Bilateral Pleural Effusion Research Articles

Efficacy of Osimertinib for EGFR Exon 20 Insertion Mutation-positive Non-small Cell Lung Cancer with Brain Metastases in a Very Elderly Man

Background. Epidermal growth factor receptor (EGFR) exon 20 insertion mutations represent the third most common EGFR mutation in non-small cell lung cancer (NSCLC). EGFR tyrosine kinase inhibitors (TKIs) are highly effective for EGFR-positive NSCLC but not for EGFR exon 20 insertion mutations, which carry a poor prognosis. Case. A 90-year-old man was referred to our hospital because of an infiltrative shadow and a small nodule in the right lung on chest X-ray. Chest computed tomography revealed a mass in the right lung apex, a small nodule in the right upper lobe, a hypoattenuated area in the left lobe of the liver, bilateral pleural effusion, and enlarged mediastinal lymph nodes. Thoracentesis on the right and transbronchial lung biopsy of the mass were performed. Magnetic resonance imaging of the brain revealed contrast-enhanced nodules. We finally diagnosed the patient with lung adenocarcinoma, cT3N3M1c stage IVB. Genetic testing detected EGFR exon 20 insertion mutations. Considering the patient's age, renal function and performance status (PS), we administered osimertinib, which led to the resolution of the bilateral pleural effusion and a reduction in the size of the primary lesion, as well as the intrapulmonary and brain metastases. The progression-free survival was 5.9 months. Conclusion. In EGFR exon 20 insertion mutation-positive NSCLC, platinum-based chemotherapy has been shown to be more effective than EGFR-TKIs, including osimertinib, and has been the recommended by guidelines. EGFR exon 20 insertion mutations are generally unresponsive to EGFR-TKIs, but some case reports have demonstrated the efficacy of osimertinib. In our case, osimertinib was effective in a very old patient with EGFR exon 20 insertion mutation-positive NSCLC with brain metastases. Osimertinib may be a treatment option in the elderly for whom chemotherapy and late-line treatment options are limited.

PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study

BackgroundDiagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy.MethodsProspective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea.ResultsIn total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%–69%) before POCUS compared to 65% (95% CI 53%–75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66–0.78) before POCUS compared to 0.79 (0.73–0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82–0.91) before POCUS and 0.93 (0.88–0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%–94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%–100%).ConclusionSupplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure.Trial registration: Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1.

NON-HODGKIN LYMPHOMA PRESENTING AS RECURRENT PLEUROPERICARDIAL EFFUSION- A CASE REPORT

Non-Hodgkin lymphoma is a lymphoproliferative disorder usually affecting lymphoid organs. 20% patients with non-Hodgkin lymphoma may present with pleural effusion but pericardial involvement is rare. Pleural &amp; pericardial effusion in lymphoma are usually due to direct seeding of malignant cells or by obstruction to the lymphatic drainage of pleura &amp; pericardium. We report a case of non-Hodgkin lymphoma presenting as recurrent pleuro-pericardial effusion. A middle aged male with chief complaints of progressive dyspnea, palpitation &amp; generalized pufness for past 2 months was found to have bilateral pleural effusion, pericardial effusion, ascites &amp; generalized lymphadenopathy. Right supraclavicular lymph was node was evaluated using FNAC &amp; excisional biopsy. Pleural &amp; pericardial uids were analyzed. He was diagnosed as Non-Hodgkin lymphoma and started with Rituximab, Prednisolone, Cyclophosphamide, Vincristine &amp; Doxorubicin. Patient improved on subsequent follow up

A Case of Pseudo-Pseudo Meigs Syndrome as the Initial Presentation of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a multigenic disease leading to chronic inflammatory states within organ systems. When associated with ascites, pleural effusions, and elevated CA-125 levels, it is known as pseudo-pseudo Meigs syndrome. It is a clinical diagnosis without findings of benign or malignant ovarian tumors in patients with SLE. We present a patient case of a 42-year-old woman who presented with episodic and progressively worsening ascites, bilateral pleural effusions, and elevated CA-125 levels without any evidence of benign or malignant tumors as the initial manifestation of SLE.

