Left-sided Pleural Effusion Research Articles

Unveiling the Rarity: Pleural Metastasis of Papillary Thyroid Cancer – A Case Report and Clinical Implications

Papillary thyroid cancer (PTC) is an epithelial malignancy arising from the follicular cells within the thyroid, typically slow-growing with a benign course (5-year survival >99% in locally contained malignancies). However, in unusual cases, this condition can spread to the pleura, leading to a malignant pleural effusion. The authors present a case of an 80-year-old female presenting with dyspnoea following treatment for suspected bacterial pneumonia. Imaging revealed a substantial left-sided pleural effusion. Despite interventions such as thoracentesis and intravenous antibiotics, the pleural effusion persisted. Subsequent video-assisted thoracic surgery revealed pleural biopsies positive for PTC, a disease previously believed to have been cured almost 6 decades ago. Pleural involvement in patients with PTC is exceptionally rare. A literature review conducted between 1992–2023 revealed merely seven published reports documenting PTC metastasis to the pleura. The authors’ case emphasises the significance of exploring various potential causes of a patient showing signs of subacute dyspnoea, particularly in individuals previously diagnosed with PTC, as it emphasises the possibilities of unforeseen recurrence, featuring the uncertainties and complexities of managing PTC.

Whitaker syndrome: A case report of autoimmune polyendocrine syndrome type 1 with dilated cardiomyopathy.

This case report highlights dilated cardiomyopathy as a cardiovascular complication in autoimmune polyendocrine syndrome type 1 (APS-1), emphasizing the need for early recognition and a multidisciplinary approach. Comprehensive care and regular follow-up are crucial in managing these atypical presentations to optimize patient outcomes. APS-1, also known as Whitaker syndrome, is characterized by a triad of mucocutaneous candidiasis, adrenal insufficiency, and hypoparathyroidism. This rare autosomal recessive disorder results from mutations in the autoimmune regulator (AIRE) gene. Cardiovascular and pulmonary manifestations in APS-1 are infrequently reported in the literature. We present a case of a 28-year-old male who presented with shortness of breath and pedal edema. Physical examination revealed alopecia, absence of eyebrows, hyperpigmentation on joints, oral candidiasis, and nail dystrophy. Echocardiography demonstrated dilated cardiomyopathy (DCM) and pericardial effusion. Chest x-ray showed left-sided pleural effusion. Laboratory investigations revealed hypocalcemia, hyperphosphatemia, low parathyroid hormone (PTH), low cortisol, and high adrenocorticotropic hormone (ACTH) levels. The combination of chronic mucocutaneous candidiasis (CMC), hypoparathyroidism, and adrenal insufficiency confirmed the diagnosis of APS-1. To the best of our knowledge, this is the first Pakistani and second worldwide reported case of APS-1 presenting with such a combination of manifestations. Early recognition and multidisciplinary management are crucial for improving outcomes in these patients.

Identifying Early Risk Factors for Postoperative Pulmonary Complications in Cardiac Surgery Patients.

Background and Objectives: Postoperative pulmonary complications (PPCs) are common in patients who undergo cardiac surgery and are widely acknowledged as significant contributors to increased morbidity, mortality rates, prolonged hospital stays, and healthcare costs. Clinical manifestations of PPCs can vary from mild to severe symptoms, with different radiological findings and varying incidence. Detecting early signs and identifying influencing factors of PPCs is essential to prevent patients from further complications. Our study aimed to determine the frequency, types, and risk factors significant for each PPC on the first postoperative day. The main goal of this study was to identify the incidence of pleural effusion (right-sided, left-sided, or bilateral), atelectasis, pulmonary edema, and pneumothorax as well as detect specific factors related to its development. Materials and Methods: This study was a retrospective single-center trial. It involved 314 adult patients scheduled for elective open-heart surgery under CPB. Results: Of the 314 patients reviewed, 42% developed PPCs within 12 h post-surgery. Up to 60.6% experienced one PPC, while 35.6% developed two PPCs. Pleural effusion was the most frequently observed complication in 89 patients. Left-sided effusion was the most common, presenting in 45 cases. Regression analysis showed a significant association between left-sided pleural effusion development and moderate hypoalbuminemia. Valve surgery was associated with reduced risk for left-sided effusion. Independent parameters for bilateral effusion include increased urine output and longer ICU stays. Higher BMI was inversely related to the risk of pulmonary edema. Conclusions: At least one PPC developed in almost half of the patients. Left-sided pleural effusion was the most common PPC, with hypoalbuminemia as a risk factor for effusion development. Atelectasis was the second most common. Bilateral effusion was the third most common PPC, significantly related to increased urine output. BMI was an independent risk factor for pulmonary edema development.

