Right-sided Pleuritic Chest Pain Research Articles

Atypical Presentation of Pneumonia Mimicking Pulmonary Embolism

This case report highlights the diagnostic challenge arises from the varied clinical presentation, complicating the differentiation between infarction pneumonia, community-acquired pneumonia (CAP), and pulmonary embolism (PE). The author reports a female patient in her late seventies who presents with worsening right-sided pleuritic chest pain, exertional dyspnoea, and productive cough. She was initially treated for CAP with oral amoxicillin 500 mg QDS and clarithromycin 500 mg twice daily for 5 days. She denied any night sweats or weight loss. On lung auscultation, she had right lower lobe crepitations. Subsequently, she underwent a computed tomography pulmonary angiography (CTPA) to rule out PE which demonstrated filling defects in the right pulmonary artery and right lower lobe patchy consolidation. The patient was treated with rivaroxaban 15 mg BD for 21 days followed by 20 mg OD for 4 months, and also treated for CAP with ceftriaxone 2 g OD for 7 days.

A Teenage Girl with Large Lung Mass

Extraskeletal Ewing Sarcoma is rarely reported. A fifteen-year-old girl presented with the right-sided pleuritic chest pain, shortness of breath, and productive cough with whitish sputum associated with poor oral intake. She subsequently underwent contrast-enhanced Computerized Tomography thorax, which showed lobulated heterogenous hypodensity occupying the entrance of the right superior pulmonary vein, extending to the left atrium.

Resting Hypoxia and a Strongly Positive Bubble Test: Do Not Forget Hepato-Pulmonary Syndrome.

A 40-year-old male presented to the hospital with a tender right calf, right-sided pleuritic chest pain, and haemoptysis. He has a strong family history of anti-thrombin-3 deficiency and unprovoked deep-vein thrombosis in many of his paternal family members. Computed tomography (CT) pulmonary angiography demonstrated a segmental pulmonary embolism (PE) and associated pulmonary haemorrhage/infarct in the right middle lobe (Panel-A). X-ray chest demonstrated mild pulmonary congestion (Panel-B). Resting oxygen saturation on room air (RA) was 81%; disproportionately low for his presentation with PE, however, the patient did not complain of dyspnoea.

A case of central nervous system mucormycosis in a patient with uncontrolled diabetes mellitus

A 38-year-old man with diabetes presented with lethargy, night sweats, weight loss, right-sided pleuritic chest pain, fever and rigors, and hyperglycaemia. Chest X-ray and computed tomography (CT) of chest demonstrated multifocal inflammatory changes within the lungs. Differential diagnoses

Clinical Images: Erdheim-Chester disease.

The patient, a 57-year-old man, presented to the hospital with right-sided pleuritic chest pain, dyspnea on exertion, and lower extremity edema. He was found to have a large pericardial effusion with early tamponade on echocardiography. Pericardiocentesis yielded 900 ml of serosanguineous fluid. Soon after, he developed epigastric pain. A computed tomography scan of the abdomen revealed diffuse inflammation of the retroperitoneal spaces, a rim of attenuation surrounding the aorta (A, short arrows), and a perirenal infiltrative process involving both kidneys and giving a hairy kidney appearance (A, long arrows). The differential diagnosis of a hairy kidney includes lymphoma, sarcoidosis, and Erdheim-Chester disease (ECD) (1). Knowing that ECD can affect long bones, we obtained radiographs of the femur, which revealed diffuse sclerotic foci and mild cortical thickening (B) (2). A biopsy of the femur showed sclerotic bone with histiocytoid marrow infiltrates. Further staining was positive for CD68, lysozyme, and CD163, consistent with ECD. An immunohistochemical stain was positive for BRAF V600E mutation. Vemurafenib was started, and 4 months later, a repeat positron emission tomography scan showed a vast improvement in his disease burden. ECD is a non–Langerhans histiocytic disease that affects multiple body systems. What was once a rare disease is now becoming more frequently identified as we learn more about its histopathology. ECD is of particular interest to rheumatologists because it can mimic large vessel vasculitis given that ECD can present with a thickened or coated aorta. The pathogenesis of ECD is derived from a malignancy of myeloid progenitor cells that undergo a BRAF mutation, which is typically V600E. This mutation makes it amenable to treatment with BRAF kinase inhibitors, such as vemurafenib and dabrafenib. However other treatments, such as interferon-α, interleukin 1 inhibitors, and tumor necrosis factor inhibitors, have been used as well. Author disclosures are available at https://onlinelibrary.wiley.com/action/downloadSupplement?doi=10.1002%2Facr2.11392&file=acr211392-sup-0001-Disclosureform.pdf. Disclosure Form Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

