Large Bilateral Pleural Effusions Research Articles

A unique presentation of pericardial epithelioid angiosarcoma with multifaceted complications

Introduction and importance: Angiosarcomas are rare tumors of endothelial origin and may arise in any organ. Epithelioid angiosarcomas are a subtype of angiosarcoma that are rapidly progressive and typically fatal. Case presentation: The authors report a case of a 25-year-old previously healthy female who presented initially for dyspnea and palpitations, on further evaluation she was found to have large bilateral pleural effusions and cardiac tamponade. Clinical discussion: Pericardiocentesis and thoracentesis were performed alongside biopsies that revealed atypical cellular proliferation. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed avid uptake in the anterior mediastinum, perivascular, paratracheal, subcarinal and pleural lymph nodes with large FDG uptake in the bilateral pleural effusion. Mediastinoscopy was done and biopsies showed an overtly malignant, epithelioid neoplasm with foci of vaso-formation; Keeping with high-grade epithelioid angiosarcoma of the pericardium. She received six cycles of weekly paclitaxel, but imaging for abdominal pain incidentally showed evidence of metastasis to the liver and spine so she was switched to Adriamycin-Ifosfamide for which she received one cycle so far. Her hospital course was complicated by high-output pleural effusions, chylothorax, left atrial thrombus formation and an intensive care unit stay for septic shock. Conclusion: Pericardial epithelioid angiosarcoma has been reported rarely in the literature. The authors aim to report a case of extensive metastatic pericardial epithelioid angiosarcoma in a young patient; which we believe can be an addition to the literature of a malignancy associated with poor prognosis and no definitive proven treatment regimen.

S1977 Pancreatic Pleural Fistula Presenting as Large Bilateral Pleural Effusions Without Known History of Pancreatitis

S1977 Pancreatic Pleural Fistula Presenting as Large Bilateral Pleural Effusions Without Known History of Pancreatitis

Picc Line Associated Brachiocephalic Vein Rupture with Consequent Mediastinal Placement Causing Pneumomediastinum and Large Total Parenteral Nutrition Bilateral Effusion.

PICC lines, although seen as safer, have potential for catastrophic adverse effects.The use of intracavitary electrocardiogram may be a safe adjunct and even an alternative to the use of a chest X-ray.Aspirating blood from all lumens with particular emphasis on the distal most lumen is very important.

Abstract 9812: Abracadabra Alakazam: Sudden Invasion of the Pericardium by Haemophilus Influenzae

A 25 year old man presented with three days of cough, shortness of breath, and pleuritic chest pain. Initial vital signs in the ED were normal, and exam demonstrated tonsillar erythema without exudate. Labs revealed a leukocytosis of 18.9k/μL, D-dimer of 690 ng/mL, C-reactive protein of 5.7 mg/dL, and lactate elevated to 2.9 mmol/L. High-sensitivity troponin, NT-proBNP, and SARS-CoV-2 RT-PCR were all negative. Presenting electrocardiogram demonstrated PR elevation in aVR with diffuse ST-segment elevation in the inferior and anterolateral leads. Point-of-care echocardiogram demonstrated normal biventricular function without pericardial effusion. CTPA was negative for pulmonary embolism, and he was observed for presumed acute viral pericarditis. Fourteen-hours later, he became febrile to 38.3°C, tachycardic to 133 bpm, and hypotensive to 97/65 mmHg with diffuse abdominal pain. Repeat lactate was 9.0 mmol/L. This prompted an emergent CT scan which now showed a new large pericardial effusion and bilateral pleural effusions ( Panel A ). Repeat echocardiogram confirmed a large circumferential pericardial effusion with early signs of tamponade including right atrial inversion in late diastole ( Panel B ). Emergent pericardiocentesis yielded 560 mL of brown, purulent fluid ( Panel C ) with immediate improvement in hemodynamics. Bacterial gram stain and culture grew Haemophilus influenzae ( Panel D ). Immunodeficiency screening was negative. Transient severe biventricular systolic dysfunction was noted, consistent with sepsis-induced cardiomyopathy. He completed a targeted antibiotic course with partial recovery of his ejection fraction by discharge. Purulent pericarditis is rare in developed countries, and invasive H. influenzae in a young, immunocompetent adult is particularly unusual. This case illustrates the importance of early diagnosis and management of purulent pericarditis given its potential for rapid progression and high mortality.