Pulmonary Actinomycosis in a 65-Year-Old Female with Poor Oral Dentition.

Pulmonary actinomycosis is an uncommon clinical entity that can be challenging to diagnose due to its non-specific symptomatology. Misdiagnosis and delayed treatment may result in invasive procedures and extended antimicrobial treatment courses. We report a case involving a 65-year-old female with poor oral dentition admitted for acute respiratory failure subsequently found to have a left-sided pleural effusion and perihepatic abscess formation. Cytopathology examination and microbiology studies confirmed the diagnosis of pulmonary actinomycosis.

Splenic abscess and infective endocarditis.

To determine the background, bacteriological, clinical and radiological findings, associated lesions, treatment and outcome of splenic abscesses (SAs) in infective endocarditis (IE). Retrospective study (2005-2021) of 474 patients with definite IE. The diagnosis of SA was made in 36 (7.6%) patients (31, 86.1%, males, mean age = 51.3) on abdominal CT. The main implicated organisms were Streptococcus spp (36.1%), Enterococcus faecalis (27.7%), Staphyloccus spp (19.4%). Rare agents were present in 10 patients (27.8%). Pre-existing conditions included a prosthetic valve (19.4%), previous IE (13.9%), intravenous drug use (8.4%), diabetes (25%) alcohol abuse (13.9%), liver disease (5.5%). Vegetations ≥ 15mm were present in 36.1%. Common presentations were abdominal pain (19.4%) and left-sided pleural effusion (16.5%). SA were more often small (50%; 7 multiple) than large (36.1%; 1 multiple) or microabscesses (13.9%, 3 multiple). Associated complications were extrasplenic abscesses (brain, 11.1%; lung, 5.5%; liver, 2.8%), infectious aneurysms (16.7%: 3 intracranial, 1 splenic, 1 hepatic, 1 popliteal), emboli (brain, 52.8%; spleen, 44.4%, 5 evolving to SA; kidney, 22.2%; aorta, 2.8%), osteoarticular infections (25%). Twenty-eight (77.8%) patients only received antimicrobials, 7 (19.4%) underwent splenectomy, after cardiac surgery in 5. One had percutaneous drainage. The outcome was uneventful (follow-up 3months-14years; mean: 17.2months). In SA-IE patients, the prevalence of vegetation size, Enterococcus faecalis, rare germs, diabetes, osteo-arthritic involvement and cancer was higher than in non-SA patients. Some SAs developed from splenic infarcts. IE-patients with evidence of splenic emboli should be evaluated for a possible abcedation. Cardiac surgery before splenectomy was safe.

Suspected Case of Histoplasmosis-Related Immune Reconstitution Inflammatory Syndrome Manifesting as Unilateral Pleural Effusion

Background: Histoplasmosis is a prevalent endemic mycosis that frequently causes opportunistic infections among individuals living with HIV (human immunodeficiency virus), and acquired immunodeficiency syndrome (AIDS). The initiation of antiretroviral therapy (ART) can result in a rare histoplasma-associated immune reconstitution inflammatory syndrome (IRIS) that may be difficult to distinguish between active progressive disease and inflammatory reaction to the medication. Case report: A 35-year-old male with newly diagnosed HIV and cervical biopsy-confirmed histoplasmosis was admitted from the emergency department with disseminated histoplasmosis for HIV antiretroviral treatment and antifungal treatment. Discharged after a 2-week inpatient treatment the patient returned 1 week later with a large left pleural effusion. Two liters of serosanguinous fluid were removed and all fluid cultures and cytology were negative. An extensive work-up remained negative, and given the timeline of presentation in relation to the initiation of ART, it was felt that this isolated left-sided pleural effusion was a manifestation of IRIS. Eventually, corticosteroids were given for IRIS and the patient improved and was discharged on long-term treatment. Conclusions: Immunocompromised subjects are at serious risk for a virulent, aggressive, rapidly advancing histoplasma infection and should be counselled accordingly. Any clinical signs or symptoms of organ system deterioration or compromise should be reported to the provider and a workup for histoplasmosis considered. In patients treated with antiretrovirals, IRIS is particularly confounding since it is difficult to differentiate from active disease. Using corticosteroids in already immunocompromised patients with an established fungal infection requires caution. Compliance with treatment is one of the most important components of care, especially considering the months of protocol.

Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature

BackgroundPancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion.Case presentationA 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy.ConclusionThe management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

Pleural epithelioid hemangioendothelioma in a 39-Year-old female: a case report

BackgroundEpithelioid hemangioendothelioma (EHE) is a rare malignancy of vascular origin which can be primarily be seen in various tissues. EHE originating from the pleura is an even more uncommon subtype which may mimic mesothelioma and pleural carcinomatosis. The prognosis of pleural EHE is poor and there is no consensus on the optimal therapeutic approach.Case presentationA 39-year-old middle-eastern female presented with progressive dyspnea and left shoulder discomfort. Chest computed tomography scan revealed a left side pleural effusion and pleural thickening. Pleuroscopy was done and biopsies were taken which were positive for CD31, CD34, CK, factor 8-R-antigen, and vimentin. Patient was diagnosed with pleural epithelioid hemangioendothelioma (PEHE) and chemotherapy was started and underwent extrapleural pneumonectomy 7 months later. Unfortunately, the patient passed away 10 months after diagnosis due to disease complications.ConclusionsOnce PEHE is suspected in histology it can be confirmed with immunohistochemistry. Chemotherapy, surgery or a combination of both is currently used as the treatment but the standard treatment remains a question.

A Possible Case of Hypertensive Crisis With Aortic Dissection After an Anti-COVID-19 Vaccine.

Aortic dissection, a potentially fatal event, usually presents with acute intense chest or back pain. Painless aortic dissections constitute about 10% of all cases. High blood pressure is a common finding in both painless and painful aortic dissections. During the coronavirus disease (COVID-19) pandemic, various anti-COVID vaccines have been massively used. Although these vaccines are generally safe, there is a small risk of adverse effects which are mostly mild and transient, but sometimes they could be life-threatening. We report a case of painless aortic dissection that occurred within minutes of receiving the COVID-19 inactivated vaccine. A 65-year-old woman with chronic controlled systemic hypertension developed slurred speech, decreased level of consciousness, generalized weakness, and dyspnea without chest, back, or abdominal pain a few minutes after receiving the second dose of inactivated COVID-19 vaccine; she had a systolic blood pressure of 220mmHg and left-sided pleural effusion. Drainage of the pleural effusion revealed gross blood and a spiral chest and mediastinum CT with intravenous contrast showed a penetrating atherosclerotic ulcer in the descending aorta. Therefore, thoracic endovascular aortic repair (TEVAR) was carried out, and the patient was discharged in satisfactory condition after 3days.

Point-of-care Ultrasound Identification of Tension Hydrothorax in the Emergency Department: A Case Series.

Tension hydrothorax is an uncommon emergent condition in which hemodynamic instability and respiratory compromise may occur. Emergency physicians may diagnose tension hydrothorax by point-of-care ultrasound. We discuss the key sonographic features assisting in identification. Four patients with history of malignancy who were found to have tension hydrothorax exhibited the following common ultrasound findings: massive, left-sided pleural effusion; complete, compressive atelectasis; and shift of cardiac structures into the right hemithorax, resulting in right-sided probe placement to obtain cardiac views. This is the first instance to our knowledge of point-of-care ultrasound findings in tension hydrothorax to be described in the literature.

Transudative Tuberculous Pleural Effusion Mimicking Massive Pericardial Effusion: A Case Report

The presentation of a patient with a pleural effusion can range from an incidental finding to a serious condition, which can lead to being hemodynamically compromised. Here, we discuss a 24-year-old male with a history of childhood tuberculosis who presented with shortness of breath (SOB), a non-productive cough, and recent weight loss. On examination, he was dyspnoeic but alert. On echocardiographic evaluation, a massive effusion that looked like a massive pericardial effusion was seen, while a further CT scan of the thorax showed a massive unilateral left-sided pleural effusion. Although no tuberculosis (TB) was seen in the sample of thoracocentesis, the patient was referred to a TB centre because of a history of previous tuberculosis and recent weight loss. Pleural effusion and pericardial effusion can be differentiated using echocardiography. In conditions where it is impossible, further imaging, like computer tomography, may be needed to differentiate between them. Keywords:Pleural effusion; Tuberculosis; Pericardial effusion; Cardiac tamponade

Post-Cardiac Injury Syndrome (Dressler Syndrome) Following Atrial Septal Defect (ASD) Repair: a Case Report

