LEFT-SIDED PLEURAL EFFUSION, ASCITES AND LEIOMYOMATA: AN UNUSUAL CASE OF PSEUDO-MEIGS' SYNDROME

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meigs' Syndrome has been described as the development of ovarian fibroma or fibroma-like mass with pleural effusion and ascitic fluid. It is present in approximately 1% of all ovarian fibroma, thecoma and granulosa cell tumors. Pseudo-Meigs' Syndrome is secondary to benign etiologies and reported to be more uncommon. These syndromes should be considered in women with the clinical triad of pleural effusion, ascites and a pelvic mass and can mimic more serious malignant tumors [1]. A thorough evaluation including biopsy and peritoneal and pleural fluid analyses need to be performed. CASE PRESENTATION: A G0P0 29-year-old female presents with chills and fatigue since the start of her menstrual cycle. She was found to be tachycardic, tachypneic and hypoxemic to 85% with moderate abdominal distention. CT of the chest, abdomen and pelvis showed a large left-sided pleural effusion, multiple abdominal masses with compressive effect and large-volume abdominal ascites. CA-125 level was elevated at 295 U/ml. Biopsy showed small muscle proliferation with bland spindle cells and no malignant features. Thoracentesis was consistent with exudative effusion and negative cytology. Left-sided pleural effusion continued to reaccumulate requiring multiple thoracenteses. Patient underwent left pleuroscopy with pleural biopsies showing fibrotic pleura and reactive mesothelial proliferation, negative for malignancy. There was an active ascitic fluid leak into the left hemithorax through a small, thinned-out region in the dome of the left hemidiaphragm. She underwent abdominal myomectomy several months later with resolution of symptoms. Final pathology was consistent with leiomyomata. DISCUSSION: We describe a case of abdominal leiomyomatosis resulting in ascites and leak into the left hemithorax with recurrent exudative pleural effusions and resolution after surgical myomectomy, consistent with Pseudo-Meigs' Syndrome [2]. Right-sided pleural effusions are most common as pleural fluid collects due to fluid leakage from edematous tumor resulting in translocation via diaphragmatic pores into the right hemidiaphragm [3]. Effusions are exudative in nature, although in previous studies only 1.6% of patients underwent pleural fluid analysis [4]. CA-125 are typically found to be elevated, with normalization post-surgery [5]. CA-125 levels were not re-checked post-myomectomy in our case. Surgical tumor removal results in resolution of ascites and pleural effusion [5]. Therefore, in patients presenting with pleural effusion and ascites in the setting of abdominal leiomyomata, Pseudo-Meigs' Syndrome should be suspected, and pleural fluid analysis and cytology play an important role in aiding diagnosis and further management. CONCLUSIONS: The prompt evaluation of patients with leiomyomatosis presenting with ascites and large pleural effusion can be vital in guiding future interventional management. REFERENCE #1: 1. Cowan M, Crantz J, Welsh S, Nahhas W, Lindheim SR. A rare case of acute pseudo-Meigs' Syndrome presenting with pleural effusion and ascites and a ruptured leiomyoma and hemorrhagic shock. Obstet Gynecol Cases Rev. 2016. 3:070. REFERENCE #2: 2. Peparini N, Chirletti P. Ovarian malignancies with cytologically negative pleural and peritoneal effusions: demons' or meigs' pseudo-syndromes? Int J Surg Pathol. 2009 Oct; 15(5):396-7.3. Meyers MA. The spread and localization of acute intraperitoneal effusions. Radiology. 1970 Jun;95(3):547-54. REFERENCE #3: 4. Krenke R, Maskey-Warzechowska M, Korczynski P et al. Pleural effusion in Meig's syndrome - transudate or exudate? Systematic review of the literature. Medicine (Baltimore). 2015 Dec; 94(49): e2114.5. Nguyen P, Yazdanpanah O, Schumaker B. Meigs' versus Pseudo-Meigs' Syndrome: A case of pleural effusion, ascites, and ovarian mass. Cureus. 2020 Aug; 12(8): e9704. DISCLOSURES: No relevant relationships by Sally Askar, source=Web Response No relevant relationships by Patrick Bradley, source=Web Response No relevant relationships by Labib Debiane, source=Web Response No relevant relationships by Shaikh Husnain, source=Web Response