OCCULT COCCIDIOIDOMYCOSIS: A CASE OF PLEURAL COCCIDIOIDOMYCOSIS

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coccidioides is a dimorphic fungus found in desert soil, native to parts of southwestern USA. Infection is acquired by inhalation of arthroconidia causing primary pulmonary coccidioidomycosis (Cocci) but patients can also present with unusual manifestations, which makes identifying Coccidioides infection challenging. We present a case of pleural cocci causing isolated right sided pleural effusion. CASE PRESENTATION: A Caucasian male aged 64, residing in Arizona for 40 years, presented with a 2-week history of dyspnea associated with right-sided pleuritic chest pain, anorexia, and 12-lbs weight loss in the past month. Vital signs were stable. Physical exam was significant for dullness to percussion and absent breath sounds on the right lung base. Initial labs were remarkable for a normal leukocyte count with eosinophilia at 6.6%. A chest x-ray showed a large, unilateral right pleural effusion with pleural thickening. CT imaging demonstrated a right-sided pleural effusion and nonspecific, left-sided pulmonary nodules. Thoracentesis was performed, removing 1800 ccs of serous fluid. Fluid studies were consistent with an exudative effusion. Nucleated cell count was 1230cells/mm3 with 40% eosinophils. Gram stain and culture for bacterial, fungal and acid-fast organisms were negative. Cytology was negative for malignant cells. Thoracoscopy showed inflammatory changes along with white studding on the pleural surface. Histopathology demonstrated pleura with granulomatous changes and was negative for organisms or malignancy. Screening antibodies for cocci came back positive and immunodiffusion complement-fixing showed a normal IgG but an elevated IgM level. A diagnosis of pleural cocci was made and fluconazole 400 mg daily was initiated. On a follow up visit after 6 weeks, complete resolution of the effusion and significant symptomatic improvement in the patient were noted. DISCUSSION: Symptomatic coccidioidomycosis commonly presents as community acquired pneumonia. Pleural effusions can be associated in 10% of patients with pulmonary cocci; however, it is unusual for an isolated pleural effusion to present without evidence of ipsilateral parenchymal infection, as was found in this patient. Malignancy should be ruled out in effusions with a high eosinophil count as in our patient and necessitated thoracoscopy. Pleural cocci can be diagnosed with a combination of pleural fluid analysis, blood serology, and thoracoscopy with pleural biopsy. There are no specific recommendations for treatment and our patient was treated with Azole dosed for pulmonary cocci. CONCLUSIONS: This case demonstrates that, rarely, Coccidioidomycosis can present as an isolated pleural effusion, without evidence of parenchymal involvement and requires a high index of suspicion with invasive testing to secure a diagnosis and initiate appropriate treatment. REFERENCE #1: Valdivia L, Nix D, Wright M, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia [published correction appears in Emerg Infect Dis. 2006 Aug;12(8):1307]. Emerg Infect Dis. 2006;12(6):958-962. doi:10.3201/eid1206.060028 REFERENCE #2: John N. Galgiani, Neil M. Ampel, Janis E. Blair, Antonino Catanzaro, Francesca Geertsma, Susan E. Hoover, Royce H. Johnson, Shimon Kusne, Jeffrey Lisse, Joel D. MacDonald, Shari L. Meyerson, Patricia B. Raksin, John Siever, David A. Stevens, Rebecca Sunenshine, Nicholas Theodore, 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis, Clinical Infectious Diseases, Volume 63, Issue 6, 15 September 2016, Pages e112–e146, https://doi.org/10.1093/cid/ciw360 DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by Arnold Forlemu, source=Web Response No relevant relationships by Abid Khokar, source=Web Response No relevant relationships by Ali Saeed, source=Web Response No relevant relationships by Hursh Sarma, source=Web Response No relevant relationships by Ayushi Sharma, source=Web Response