A SERIES OF GENETIC EVENTS: FIP1L1/PDGFR REARRANGEMENT LEADING TO EOSINOPHILIC MYOCARDITIS

A SERIES OF GENETIC EVENTS: FIP1L1/PDGFR REARRANGEMENT LEADING TO EOSINOPHILIC MYOCARDITIS

A Case Of Recurrent Constrictive Pericarditis With Diffuse Fibrosis

<h3>Background</h3> Evaluation for etiology of constrictive pericarditis is essential in guiding management. Uncommon etiologies include fibrosing mediastinitis, which is caused by proliferation of fibrous tissue in the mediastinum and Erdheim-Chester disease (ECD) which is characterized by inflammatory infiltration of lesions by histiocytes, often with involvement of the pericardium and aorta. <h3>Case</h3> A 46-year-old male with a history of idiopathic retroperitoneal fibrosis with thoracic and abdominal infiltrative masses, recurrent constrictive pericarditis and pericardial effusions, and recurrent admissions for heart failure with preserved ejection fraction (HFpEF) exacerbations presented with worsening shortness of breath and lower extremity edema. He previously underwent pericardial window and steroid therapy with minimal improvement. He was diagnosed with ECD. CT scan revealed large bilateral pleural effusions, soft tissue infiltration surrounding the heart and retroperitoneum, and diffuse pericardial thickening. Echocardiography findings were suggestive of constrictive pericarditis and reduced ejection fraction of 40%. Cardiac MRI confirmed these findings. Cardiac catheterization was consistent with constrictive physiology (Figure 1 A-H). Endomyocardial biopsies revealed scattered lymphocytes with no fibrosis or histiocyte infiltration. He underwent pericardiectomy, from the superior vena cava to the inferior vena cava and phrenic nerve to left anterior descending artery, with repeat biopsies revealing acute and chronic inflammation with extensive fibrosis. Follow up echocardiography showed improvement of septal motion variation and elimination of respiratory effect on mitral valve motions. <h3>Discussion</h3> Imaging was initially concerning for ECD given cardiac findings with retroperitoneal fibrosis. However, biopsies were inconsistent with ECD. Due to constrictive physiology, he underwent pericardiectomy with repeat biopsies revealing acute and chronic inflammation with extensive fibrosis, yielding a more likely diagnosis of idiopathic fibrosing mediastinitis. Treatment for idiopathic fibrosing mediastinitis is symptomatic relief with surgical resection. <h3>Conclusion</h3> Recurrent constrictive pericarditis with extensive multiorgan fibrosis is uncommon and ECD and fibrosing mediastinitis should be differential diagnoses in order to guide appropriate management.

