A 69-Year-Old Woman With Recurrent Symptomatic Pleural Effusions

Abstract

### History The patient is a 69-year-old woman from Venezuela who was referred for evaluation of chronically recurring symptomatic pleural effusions. She had a history of stage II invasive ductal carcinoma of the left breast treated with mastectomy and radiation therapy in 1982, autoimmune cholangitis, and severe osteoporosis. On admission, the patient had bilateral pleural effusions and complained of severe dyspnea on exertion. She could not walk further than 20 ft without severe shortness of breath. The patient noted that the dyspnea improved with laying flat in bed. She also complained of a chronic nonproductive cough and bilateral swelling of her lower extremities. She had no complaints of chest pain, sputum production, fever, or night sweats. She did note a 15-lb weight loss over the previous 6 months. The patient’s evaluation had begun before this admission, in part in Venezuela as well as in our medical center. The patient had undergone several thoracenteses, all of which produced fluid characterized as a transudate that was negative for malignancy and infectious disease. Pleural biopsy likewise was nondiagnostic, revealing fibrosis and mesothelial hyperplasia. Pulmonary function tests revealed mild airway obstruction in May 1993 and August 1994. There was significant improvement in airway mechanics after inhalation of a bronchodilator. The diffusion capacity for carbon monoxide was substantially reduced to 49% of predicted in 1994, whereas the diffusion limit for carbon monoxide (DLco) was 81% of predicted in 1993. Cardiac catheterization performed in February 1994 revealed normal coronary arteries. Multiple gated acquisition (MUGA) radionucleotide ventriculography revealed an ejection fraction of 65%. Echocardiogram was reported to show that the left and right ventricles were normal in size and systolic function, the left atrium was mildly dilated, and there was minimal mitral regurgitation and no pericardial effusion. The patient’s past medical history revealed she had breast cancer in …