Tubercular Pleural Effusion in a Patient of Ulcerative Colitis Treated With Tofacitinib.

To the Editors,A 45-year-old female presented in January 2021 with bloody diarrhea for 2 weeks (7-8 bowel movements/day). She had been diagnosed with left-sided ulcerative colitis 7 years back and was on maintenance therapy with oral mesalamine (3.6 gram/day) and azathioprine (100 mg/day). Sigmoidoscopy revealed hyperaemia, friability, and deep ulcerations (complete Mayo score, 10). Intravenous methylprednisolone of 60 mg/day was initiated, but stool frequency remained high (8/day) after 3 days of steroids. Because patient could not afford biologics, 10 mg of oral tofacitinib twice a day was started on the fifth day. The chest roentgenogram and Mantoux test done prior to starting tofacitinib were normal. She responded by the fourth day of oral tofacitinib and was discharged. After 8 weeks, tofacitinib dose was reduced to 5 mg twice daily. In May 2021, she presented with fever, right-sided pleuritic chest pain, and nonproductive cough. The symptoms persisted even after an empiric...

AN UNUSUAL PRESENTATION OF CHRONIC COUGH: PLASTIC BRONCHITIS AND CHYLOPTYSIS

SESSION TITLE: Fellows Cardiothoracic Surgery Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Plastic bronchitis and chyloptysis are rare medical conditions characterized by expectoration of bronchial cast and production of white milky sputum rich in chyle, respectively. Plastic bronchitis is associated with congenital heart disease in children and lymphatic system disease in adults. CASE PRESENTATION: A 49-year-old Hispanic female with no past medical history presented with dyspnea and right-sided pleuritic chest pain during her first pregnancy 27 years ago. Initial evaluation, work up and imaging studies revealed right-sided chylothorax requiring chest tube placement, thoracotomy with decortication, and thoracic duct ligation. One month later, cisterna chyli ligation and right lower lobe wedge resection were performed. Right lower lobe biopsy results disclosed chronic interstitial pneumonitis and focal foreign body reaction. During follow up patient reported resolution of symptoms. In May 2019, the patient presented to our institution with four-month history of dyspnea, dry cough, and expectoration episodes of a thick, white-red, cord-like material accompanied by viscous milky white sputum. The patient’s symptoms progressively worsened where she developed a choking sensation at night and in supine position. Chest CT scan show small areas of ground glass airspace opacity in the dependent portions of bilateral lungs with concentric thickening of the right pleura. Bronchoscopy was performed and was notable for milky-white secretions with abundant pale and slightly red, stranded bronchial casts lodged within the left lower lobe anterior segment. Bronchial lavage and aspiration specimen sent for oil red stain showed macrophages with lipid droplets. These findings were consistent with the clinical impression of chyloptysis producing subsequent plastic bronchitis. Cytology was negative for malignancy. Patient completed course of broad spectrum antibiotics and steroids with partial improvement in her condition. She currently is under evaluation for embolization and/or invasive approach. DISCUSSION: This case addresses a 49-year-old female who presented with milky-white sputum and cough. Bronchoscopy showed milky-white secretions and bronchial cast, bronchial lavage was positive for oil red stain which confirms chyloptysis causing plastic bronchitis. She completed a course of antibiotics and steroids with partial improvement in her condition. Now is under evaluation for embolization and/or invasive approach. CONCLUSIONS: This case illustrates an unusual presentation of chronic cough and chyloptysis, confirmed by bronchoscopy. Plastic bronchitis and chyloptysis rare medical conditions that should be suspected after obtaining thorough history and physical exam, high index of suspicion is fundamental for the recognition and treatment of this rare entity. Reference #1: Itkin M, Mccormack FX, Dori Y. Diagnosis and Treatment of Lymphatic Plastic Bronchitis in Adults Using Advanced Lymphatic Imaging and Percutaneous Embolization. Annals of the American Thoracic Society. 2016;13(10):1689-1696. Reference #2: Lim KG, Rosenow EC, Staats BS, Morgenthaler TI. Chyloptysis in Adults: Presentation, Recognition, and Differential Diagnosis. Chest. 2004; 125:336-304. Reference #3: Stoddart A, Dincer HE, Iber C, Tomic R, Bhargava M. Chyloptysis causing plastic bronchitis. Respiratory Medicine Case Reports. 2014; 13:4-6. DISCLOSURES: No relevant relationships by Michael Cruz, source=Web Response No relevant relationships by Ricardo Fernandez, source=Web Response No relevant relationships by Giovanni Veloz Irizarry, source=Web Response