O16 A diagnosis of BehÇet’s Disease with secondary antiphospholipid syndrome

O16 A diagnosis of BehÇet’s Disease with secondary antiphospholipid syndrome

SPILLED MILK: BUFFALO CHEST WITH BILATERAL CHYLOTHORAX

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The term "buffalo chest" is used to define a single pleural space with no anatomic separation of the two hemithoraces, seen in an American buffalo or bison. There have been less than ten cases reported where spontaneous bilateral pneumothorax was suspected due to interpleural communication. The interpleural connection reported have been associated with major invasive thoracic procedures such as esophagectomy, cardiothoracic surgery, pacemaker and central venous catheter placements. We present a rare case of simultaneous bilateral chylothorax fashioned by such an interpleural communication. CASE PRESENTATION: A 45-year-old male chronic smoker with past medical history of esophagitis presented with one week of cough and reflux. He otherwise denied fevers, odynophagia, chest pain, weight loss or early satiety. He was hypoxic on admission requiring 2 L oxygen supplementation. Physical exam revealed decreased breath sounds in the left lower lung base. Chest radiograph showed minimal atelectasis at the left lung base. CT Chest showed a large sliding hiatal hernia with distention of esophagus and centrilobular nodules in the right middle lobe and bilateral lower lobes. The presumptive diagnosis was aspiration pneumonia likely secondary to hiatal hernia. Thus, he underwent laparoscopic para-esophageal hernia repair with EGD. Two days later, he developed acute hypoxic respiratory failure and was intubated. Chest radiograph was concerning for new large bilateral pleural effusions. Within hours, he underwent an ultrasound guided right thoracentesis draining four liters of opaque, pink, non-purulent fluid (figure 1). Left thoracentesis drained only five mL. Pleural fluid revealed pH 7.48, elevated triglycerides (600 mg/dL) and low cholesterol (50 mg/dL) indicating chylothorax. He had bilateral chest tubes placed and was on placed on bowel rest. Decision was made to evaluate for thoracic duct injury in the setting of recent hiatal hernia repair and he was taken for right video-assisted thoracoscopic surgery with thoracic duct ligation and talc pleurodesis. It was seen that there was a communication from the pleural cavity into the mediastinal area from the hiatal hernia dissection. This interpleural communication explained the resolution of the bilateral chylothorax with a single right-sided thoracentesis. Patient was extubated thereafter and was discharged. DISCUSSION: This report documents a rare case of bilateral chylothorax completely resolved with a single sided thoracentesis. The phenomenon was explained by the interpleural connection formed during hiatal hernia repair suggesting buffalo chest. CONCLUSIONS: Recognition of buffalo chest syndrome as a life-threatening complication is important in the setting of iatrogenic injuries during mediastinal surgeries. Prompt resolution can be achieved with a single sided thoracentesis. REFERENCE #1: Eguchi T, Hamanaka K, Kobayashi N, et al. Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication. Ann Thorac Surg 2011;92:1124-6 Hartin DJ, Kendall R, Boyle AA, et al. Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication. Emerg Med J 2006;23:483-6 REFERENCE #2: Männer J, Jakob C, Steding G, et al. Horseshoe lung: report on a new variant—"inverted" horseshoe lung--with embryological reflections on the formal pathogenesis of horseshoe lungs. Ann Anat 2001;183:261-5 REFERENCE #3: Rali AS, Manyam H. Bilateral Pneumothoraces Following BiV ICD Placement: A Case of Buffalo Chest Syndrome. Am J Case Rep. 2015;16:703–6. DISCLOSURES: No relevant relationships by Jaclyn Boozalis, source=Web Response No relevant relationships by Kevin Ferriter, source=Web Response No relevant relationships by Paul Harford, source=Web Response No relevant relationships by Kanza Muzaffar, source=Web Response No relevant relationships by Nisha Soneji, source=Admin input

P53-5 Severe hypercalcemia in renal cell carcinoma: The diverse manifestations of genitourinary malignancies

Hypercalcemia of malignancy is a common paraneoplastic syndrome among patients with renal cell carcinoma (RCC), affecting up to 20% of patients. We report a case of metastatic RCC in a man presenting with severe hypercalcemia. A 76-year-old gentleman presented with 2 weeks of lethargy and dyspnea. He had a 50 pack-year smoking history. Examination revealed diminished breath sounds. Abdomen was soft with mild left flank tenderness. Blood tests revealed severe hypercalcemia (corrected calcium 4.09 mmol/L, range: 2.10-2.60 mmol/L), with a concurrent suppressed parathyroid hormone (PTH) level (0.5 pmol/L, range: 1.3-7.6 pmol/L), consistent with non-PTH mediated hypercalcemia. Chest X-ray showed bilateral pleural effusions with nodular opacities. A CT demonstrated an 8cm mass arising from the superior pole of the left kidney suspicious for a renal cell carcinoma, with innumerable pulmonary nodules, large bilateral pleural effusions, as well as mediastinal, hilar and para-aortic lymphadenopathy. Iatrogenic hypercalcemia and multiple myeloma were excluded. 1,25-dihydroxyvitamin D level was normal. Measurement of parathyroid hormone-related peptide was not feasible. Following treatment with intravenous fluid and zoledronic acid, his calcium level normalized twelve days later. He underwent a therapeutic and diagnostic thoracentesis. His radiological findings and pleural fluid cytology result were in keeping with metastatic renal cell carcinoma. He was commenced on pazopanib. He required bilateral long-term indwelling pleural catheter insertion for recurrent bilateral pleural effusions. He was discharged home after 4 weeks of hospitalization but was readmitted to hospital 6 weeks later with worsening dyspnea. CT showed progression of pulmonary metastases. He died 12 weeks after his initial presentation. RCC has protean manifestations and hypercalcemia is the most common paraneoplastic complication of RCC.

