-5 RBCs

Urine Cr 45

Urine urea 219

Feurea 41%

 

IgG 1046 mg/dL (690-1600)

  • IgG-1 = 690
  • IgG-2 = 181
  • IgG-3 = 15
  • IgG-4 = 7.5

 

Abdominal US:

Moderate bilateral hydronephrosis. No obstructing lesion is identified within the renal collecting systems.

Bilateral pleural effusions.

 

CXR:

 

Pleural Fluid:

Yellow color

Cell count = 1073 (PMN 5%, lymph 23%, 9% mono, 63% other)

Protein 4.3, ratio: 4.3/6.0 = 0.72

LDH 221, ratio: 221/154 = 1.44

Glucose 72

Gram stain negative, no organisms

Fungal culture negative

 

Pleural Fluid Cytology:

 

CT Abdomen/Pelvis with Contrast:

 

The patient had evidence of bilateral hydronephrosis and pleural effusions.  CT A/P demonstrated retroperitoneal fibrosis encasing the bilateral renal arteries and abdominal aorta, with hepatosplenomegaly, and mild T12 vertebral body compression fracture. Urology performed cystocospy with ureteral stent placement however renal function worsened requring IR to place nephrostomy tubes.  Pleural fluid was obtained with cytology positive for adenocarcinoma.  The patient’s IgG4 levels were not elevated.  Overall, it was though that the patient had retroperitoneal fibrosis secondary to malignancy which was discovered to be signet ring cell adenocarcinoma of the gastrointestinal tract.

 


Morning Report Pearls:

Retroperitoneal fibrosis is a rare entity that involves fibrotic tissue encasing abdominal organs including the ureters. Hydronephrosis without any obvious causative lesion on abdominal ultrasound is a classic finding that was seen in this patient.

 

It can be primary or secondary in nature.  Primary disease includes IgG4 disease. Secondary causes include: Drugs, Biologics, Malignancy, Infections, Autoimmune disease, Radiation, Retroperitoneal hemorrhage, and Surgery

 

10/25/17 Resident Morning Report – Shortness of Breath, Fevers, Cough, Pleural Effusion, Pleural TB

CC: Shortness of breath, Cough

ID: This is a 20 yo female with no significant past medical history who presents with cough and shortness of breath for 2 weeks.  Three days into her course, she was diagnosed with pneumonia at an outside emergency department and was discharged home with a course of amoxicillin.  However, her symptoms worsened despite 6 days of antibiotics. New symptoms appeared a few days prior to admission including including pleuritic chest pain, worsening shortness of breath when supine, chills as well as fevers. Of note, patient is from Mexico and moved to the United States at 6 years-old.  Her family frequently visits her from Mexico, the last visit occurring one month ago. On exam patient is febrile to 39.8 degrees Celsius, tachycardic to 130 with significant findings of decrease breath sounds on the left side in addition to decrease fremitus and dullness to percussion. CXR obtained showed a large effusion that layered out on lateral decubitus position. Pleural fluid returned consistent with a lymphocyte predominant, exudative process.  Cytology was sent twice which showed no atypical cells but an elevated adenosine deaminase was detected making Pleural Tuberculosis highest on the differential.  Given the suspicion for extra pulmonary TB, a pleural biopsy was pursued and patient was empirically started on RIPE therapy. Pleural biopsy showed necrotizing granulomas but AFB stain negative.  Four weeks later, cultures from pleural fluid and pleural biopsy grew out Mycobacterium Tuberculosis.

 

CXR:

Pleural Fluid Analysis:

  • Nucleated Cells 372/cumm
  • Segmented Neutrophils 6%
  • Lymphocytes 72%
  • Monocytes 22%
  • Serum LDH 194
  • Serum Protein 8.2
  • Pleural Fluid Protein/Total Serum Protein = 0.7
  • Pleural Fluid LDH/Serum LDH = 3.3
  • pH 7.31
  • Glucose 70
  • Adenosine Deaminase 60

Pleural Biopsy:


Morning Report Pearls:

When an exudative effusion is diagnosed using Light’s Criteria, it is important to check that it is not a pseudoexudate which can occur due to inherent errors in using protein and LDH pleural/serum ratios but particularly in the setting of diuretic use.  If pleural albumin – serum albumin >1.2 then this is consistent with a pseudoexudate and the fluid likely represents a transudative effusion rather then exudative.  Pleural fluid total protein – serum total protein >3.1 can also be used instead of the albumin gradient.

 

Nucleated cell counts are useful in differentiating etiologies:

 

It is important to define if a parapneumonic effusion in a non-resolving pneumonia is complicated or an empyema.  Luckily with our patient, this was not the case.  However if diagnosed with either, management changes as the patient requires drainage of the effusion in addition to antibiotic therapy:

 

Given this patient had a true lymphocytic exudative effusion in the setting of tuberculosis risk factors, an adenosine deaminase was correctly sent. It is important to remember the utility of the various TB studies:

  • Smear and culture of pleural fluid for AFB is very specific but low sensitivity of around 5%
  • Adenosine deaminase is elevated in most tuberculosis pleural effusion with a sensitivity around 95%
  • Pleural biopsy is the most likely to yield a positive mycobacterial culture, greater then 70%