ANASARCA AND MALIGNANT PLEURAL EFFUSION

Abstract

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Anasarca is commonly caused by proteinuria, gastroenteral protein loss, low-synthesis states, or low intake. Etiologies of anasarca include nephrotic syndrome, cirrhosis, protein-losing enteropathy, and malnutrition [1]. Our case describes diffuse edema secondary to protein loss from recurrent malignant pleural effusion, an etiology not previously reported in the literature. CASE PRESENTATION: A 59-year-old male with stage IV non-small cell lung cancer presented with complaint of increased bilateral lower extremity edema. In the preceding month he had experienced recurrent right-sided pleural effusions requiring multiple thoracenteses and placement of a right indwelling pleural catheter. He reported draining up to 800 cc daily, with volumes of 500 cc every other day at the time of admission. The patient's lower extremity edema evolved over a span of one month and had significantly increased just prior to admission, precluding his ability to don footwear. The patient's exam was significant for diffuse edema most prominent at the feet and ankles and diminished breath sounds with dullness to percussion at the right lung base. Workup showed non-nephrotic range proteinuria, no evidence of cirrhosis, and normal ejection fraction on transthoracic echocardiogram. His total serum protein was 5.3 g/dL and serum albumin was 2.6 g/dL. He continued to drain pleural fluid from his pleural catheter at an average of 150-250cc/day. Pleural fluid protein was as high as 2.2 g/dL. Average daily pleural drainage was 200 cc, resulting in a daily protein loss of approximately 4g/day. This degree of protein loss was surmised to be the likely cause of the patient's anasarca. Over the course of his admission, the patient underwent multiple dialysis sessions resulting in a total net weight loss of 15kg. He demonstrated improvement in edema about his abdomen and legs but his ankles and feet continued to have pitting edema to a depth of 4-5 mm. DISCUSSION: This is an unusual case of protein loss via recurrent pleural effusion leading to anasarca. Diffuse edema resulting from recurrent/persistent malignant has not been previously described and thus, there is no clear guidance regarding potential complications nor management options. Other more common causes of anasarca may give some insight regarding potential problems and possible therapies. In low-protein states, diuresis has been a standard of care. Data from the treatment of nephrotic syndrome has demonstrated the loss of clotting factors resulting in coagulopathy. Additionally, patients are at increased cardiac risk due to increased lipid levels from upregulated liver synthesis [2]. Furthermore, loss of antibodies and other proteins theoretically increases the risk for infection [3]. CONCLUSIONS: The prevalence of malignant effusions leading to anasarca is unclear. This case highlights a cause of anasarca that should be considered in similar patient populations. REFERENCE #1: Blankfield RP, Finkelhor RS, Alexander JJ, Flocke SA, Maiocco J, Goodwin M, Zyzanski SJ. Etiology and diagnosis of bilateral leg edema in primary care. Am J Med. 1998;105(3):192. REFERENCE #2: Crew RJ, Radhakrishnan J, Appel G. Complications of the nephrotic syndrome and their treatment. Clin Nephrol. 2004;62(4):245. REFERENCE #3: Umar SB, DiBaise JK. Protein-losing enteropathy: case illustrations and clinical review. Am J Gastroenterol. 2010;105(1):43. Epub 2009 Sep 29. DISCLOSURES: No relevant relationships by Jaime Stull, source=Web Response