AMBULATORY PLEURODESIS: SUCCESSFUL USE OF TALC WITH INDWELLING PLEURAL CATHETER FOR MANAGEMENT OF BILATERAL MALIGNANT PLEURAL EFFUSIONS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Malignant pleural effusions affect more than 750,000 patients each year in Europe and the United States and account for greater than 125,000 hospitalizations and have an estimated cost of $5 billion per year1,2. Treatment for malignant pleural effusions with expandable lung would favor treatment with talc pleurodesis and often requires days of inpatient hospitalization for management and observation3. Placement of indwelling pleural catheters (IPCs) can be used as successful alternative for management of symptoms in an ambulatory setting3,4. Additionally, administration of talc through an IPC shows increased probability of pleurodesis4. We present a patient with bilateral malignant pleural effusions with successful bilateral pleurodesis using talc instilled through bilateral IPCs. CASE PRESENTATION: A 72-year-old man with a past medical history significant for metastatic melanoma presented to the ED with complaints of progressive dyspnea at rest. Imaging revealed large bilateral pleural effusions with symptomatic improvement with therapeutic thoracentesis. Initial studies were consistent with exudative effusion with negative cytology and patient was discharged with follow-up in Pulmonary Clinic. He underwent repeat large-volume thoracentesis with repeat cytology showing metastatic melanoma. Given rapidly re-accumulating fluid and symptoms, a left IPC was placed with significant improvement and a right IPC was placed 2 weeks later with continued improvement and decreased effusions on repeat U/S. At this time, further management with talc pleurodesis was discussed to ideally eliminate the need of IPCs and enhance the patient’s quality of life. Talc was instilled per IPC plus protocol4 with subsequent ultrasound monitoring with <25 cc of output daily. Given good apposition, the left IPC was removed and 2 weeks later, talc was administered to the right IPC with similar results on ultrasound with upcoming removal of right IPC given continued good apposition and decreased drainage. DISCUSSION: We demonstrate a validated alternative treatment strategy in a patient with bilateral malignant pleural effusions. This presents a plausible alternative to patients to decrease hospital days and expenses, while improving quality of life and allowing for pleurodesis in an outpatient setting. We show success using bilateral IPCs with sequential talc pleurodesis and removal of IPCs. No hospitalizations were made during this time period and the patient tolerated all procedures well. CONCLUSIONS: Given continued advancement in techniques, we continue to show patient-centered care in a challenging population with an outpatient centered treatment approach and use of U/S imaging for clinical management. Reference #1: 1. Marel M, Zrustova M, et al. The incidence of pleural effusion in a well-defined region: epidemiology study in Central Bohemia. Chest 1993; 104:1486-9. Reference #2: 2. Taghizadeh N, Fortin M, Tremblay A. US hospitalizations for malignant pleural effusions: data from the 2012 National Inpatient Sample. Chest 2017;151:845–854. Reference #3: 3. Feller-Kopman D, Reddy C, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guidelines. Am J Respir Crit Care Med. 2018 Oct 1; 198(7):839-849. 4. Bhatnagar R, Keenan E, et al. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. N Engl J Med. 2018 Apr 5;378(14):1313-1322. DISCLOSURES: No relevant relationships by Michael Gonzales, source=Web Response No relevant relationships by Tyson Sjulin, source=Web Response No relevant relationships by John Untisz, source=Web Response