Malignant pleural effusion from a case of squamous-cell carcinoma of the oral cavity: Cytological detection of a rare outcome.

Distant metastases from carcinomas of the oral cavity are rare. Detection of these metastasis are essential for staging and management of the patient. These tumours may metastasize to lung, liver, brain and bone; but pleural involvement by squamous-cell carcinoma is distinctly rare. We present a case of bilateral pleural effusion arising from distant metastasis of squamous-cell carcinoma detected on cytology.

Malignant pleural effusion, an unusual presentation of metastatic adenoid cystic carcinoma: a case report

Adenoid cystic carcinoma is a rare tumour exhibiting a dual population of myoepithelial and ductal cells, that represents 5–10% of salivary gland tumours and 1% of all head and neck malignancies.1 It is characterised by a protracted clinical course with late metastasis and poor long-term prognosis.1 Its most common site of haematogenous metastasis is the lung, followed by liver and bone.1 Despite the relatively common pulmonary and pleural involvement of metastatic adenoid cystic carcinoma, exfoliated metastatic adenoid cystic carcinoma in pleural fluid is rare.1 We report a case of a 38-year-old female who presented with respiratory symptoms on a background of adenoid cystic carcinoma of the floor of the mouth, previously treated with surgical excision and radiotherapy. Imaging studies showed multiple moderately avid pulmonary lesions, bilateral pleural thickening and effusions, and moderately avid epicardial lymph nodes. Video-assisted thoracoscopic surgery showed pleural carcinomatosis and pleural effusion. Cytologic evaluation of the pleural fluid was morphologically and immunophenotypically consistent with metastatic adenoid cystic carcinoma. The patient was referred to medical oncology for consideration of systemic therapy. Reference 1. Arshad A. Malignant pleural effusion, an unusual presentation of metastatic adenoid cystic carcinoma: a case report and review of the literature. North Am J Med Sci 2017; 10: 9–13.

Unusual presentation of rheumatoid arthritis as bilateral pleural effusion and asymmetrical arthropathy

Rheumatoid arthritis (RA) is one of the most frequent chronic autoimmune diseases affecting the joints and the appendicular skeletal system. RA can present with multiple presentations and pulmonary involvement also can occur in RA. Inflammatory pleural effusions are uncommon in RA individuals, occurring in roughly 2–5% of cases. Here, we report a case where the patient came with pleural effusion on both sides and asymmetrical arthritis with a background of cervical radiculopathy due to an injury that occurred at school age. Further examination of the individual and the pleural fluid revealed that it was compatible with pleural effusion caused by RA. The joints on the weak side were devoid of all intense features of RA. Oral non-steroidal anti-inflammatory medications and disease-modifying anti-rheumatic medicines worked effectively for the patient.

Bilateral Aspiration of Pleural Fluid in a Case of Contarini Syndrome

Contarini syndrome refers to the presence of bilateral pleural effusions with different characteristics resulting from distinct aetiologies on each side. The syndrome was named after Francesco Contarini, the 95th Doge of Venice, who had right-sided transudative effusion possibly due to heart failure, and left-sided exudative effusion due to parapneumonic effusion. While bilateral pleural effusions typically exhibit similar characteristics and are secondary to the same underlying cause, such as heart failure or malignancy, there have been rare reports of bilateral effusions with different characteristics. In this case report, we present the case of a 53-year-old female with known breast carcinoma who presented with right-sided exudative pleural effusion and left-sided transudative pleural effusion, each with distinct aetiologies, thus establishing Contarini syndrome. This report highlights the importance of considering the possibility of two separate aetiologies for bilateral pleural effusions, which should not be overlooked in clinical practice

Computed Tomography-Chest in COVID-19 Pneumonia and cardiac failure: An Imaging Enigma