Hiding in plain sight: Diagnosing pleural tuberculosis using lung ultrasound

Diagnosing pleural tuberculosis can be difficult in patients with ambiguous presentation, especially in resource-limited health centres. Thus, lung ultrasound had been studied as a novel method in helping clinicians to diagnose this condition. A 48-year-old woman presented with worsening dyspnoea and orthopnoea for one week. She had also experienced weight loss, minimal dry cough and right-sided pleuritic chest pain for several weeks. A chest radiograph showed a right lower zone pleural effusion with no apparent lung consolidation. Lung ultrasound showed a right apical consolidation and right lower zone septated pleural effusion. Pleural fluid investigations showed exudative features of mixed lymphocytic, mesothelial and neutrophilic cellular components. Tuberculin skin test was strongly positive. She was subsequently treated for pleural tuberculosis. One month after treatment, her symptoms had improved considerably. Lung ultrasound has been found to be more effective than chest radiograph in detecting consolidation and diagnosing pneumonia. The portability and efficacy of today's ultrasound machines, including the handheld types, show that lung ultrasound is a practical, reliable and valuable diagnostic tool in managing pulmonary conditions including tuberculosis, provided that the operators are adequately trained. Lung ultrasound in tuberculosis is the next frontier for clinicians and researchers.

Lobar Pneumonia in a Farmer Responded to Anti-melioidosis Antibiotics

A 46-year-old male, farmer, with no prior medical illness presented with a one-month history of intermittent right-sided pleuritic chest pain and productive cough. He complained of fever and breathlessness 3 days before current presentation to the district hospital. He denied any haemoptysis, night sweats, or contact with pulmonary tuberculosis. On examination, the vital signs were normal and lung auscultation revealed bronchial breath sounds and crepitation over the right upper zone. Chest radiograph demonstrated a right upper lobe consolidation with presence of air bronchogram and abdominal ultrasonography was normal. He was admitted for intravenous antibiotic therapy for a presumptive diagnosis of community-acquired pneumonia. He was initially treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours. Differential diagnosis of pulmonary tuberculosis was also considered but later ruled out as the sputum for direct smear microscopy, GenXpert and culture for Mycobacterium tuberculosis were negative. The melioidosis IgM (ELISA), multiple blood and sputum cultures were also negative. A PCR-based confirmatory test for melioidosis was however not available at our setting. In the ward, he continued to have persistent fever and repeated chest radiograph after 1 week of antibiotic showed worsening of right upper lobe consolidation. At this point in time, melioidosis was suspected due to the risk factor of farming. Antibiotic was then changed to intravenous ceftazidime 2 g every 6 hours. The patient responded positively as evidenced by the resolution of fever and respiratory symptoms, and repeated chest radiograph showed improving consolidation at 2 weeks. He was discharged after completing a 2-week course of intravenous ceftazidime, and simultaneously started on oral trimethoprim-sulfamethoxazole as eradication therapy. Upon review in the outpatient clinic 6 weeks later, chest radiograph showed marked improvement with minimal residual right upper lobe consolidation. He was clinically well and did not show any symptoms of relapse. He was planned for eradication therapy of 20 weeks’ duration.