Dressler syndrome is a type of secondary pericarditis that can be accompanied by pleural effusion or pericardial effusion resulting from injury of the pericardium or heart tissue. A 33-year-old male was admitted to the emergency department with pleuritic chest pain radiating to both shoulders and fever. Two months before the admission, the patient underwent traditional open-heart surgery with median sternotomy and pericardiectomy for atrial septal defect (ASD) closure. Blood tests showed elevated acute phase reactants (leukocytosis, high erythrocyte sedimentation rate, and C-reactive protein). Left-sided pleural effusion was revealed on chest CT scan. Diagnosis of Dressler syndrome was established. The patient’s pleuritic chest pain and shoulder pain improved clinically with a short course of colchicine. Although Dressler syndrome is rarely seen, it should be considered in the differential diagnosis of pleuritic chest pain. Special attention should be paid to Dressler’s syndrome because pericarditis can develop following cardiac surgery.

June 2023 Medical Image of the Month: Solitary Fibrous Tumor of the Pleura

No abstract available. Article truncated after 150 words. An 85-year-old man presented to our institution for a second opinion and for management of a recurrent left-sided pleural effusion. The patient has a history of CLL, which was diagnosed with a chest wall biopsy 4 years prior to presentation. Since that time, he has undergone chemotherapy and had a good response. In the past 18 months, the patient has had their left-sided pleural effusion drained 24 times. The patient also has a history of hypothyroidism and has had a cholecystectomy. The patient brought multiple outside imaging studies with him for review. An image capture from a recent ultrasound-guided left thoracentesis (Figure 1A) demonstrated, in retrospect, a pedunculated left lower lobe mass. An outside PET-CT (Figure 1B) was also available, confirming the presence of this mass, which had relatively uniform, low level FDG uptake such that it evade notice on first interpretation. A CT angiogram (Figure 2) demonstrated a large …

Chylothorax due to hepatic alveolar echinococcosis with infiltration of diaphragm and left pleura: a case report

BackgroundAlveolar echinococcosis (AE) is an endemic parasitic zoonosis in Germany. In most cases, the liver is the primary organ affected.Case presentationA 59-year old female patient presented with increasing exertional dyspnea and unintentional weight loss. A computed tomography (CT) scan showed a left-sided chylous pleural effusion and multiple intrahepatic masses with infiltration of the diaphragm and the pleura. The findings were initially misinterpreted as hepatocellular carcinoma (HCC) with infiltrating growth. Liver biopsy of one of the masses showed no evidence of malignancy, but an amorphous necrosis of unclear origin. HCC was further ruled out by magnetic resonance imaging (MRI). However, MRI findings were highly suspicious for hepatothoracic dissemination and complications due to AE. Typical histologic findings in a repeated and more specific examination of the liver tissue and a positive serology for echinococcosis confirmed the diagnosis of AE. As the hepatic and pulmonary manifestations were considered inoperable in a curative matter, an anti-parasitic treatment with albendazole was initiated. A video-assisted thoracoscopic surgery (VATS) with removal of the chylous effusion as well as a talc pleurodesis was performed to relieve the patient from dyspnea. Two months later, the patient was asymptomatic and a positron emission tomography (PET)-CT-scan with [18 F] fluoro-2-deoxy-d-glucose (FDG) showed a remarkable diminution of the hepatic manifestation.ConclusionsThis case demonstrates a rare presentation of alveolar echinococcosis with a focus on pulmonary symptoms, emphasizing the importance of evaluation for pulmonary involvement in patients with AE and respiratory symptoms.

Extramedullary relapse of Immunoglobulin A-kappa myeloma manifesting as plasmacytoma of the pleura without bone marrow involvement and following autologous bone marrow transplant: a case report

BackgroundRecurrence of multiple myeloma is among the most challenging issues for patients and treating physicians reported after autologous stem cell transplantation. However, extramedullary involvement after chemotherapy and transplantation has been rarely reported, especially as pleural manifestations. Protein electrophoresis indicated immunoglobulin A monoclonal kappa plasma cell neoplasm in our case.Case presentationA 48-year-old middle-eastern man was referred to our clinic with cough, dyspnea, fever, and left side pleural effusion. A year after chemotherapy and autologous bone marrow transplantation, the patient presented with features in favor of pleural relapse, without bone marrow involvement. Protein electrophoresis demonstrated immunoglobulin A monoclonal kappa plasma cell neoplasm in our case. The patient was effectively treated with dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide with no notable adverse effects.ConclusionPhysicians should be aware of various presentations of multiple myeloma relapse, especially in autologous stem cell transplantation patients. Atypical and unique presentations such as the pleural involvement warrant further reporting of evidence to provide early management and treatment options.