BACKGROUND- Computed tomography (CT) of the chest is an efficient tool to assess COVID-19 pneumonia. Nevertheless, imaging characteristics that overlap with cardiogenic pulmonary edema are not infrequent. CT chest characteristics pose challenges for which additional transthoracic echocardiography is an additional invaluable simple tool to aid in the diagnosis. In this article, we present the CT chest findings of patients with only covid-19 pneumonia, isolated heart failure, and combined covid-19 pneumonia and heart failure. Methods- This study included 120 patients in a tertiary care hospital in South India with dyspnoea and SP02 ≤ 95% between April 2021 to March 2022 who were subjected to chest CT imaging and transthoracic echocardiography and the results were analyzed. Isolated COVID-19 (n=60), isolated heart failure (n=39), and combined covid-19 pneumonia and heart failure (n-21) were identified depending on the CT chest imaging features. Results- There was no statistical difference in the imaging findings like ground glass opacities, crazy pavementpatternswithCOVID-19pneumonia, HF, and also in combined (covid 19 + cardiac failure )groups. However, in HF patients, diffuse patterns were more common than in COVID-19 pneumonia, which was statistically significant (p=0.001). Notably, CT images in HF patients were more likely to have interlobular septal thickening (ILST)(p=0.001) cardiomegaly (p=0.001), increased artery-to-bronchus ratio (p=0.0001), and bilateral pleural effusion (p=0.0001 ), and pericardial effusion (p=0.0001 ) Conclusion- Chest CT is an indispensable tool in the early diagnosis of COVID-19 pneumonia.CT chest features overlap, and separating COVID-19 pneumonia from heart failure is not always easy. Yet, certain specific CT features may suggest heart failure over covid -19 pneumonia. In HF patients, thickening of the interlobular septa, increased artery-to-bronchus ratio, cardiomegaly, and bilateral pleural effusion, pericardial effusion are more common. Additional transthoracic echo showing dilated left ventricle with reduced ejection fraction is an additional key to aid diagnosis.

Comparison of novel coronavirus pneumonia combined with left heart failure and heavy neocoronary pneumonia in highland snowy areas

This paper collects clinical data from a patient with novel coronavirus pneumonia combined with left heart failure and a patient with severe novel coronavirus pneumonia living in a highland area. We analyzed the difference between the clinical treatment of novel coronavirus pneumonia combined with left heart failure cardiogenic shock and the clinical treatment of severe novel coronavirus pneumonia. The results showed that patients with combined left heart failure presented with typical patchy shadows in both lungs, bilateral pleural effusion, increased BNP, and a minimum partial pressure of oxygen of 48 mmHg at rest, which was converted to negative nucleic acid after antiviral, oxygen therapy, and cardiac diuresis; patients with severe novel coronavirus pneumonia had hemoptysis, multilobar patchy shadows in both lungs, massive ground glass shadows, adjacent pleural adhesions, and no pleural fluid. After oxygen therapy, antiviral drugs and hormone therapy, the patient's SPO2 increased to more than 90%, the pulmonary ground glass shadow was absorbed, and the nucleic acid turned negative. Patients with high altitude severe novel coronavirus pneumonia compared to patients with novel coronavirus pneumonia combined with left heart failure because of more severe hypoxemia due to alveolar exudation, and novel coronavirus pneumonia combined with left heart failure aggravated the severity of the disease. The increased number of hematologic tests, imaging tests, rapid diagnosis and treatment early intervention can reduce mortality in patients with severe novel coronavirus pneumonia.

Seizure-Induced Coma in Patient with Haemoglobin 1.3 gram per decilitre and MultiOrgan Dysfunction: A Rare Case Report