BET 1: Lopinavir–ritonavir and COVID-19

(In adult patients admitted to hospital with confirmed COVID-19) does (lopinavir–ritonavir) lead to (reduced mortality and/or reduced length of stay and/or reduced time to improvement)? A 52-year-old man presented to...

PART OR NOT TO PART: BRONCHO-PULMONARY SEQUESTRATION, A RARE BUT POTENTIALLY DANGEROUS ANATOMICAL ANOMALY

TYPE: Abstract Publication TOPIC: Genetic and Developmental Disorders PURPOSE: Bronchopulmonary sequestration is a rare but potentially dangerous anatomical anomaly. With our case, we hope to increase awareness about this entity. METHODS: 26 year-old female presented with right-sided pleuritic chest pain and associated intermittent dry cough. She denied dyspnea, wheezing, hemoptysis, fever, chills or sick contacts. Medical history was significant for SLE on hydroxychloroquine. Physical exam and initial lab work were unremarkable. CT chest with IV contrast incidentally revealed a focal area of consolidation in the RLL with large feeding vessel arising directly from descending thoracic aorta. No discrete draining veins were identified. She was diagnosed with intralobar RLL bronchopulmonary sequestration. Her chest pain was attributed to serositis and improved with short course of steroids and NSAIDs. But management of her bronchopulmonary sequestration was tricky. RESULTS: It is a rare abnormality of the respiratory tract consisting of nonfunctioning lung tissue lacking communication with tracheobronchial tree and receiving its arterial blood supply from systemic circulation. Usually diagnosed in-utero or in childhood, but can rarely be asymptomatic, eventually leading to major complications like massive hemoptysis, recurrent pneumonias, high-output cardiac failure; occasionally reports of neoplasms arising within the sequestration have been reported. CONCLUSIONS: Management options include observation, surgical resection or coil embolization of feeding artery. We discussed her case in multidisciplinary pulmonary-radiology conference. She did not have high risk features like large lesion ∼20% of hemithorax, bilaterality, multifocal/cystic lesions, but due to risk of infection and hemoptysis, consensus opinion recommended treatment with surgical resection of the RLL sequestration. CLINICAL IMPLICATIONS: Bronchopulmonary sequestration requires careful risk benefit deliberation. DISCLOSURE: No significant relationships. KEYWORD: Bronchopulmonary sequestration

