unusual cause of pleural effusion dr. mazen badawi dr. abdulrahman al-demerdash prof. omer al-amoudi

Unusual Cause of Pleural Effusion

Dr. Mazen Badawi

Dr. Abdulrahman Al-Demerdash

Prof. Omer Al-Amoudi

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

Week 2

Partial improvement Having heaviness in Rt side of chest Received 2nd course of antibiotics for

suspected pneumonia

Week 3

Patient developed shortness of breathSeen in our OPDAdmitted

Week 3 : History

Cough, pleuritic chest painSmoker for 35 years, DM and HTN on

oral medicationsOther systemic review was

unremarkable

Week 3 : Examination

Signs of Rt. Sided moderate pleural effusion

Week 3 : Examination

Incidental findings Left small breast mass Goiter

Otherwise, normal

Week 3 : Investigations

CBC, U&E , LFT normalCXR= moderate Rt sided pleural

effusion

Diagnosis so far ?…

Week 3 : Management

Initial DX Parapneumonic effusion

Pleural tapping done light yellowish fluid sent for diagnostics IV antibiotics were started Chest tube inserted

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

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

Week 4

Chest tube drainage turned to be more whitish

Daily drainage = 300cc for more than 2 weeks

?

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

Week 4 : The lab story

pleural TG sample

Surprisingly …

TG =450 mg/dl

Diagnosis :

TG > 110 mg/dl chylothorax

Possibly ruptured thoracic duct, due to : Lymphoma : HD, NHL Lung CA Mets.

Week 5

Surgeons were hesitant for immediate mediastinoscopy

Breast and thyroid lesion were biopsied

Week 6

Thyroid FNA Follicular growth, no malignant cells

Breast biopsy hemangioma

Week 7

Patient admitted under surgical care, underwent mediastinoscopy.

LN histopathology : Invasive keratinizing squamous carcinoma, well differentiated

1ry is ? : Lungs, larynx, nasopharynx, esophagus

Plan

Localizing primary site, stagingTreating

Thank You…