People of all ages are affected by anaemia which is a serious global health problem. Iron Deficiency Anaemia (IDA) seems to be the most commonly occurring type of anaemia in women. Elderly people with anaemia have higher morbidity and mortality. The purpose of treatment is to tackle the disorder’s underlying cause. Older people with persistent anaemia may need regular blood transfusions. The authors present a case report of a 55-year-old woman who visited the Emergency Department with primary complaints of convulsions and subsequent unconsciousness. She had generalised oedema and weakness since eight days. On examination she was afebrile with pulse 92 beats/min, Blood Pressure (BP) of 80 mmHg systolic. Laboratory results showed haemoglobin of 1.3 g/dL, increased White Blood Cells (WBC) and peripheral smear showed pencil-shaped cells and teardrop cells. Radiological investigation showed grade III renal parenchymal disease, cirrhosis of liver, gross ascites with bilateral pleural effusion, and splenic cyst. A 2D Echocardiography was done, which was suggestive of left ventricular hypertrophy, mild to moderate systolic dysfunction, along with dilated left ventricle. She was intubated in view of low Glasgow Coma Scale (GCS) and unconsciousness. On further stay in the hospital, she received blood transfusion. Hence, this case is a rare finding of severe anaemia.

A case of bilateral recurrent tuberculous pleural effusion in a middle-aged male

A case of bilateral recurrent tuberculous pleural effusion in a middle-aged male

Bilateral Malignant Pleural Effusion as an Initial Manifestation of Acute Lymphoblastic Leukemia: A Rare Case Report

Bilateral Malignant Pleural Effusion as an Initial Manifestation of Acute Lymphoblastic Leukemia: A Rare Case Report

Complications of synchronous microwave ablation and biopsy versus microwave ablation alone for pulmonary sub-solid nodules: a retrospective, large sample, case-control study.

This was a retrospective, large-sample, case-control study assessing the complications associated with synchronous microwave ablation (MWA) and biopsy for pulmonary sub-solid nodules or ground-glass nodules (GGNs) versus MWA alone. We aimed to verify the safety of synchronous MWA and biopsy for treating GGNs. From May 2020 to December 2021, 326 patients with GGNs were enrolled. Among them, 164 patients underwent MWA alone (group A) and 162 patients underwent synchronous MWA and biopsy (group B). We assessed the complications, technical success, and positivity rate of the biopsy. The major complications were similar between the two groups, and included pneumothorax (group A vs. group B, 19.5% vs. 13.6%; P=0.150), hemothorax (0.6% vs. 1.2%; P=1.000), pleural effusion (1.2% vs. 0.6%; P=1.000), and pulmonary infection (4.9% vs. 6.2%; P=0.609). No massive hemoptysis, bronchopleural fistula, or air embolism developed. Minor complications including intrapulmonary hemorrhage (group A vs. group B, 28.7% vs. 62.3%, P<0.001), mild pneumothorax (20.7% vs. 29.6%, P=0.587), mild ipsilateral pleural effusion (30.5% vs. 27.8%, P=0.590), mild bilateral pleural effusion (16.5% vs. 22.2%, P=0.188), and subcutaneous emphysema (4.3% vs. 5.6%, P=0.498) were observed. The side effects, including pain, cough, post-ablation syndrome, and post-ablation chronic pain syndrome, were similar between the two groups. The positive diagnosis rate of biopsy in group B was 88.3%. Compared with MWA alone, synchronous MWA and biopsy did not increase the risk of major complications. Although some minor complications developed, synchronous MWA and biopsy is safe for treating pulmonary GGNs.

Therapeutic dilemmas in the management of a patient with long-term rheumatoid arthritis and severe clinical presentation of SARS-CoV-2 infection

Introduction. The objective of this case report is to present a clinical course of SARS-CoV-2 infection in a patient with long-term rheumatoid arthritis and concomitant rituximab therapy. Case outline. A 58-year-old female patient was diagnosed with seropositive rheumatoid arthritis at the age of 35. She was primarily prescribed chloroquine and glucocorticoid, afterwards methotrexate and biological agent ? etanercept. Because of a secondary loss of response, etanercept was switched to rituximab. She had 13 cycles of rituximab and the last was given in June 2020. In December 2020, she was hospitalized due to bilateral pneumonia and respiratory insufficiency. The results of the laboratory analysis revealed anemia, leukocytosis, thrombocytosis, and markedly elevated C-reactive protein, procalcitonin, D-dimer, transaminases. The findings of the chest computed tomography scan were consistent with COVID-19 pneumonia features with accompanying bilateral pleural effusion. The patient was treated with antibiotics, corticosteroids, tocilizumab, hepatoprotective, gastroprotective, oxygen therapy, and parenteral anticoagulant. Three months after recovering from pneumonia, she developed arthritis flare, hence a JAK inhibitor, baricitinib, was started. Low disease activity was achieved with baricitinib monotherapy. Conclusion. Due to risk of severe COVID-19, caution may be required when applying immunosuppressive therapy in patients with rheumatic diseases.