Republished: Sertraline-induced hypersensitivity pneumonitis

In conjunction with BMJ Case Reports , DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years. Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is a granulomatous, non-IgE-mediated hypersensitivity reaction of the alveoli and distal bronchioles presenting as an acute, subacute or chronic condition. It is most commonly associated with exposure to extrinsic allergens (eg, avian dust, mould and tobacco) and medications including antiarrhythmics (eg, amiodarone), cytotoxics (eg, methotrexate) and antiepileptics (eg, carbamazepine). Individuals diagnosed with this condition can present with severe hypoxia and respiratory failure. The fundamental principle of management is to remove the causative allergen. Evidence implicating selective serotonin reuptake inhibitors (SSRIs) as a causative agent is limited, and this case report describes a rare clinical presentation of HP associated with sertraline, how it was diagnosed and subsequently treated. It is anticipated that raising awareness of this interaction will assist multidisciplinary teams, managing patients diagnosed with HP, to be more cognisant of sertraline as being an aetiological factor for this condition. This case report describes the clinical presentation of a severe hypersensitivity pneumonitis (HP) associated with a frequently prescribed selective serotonin re-uptake inhibitor (sertraline), its diagnosis and subsequent management. It is anticipated that raising awareness of this interaction will assist multidisciplinary teams managing patients diagnosed with HP, to be more cognisant of sertraline as being an aetiological factor for this disease. On 31 July 2018, a 47-year-old Caucasian female (78 kg) presented to the Accident and Emergency (A&E) department with shortness of breath, right-sided pleuritic chest pain and a productive cough. Her medical history revealed she suffered from severe …

Pleural Sarcoidosis and Occult Lymphatic Anthracosis: An Unusual Symptomatic Association.

Sarcoidosis is a chronic multisystemic inflammatory disease of unknown aetiology. Virtually any organ or system can be involved, resulting in a wide range of clinical presentation. Pleural sarcoidosis is rare. Pleural effusion can only be attributed to pleural sarcoidosis in the presence of pleural non-caseating epithelioid granulomas and after excluding other granulomatous diseases. Anthracosis is a pneumoconiosis associated with thoracic adenopathies and bronchial disease, and it is usually asymptomatic. The authors present a case of a middle-aged man hospitalized due to cough, right-sided pleuritic chest pain and trepopnoea.LEARNING POINTSTo pursue a systematic and exhaustive investigation of pleuraleffusion until a definitive diagnosis is established.To recognize atypical presentations of sarcoidosis with a high degree of suspicion whenever the initial investigation is inconclusive.

Right middle and lower lobe collapse by an ascending thoracic aortic aneurysm

We report a case of a 60-year-old male patient who presented to the Emergency Department of Christian Medical College, Vellore, with a history of right-sided pleuritic chest pain. Thoracic aortic aneurysms are usually asymptomatic unless any complication occurs (e.g., dissection, rupture) or an imaging study has been performed demonstrating the aneurysm. Chest radiograph of this patient showed collapse of right main bronchus due to an aneurysm, which to our knowledge has not been previously reported in literature.

THORACIC ENDOMETRIOSIS SYNDROME PRESENTING AS RECURRENT CATAMENIAL PNEUMOTHORAX

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Catamenial pneumothorax (CP) is a rare spontaneous pneumothorax (PTX) that occurs cyclically with menstrual periods. It is part of the spectrum of thoracic endometriosis syndrome (TES) in which ectopic endometrial tissue is implanted in thoracic structures. CASE PRESENTATION: A 36-year-old G0P0 female nurse, presented with worsening right-sided pleuritic chest pain for 6 days. She had a history of stage 4 endometriosis associated with recurrent CP. Her first episode was 4 years ago when she had a large right-sided PTX in association with biopsy proven diaphragmatic endometriosis, treated with a right middle lobe wedge resection and chemical pleurodesis. She had multiple recurrences of PTX requiring repeat pleurodesis and subsequent long-term medical therapy with leuprolide and combination oral contraceptive pills. On examination, she was hemodynamically stable with decreased breath sounds in the right lower lung field. CT chest revealed a moderate volume right PTX, a sub-pleural right lower lobe mass and pleural thickening. She underwent a video-assisted thoracoscopic surgery (VATS) with combination (mechanical and chemical) pleurodesis. Pleural biopsy was negative for endometriosis. Postoperative chest x-rays revealed a resolving pneumothorax. Three days after surgery, the patient was discharged home. DISCUSSION: CP is characterized by collapsed lung, which occurs within 3 days of menstruation onset. The pathophysiology involves deposition of focal endometrial pleural implants migrating during leakage of air from the peritoneal cavity, which subsequently break down during menstruation or hypertrophy in response to hormonal changes. Another plausible theory is vasoconstriction and bronchospasm induced by prostaglandin F2 release during menses leading to alveolar rupture and PTX. Due to the vague symptomatology and limited disease awareness, the diagnosis is often missed or delayed leading to life-threatening complications. Histologically proven thoracic endometriosis is frequently but not always associated with CP. Our patient is unique as she previously had a diaphragmatic endometriosis associated CP and later had a non-TES associated bout of CP. Recent evidence suggests that combination surgical (VATS) followed by medical (GnRH agonist) therapy effectively suppresses CP recurrence. However, our patient suffered multiple recurrences even after both modalities. A combination of mechanical and chemical pleurodesis was attempted in an effort to prevent further recurrences. CONCLUSIONS: TES remains an exceedingly rare condition and very few cases have been reported. Our case is unique given her multiple recurrences and unresponsiveness to guideline directed therapies. Physicians should keep a high level of clinical suspicion for thoracic endometriosis in non-smoking women over 31 years, with a history of pelvic endometriosis, and presenting with recurrent pneumothorax. Reference #1: Junejo SZ, Singh Lubana S, Shina SS, Tuli SS.A Case of Thoracic Endometriosis Syndrome Presenting with Recurrent Catamenial Pneumothorax. Am J Case Rep. 2018 May 17;19:573-576. DISCLOSURES: No relevant relationships by Prasanta Basak, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Ahmed Qavi, source=Web Response