Thoracic duct leakage in a patient with Type B-Non-Hodgkin lymphoma treated with transvenous retrograde access embolization: a case report.

Thoracic duct (TD) is the largest lymphatic vessel in the body and drains the lymph at the junction between the left subclavian and jugular veins. Chylothorax (CTX) represents an accumulation of lymphatic fluid in the pleural space. We present a case of a 65 years-old man with an histologically diagnosed mediastinal type B non-Hodgkin Lymphoma, treated with chemo-immunotherapy. CT scan during follow up showed significant left side pleural effusion, amounting to 2.8 litres after drainage. Conservative treatment with low fat parenteral nutrition was started without reduction of drainage output, then lymphangiography (LP) with Lipiodol was performed demonstrating a leak in the distal TD. CTX increased in the following days, and a further LP was performed. Using transvenous retrograde access we catheterized TD at the left subclavian jugular veins using a microcatheter. The leak was treated with multiple conventional and controlled delivery microcroils and cyanoacrylate, obtaining complete embolization without residual leak.

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

A Rare Case of Hodgkin’s Lymphoma Presenting as Hypereosinophilia

Although eosinophilia is a recognised associated feature of Hodgkin’s Lymphoma, hypereosinophilia is seldom the presenting feature in the patient. Here, the authors report an unusual case of a 21-year-old male patient who presented to the General Medicine outpatient department of the hospital with a history of multiple episodes of left-sided pleural effusion in addition to mediastinal and cervical lymphadenopathy. Baseline investigations revealed hypereosinophilia which was persistent despite Diethylcarbamazine (DEC) and steroid therapy. Computer Tomography (CT) guided biopsy of an anterior mediastinal mass, likely to be thymus, led to the diagnosis of Hodgkin's Lymphoma. The patient was transferred to the Haematology department where he was started on Adriamycin, Bleomycin, Vinblastine and Dacarbazine (ABVD) chemotherapy regimen. Despite the fact that blood eosinophilia is an associated finding, it is rare for a patient to present with it. The authors also discuss the discrepancies related to the credibility of eosinophilia as a prognostic marker for Hodgkin’s disease.

Massive Right-sided Pleural Effusion due to Pancreaticopleural Fistula: A Rare Case Report

Pancreaticopleural Fistula (PPF), a rare occurrence, is characterised by an abnormal connection between pleural and peritoneal cavity. It forms usually due to the rupture of pancreatic pseudocyst. Pancreatic pseudocyst is formed due to the repeated episodes of acute or chronic pancreatitis. Most pancreatic pathologies, such as acute and chronic pancreatitis, cause clinically insignificant effusions that resolve with disease control, whereas PPF causes massive effusion and is thus rarely considered as a cause of massive pleural effusion due to its low incidence. PPF are most common in middle-aged alcoholic males and typically present as massive recurrent left-sided pleural effusions. In the present case, a 50-year-old male presented to the Department of Respiratory Medicine with the complaint of right-sided chest pain, progressive breathlessness, abdominal pain and loss of appetite. Patient was labourer by occupation, chronic alcoholic, non diabetic. Contrast Enhanced Computed Tomography (CECT) thorax with abdomen showed massive right-sided pleural effusion and pancreatitis. A diagnosis of PPF was confirmed as its cause. Pleural fluid analysis for elevated amylase, confirms the diagnosis and investigations such as CECT thorax and abdomen, Endoscopic Retrograde Cholangiopancreatography (ERCP), or Magnetic Resonance Cholangiopancreatography (MRCP) may be used to establish the fistulous communication between the pancreas and the pleural cavity. PPF should always be considered as a differential diagnosis while finding a cause for right-sided pleural effusion.

Dyspnea with chylothorax: Importance of examining the nails

A previously healthy 53-year-old man presented to our department with 2 months of dyspnea. Lung examination revealed a left-sided pleural effusion confirmed on the chest radiograph (Fig. 1A) and CT scan. Physical examination was remarkable for dystrophic fingernails and toenails appeared 3 years ago, with yellowish discoloration, thickening of the nail plates, enhanced transverse curvature of some nails and the absence of lunula and cuticle (Fig. 1B,1C). No lymphedema was present. The pleural fluid appeared milky white with triglycerides > 110 mg/dL and the presence of chylomicrons, consistent with a chylothorax.