Primary Cardiac Burkitt’s Lymphoma- A Deadlock

Burkitt’s lymphoma is a high-grade, extremely aggressive form of B-cell non Hodgkin lymphoma with a very fast replication time (tumour doubling time of around 25 hours). The three forms of Burkitt’s lymphoma are documented which include endemic, sporadic, and immunodeficiency associated. It is enormously rare with less than 30 cases reported till date. Primary cardiac lymphoma is a rare cardiac neoplasm. The most common type is diffuse large B-cell lymphoma. Diagnosis is usually late and with poor prognosis. Primary cardiac lymphoma is more common in immunodeficient patients. This is a case of primary cardiac Burkitt’s lymphoma which was diagnosed in a 58-year-old immunocompetent male. The patient’s two-dimensional echocardiography and plain Computed Tomography (CT) scan of the chest revealed presence of massive pericardial effusion with mild to moderate bilateral pleural effusion. Cardiac Positron Emission Tomography (PET) CT revealed a soft tissue mass at atrioventricular groove which indicated either pericardial lymphoma or inflammatory serositis. The patient was opted for surgery, but the mass was noted involving the free wall of right ventricle including the diaphragmatic surface which extended onto atrioventricular groove and base of right atrial appendage. Thus, a decision to not proceed further with surgical repair was made. The histopathological and cytogenetic findings confirmed the presence of Burkitt's lymphoma. Later, it was discovered that the patient died within one month of diagnosis.

Septic shock due to splenic abscess, complicated by empyema, secondary to colosplenic fistula post-gastrojejunostomy procedure: a case report

Background: Splenic abscess is a rare disease that can be due to many causes including infections or adnominal trauma and surgery. Complications of splenic abscess are fatal including septic shock which can be defined as sepsis leading to circulatory, cellular, and metabolic abnormalities, and the patient cannot maintain mean arterial pressure. Case Presentation: In this case, we report a 71-year-old male patient known to have diabetes mellitus, dyslipidemia, hypertension, and coronary artery disease. Past surgical history revealed that he underwent exploratory laparotomy and graham patch repair, followed by exploratory laparotomy with gastrojejunostomy. Patient has a history of deep venous thrombosis for 1 month on anticoagulant. He presented to the emergency department because of decreased level of consciousness. The patient appeared obtunded and pale, his blood pressure and oxygen saturation were low. Computed tomography (CT) pulmonary angiogram showed massive bilateral pleural effusion and abdominal CT showed splenic abscess and colosplenic fistula. Conclusion: Because splenic abscess secondary to previous abdominal surgeries is a rare condition, emergency physicians should have a high index of suspicion for such a rare phenomenon if they encounter severe sepsis or septic shock.

A Rare Case of Childhood Hepatitis A Infection with Bilateral Pleural Effusion Acalculous Cholecystitis and Massive Ascites

A Rare Case of Childhood Hepatitis A Infection with Bilateral Pleural Effusion Acalculous Cholecystitis and Massive Ascites

Demystifying a case of bilateral pleural effusion

Demystifying a case of bilateral pleural effusion

Congenital Chylothorax as a Cause of Non Immune Hydrops: A Case Report

Chylothorax is a rare cause of non immune hydrops fetalis &amp; presents with respiratory distress at birth. We present a late preterm diagnosed antenatally as hydrops with chylothorax with bilateral pleural effusion and respiratory distress at birth requiring mechanical ventilation. Baby was managed successfully with intercostal drainage, octreotide infusion &amp; MCT milk formula.