A RARE CASE OF CHYLOTHORAX SHROUDING A MALIGNANT PLEURAL EFFUSION

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Chylothorax is the collection of lymph in the pleural space and it is extremely rare to find an underlying malignant pleural effusion. Chylothorax is also usually unilateral and seldom a bilateral finding. Here we present a patient with underlying gastric malignancy with chylothorax and underlying malignant pleural effusion. CASE PRESENTATION: This was a 38 year old male who was diagnosed with gastric adenocarcinoma a month prior and completed the first round of chemotherapy, and presented to the hospital with shortness of breath and cough. Clinical exam showed a patient in no respiratory distress at rest and pulmonary exam shows stony dullness on percussion of the posterior lower lung zones. Auscultation revealed diminished vesicular breath sounds in the same area. A computerized tomography (CT) scan of the chest showed large bilateral pleural effusions and significant mediastinal lymphadenopathy. Patient underwent thoracentesis bilaterally which revealed large amount of turbid orange colored fluid. Analysis showed 58375 RBC/mm3, 2170 WBC/mm3, glucose of 64mg/dL, protein of 3.3g/dL, LDH of 873U/L, cholesterol of 64mg/dL, and triglycerides of 123mg/dL. Cytopathology revealed malignant cells positive for adenocarcinoma with gastric primary. Unfortunately, he developed recurrent pleural effusions. In view of developing recurrent episodes of respiratory distress, placement of a PleurX® catheter was planned. Unfortunately, the patient went into multi-organ system failure and eventually expired. DISCUSSION: In the review of articles of patients with gastric carcinoma, as in this case presenting with chylothorax as one of the presenting manifestations, there have been 14 accessible case reports so far and only one of them reports the fluid being malignant. A review of the primary malignancies showed that 9 exhibited signet ring cell carcinoma and 3 had poorly differentiated gastric adenocarcinoma and has been associated with high mortality and morbidity. Gastric malignancy with underlying chylothorax is a rare presentation. The mechanism is likely from tumor cells invading lymphatic channels diffusely. This obstruction causes the chylothorax however less likely is the cause for the malignant pleural effusion. The local invasion of metastatic cells into the pleural lining may have caused the malignant component. Chylothorax can also be associated with lymphedema. The chylothoraces have been treated by therapeutic thoracentesis, intercostal tube drainage and restriction of oral intake and continued treatment of the underlying cause. CONCLUSIONS: Although gastric adenocarcinoma has known to metastasize to pleural space to cause pleural effusion, this is the second case known to the best of our knowledge to have concurrent findings of chylothorax with a malignant pleural effusion. This also stands true for chylothorax from other reasons as well with the rarity of underlying malignant effusion. Reference #1: Devaraj U, Ramachandran P, Correa M, D'souza GA. Chylothorax in gastric adenocarcinoma: A case report and systematic review of the English literature. Lung India. 2014 Jan-Mar;31(1):47-52. https://doi.org/10.4103/0970-2113.125906. PubMed PMID: 24669083; PubMed Central PMCID: PMC3960811. Reference #2: Wu J, Lv L, Zhou K, Huo J. Chylothorax and lymphedema as the initial manifestations of gastric carcinoma: A case report and review of the literature. Oncol Lett. 2016 Apr;11(4):2835-2838. https://doi.org/10.3892/ol.2016.4285. Epub 2016 Feb 29. PubMed PMID: 27073560; PubMed Central PMCID: PMC4812189. DISCLOSURES: No relevant relationships by Jacob Mathew, source=Web Response No relevant relationships by Anish Samuel, source=Web Response No relevant relationships by Ahmed Sharaan, source=Web Response

Stretching et chylothorax

Chylothorax is a rare cause of pleural effusion. The most common causes are iatrogenic or medical. We report an unusual and rare cause of bilateral chylothorax. A 73-year-old woman with no past history was admitted to the emergency department for sudden onset of dyspnoea. Chest X-ray and thoracic CT scan revealed large bilateral pleural effusions. Analysis of the fluid revealed a chylothorax. The patient was treated by chest tube drainage and a fat free (medium chain triglyceride) diet. This led to drying up of the effusions and rapid discharge. Complementary imaging examinations with chest-abdomen-pelvis CT, PET CT and pelvic MRI did not reveal any underlying cause. The final diagnosis was bilateral traumatic chylothorax caused by tearing of the thoracic duct during stretching exercises. Following a literature review, similar cases with the same clinical presentation were found. Combined treatment with thoracic drainage and medium chain triglyceride diet was effective in drying up the effusions. Our diagnosis was a diagnosis of exclusion. It is important to exclude a medical cause by thorough investigation.

Large Pericardial Effusion Due to Paragonimiasis in a 4-Year-Old Chinese Boy.

Large pericardial effusion (PE) and bilateral pleural effusion were found in a 4-year-old Chinese boy. An emergent surgery was performed. The biopsy showed massive eosinophil infiltration. Serologic test for Paragonimus skrjabini was positive. Postoperative praziquantel therapy was effective.

Native Valve Propionibacterium acnes Endocarditis From Self-injection of Vitamins

Native Valve Propionibacterium acnes Endocarditis From Self-injection of Vitamins

Mediastinal Lymphoma Presenting as a Pericardial Effusion and Systolic Murmur

A healthy Taiwanese 28-year-old male presented with 1 month of dyspnoea, non-productive cough and night sweats that were unresponsive to multiple courses of antibiotics. On presentation he was febrile, tachycardic and tachypnoeic, with an elevated jugular venous pressure, systolic murmur and reduced air entry at both lung bases. His C-reactive protein (120 mg/L) and lactate dehydrogenase (LDH) (443 U/L) were elevated. Large bilateral pleural effusions were confirmed on chest x-ray. Urgent echocardiography demonstrated a large pericardial effusion with features of tamponade. The right ventricle (RV) was also noted to be dilated. Successful pericardiocentesis was performed without improvement in tachycardia or inferior vena cava (IVC) dimension.

Massive Serositis as the Initial Presentation of Systemic Lupus Erythe-matosus: A Report of Two Cases and Review of the Literature

Large volume effusions as a manifestation of active systemic lupus erythematous (SLE) is rare, and when it does occur, it is usually associated with complications of chronic lupus disease, such as nephrotic syndrome, constrictive pericarditis, heart failure or Budd-Chiari syndrome. Massive serositis as a presenting feature of SLE is rare. We de-scribe two adult cases of new onset SLE presenting with massive ascites in the first case, and large bilateral pleural effusions in the second case. The serositis in both patients responded well to high dose steroid therapy with signifi-cant improvement in symptoms. Only a small number of case reports describing massive ascites or large pleural effusions as initial manifestations of new onset SLE have been published. A literature review of these case reports and their treatment outcomes is described.

Plasmablastic lymphoma presenting as a large intracardiac mass and bilateral pleural effusions

Plasmablastic lymphoma (PBL) is a rare aggressive lymphoma arising most frequently in the oral cavity of HIV-infected patients. Rare cases of PBL have been reported in extra-oral sites, as well as in HIV-negative patients. Cardiac involvement by lymphoma is very rare. The most common primary cardiac lymphoma is diffuse large B-cell lymphoma. We report an unusual case of PBL in a 49-year-old, HIV-positive man presenting with a large intracardiac mass and bilateral pleural effusions. Histological examination of the cardiac mass biopsy and cytological evaluation of the pleural fluid demonstrated large lymphoma cells with plasmablastic differentiation. By immunohistochemistry, the large lymphoma cells expressed CD30, CD45, CD138, MUM1, and kappa light chain, were weakly positive for EMA, and were negative for T-cell and B-cell markers, lambda light chain, and human herpes virus 8 (HHV8). In situ hybridization for Epstein Barr Virus-encoded RNA (EBER) was negative in large lymphoma cells. To our knowledge, in the English literature, this is the second reported case of PBL with cardiac origin and the first reported case of PBL that presents as a combination of intracardiac mass and pleural effusions.

Electrical alternans due to large bilateral pleural effusion without pericardial effusion

A 53-year-old woman, with a history of breast cancer presented with acute respiratory failure (arterial oxygen saturation 87% while the patient was breathing 15L/min of oxygen) and pulsus paradoxus in the setting of sepsis and acute renal failure. Electrocardiogram showed electrical alternans associated with 2/1 intermittent precordial ST-segment elevation (Fig. 1A, arrows). Bedside echocardiography showed left ventricular systolic dysfunction associated with large bilateral pleural effusions (white arrows) and small pericardial effusion (asterisk) (Fig.

Case-based discussion from North Tyneside General Hospital: somatostatin analogues in yellow nail syndrome associated with recurrent pleural effusions

Kristian Brooks (KB): A 77-year-old man presented to accident and emergency with a 1-month history of progressive breathlessness and reduced exercise tolerance. He had no chest pain, cough or wheeze,...

A very complicated pleural effusion

Case report A 33-year-old male attended the emergency department with a three day history of dyspnoea. He had previously completed treatment for pulmonary tuberculosis and was HIV-positive on antiretroviral therapy. On examination, he was tachypnoeic with saturations of 89% on air. He had reduced air entry throughout the right lung and muffled heart sounds. He was afebrile and haemodynamically stable. Plain chest radiograph showed large bilateral pleural effusions, worse on the right. Urgent small-bore catheter drainage of the right lung was performed. Biochemistry showed an exudative effusion. 3.2 litres of fluid was drained within 4 hours, with an improvement in clinical condition. The patient then became increasingly tachypnoeic and rapidly desaturated. Repeat chest radiograph showed partial drainage of the effusion, however now with a 2 cm pneumothorax and oedematous right lung field. Sublingual nitrate, furosemide and an intercostal drain were placed with initial good response. The patient was admitted, but unfortunately died overnight. Discussion Re-expansion pulmonary oedema is a recognised complication of large pleural effusion drainage. The mechanism remains unclear, although reduced left ventricular function, in this case from a possible pericardial effusion, may be a precipitant. To prevent this phenomenon the British Thoracic Society recommends draining a maximum of 1.5 litres of fluid. This case was further complicated by a pneumothorax; again a recognised complication, especially if there is underlying poor compliance of the lung parenchyma. Re-expansion pulmonary oedema has an incidence of