AN UNCOMMON MALIGNANT PLEURAL EFFUSION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Malignant pleural effusions (MPE) are usually related to metastatic disease, most commonly from lung cancer and breast cancer. We present a case of primary pleural low-grade B-cell lymphoma, presenting with a right pleural effusion, which management defers from other etiologies of MPE. CASE PRESENTATION: An 84-year-old man with a past medical history of laryngeal cancer and atrial fibrillation, who presented to the emergency department with progressive exertional shortness of breath associated with dry cough and onset of right-sided pleuritic chest pain the past 3 days. Review of Systems was otherwise negative. Social history was non-contributory. On physical examination he was in mild-to-moderate respiratory distress, tachycardic, tachypneic and afebrile, with decreased breath sounds and dullness to percussion over the right hemithorax. Chest radiograph revealed a large right-sided pleural effusion (Fig. 1). Thoracentesis was performed and one and a half liters of cloudy exudative fluid was drained. Repeat radiograph showed adequate interval lung re-expansion (Fig. 2). Cytology analysis demonstrated low grade B cell lymphoma with CD20 positive. Staging CT/PET scan and bone marrow biopsy were normal. The patient was started on rituximab and bendamustine with no intrapleural catheter (IPC) placement after the oncologist and pulmonologist were consulted. There were no immediate complications or recurrence of pleural effusion and the patient was discharged home with outpatient follow up. DISCUSSION: Malignant pleural effusions are the second leading cause of exudative effusions. Pleural involvement by metastatic disease, including lymphoma is common, however primary pleural lymphoma remains an extremely rare condition, representing only 7% of all lymphomas (1). From all the reported cases, low-grade B-cell lymphoma representing 1.34% (2). Recent guidelines published by the American Thoracic Society regarding management of malignant pleural effusion take in consideration lung re-expansion and life expectancy before moving forward with therapeutic interventions. Outweighing benefits and risk regarding IPC, pleurodesis and combination of both should be discussed with patients and the multidisciplinary team for the benefit of the patients. As in our case, due to the high chemotherapeutic response, he will benefit from holding any unnecessary interventional procedures, avoided increased risk for infections, periprocedural complications and limitation of daily activities. Chemotherapy was initiated with close monitoring for newly developing pleural effusion. CONCLUSIONS: We submit a unique case of primary pleural low-grade B cell lymphoma presenting with large malignant pleural effusion in which management can differ from recommended guidelines. This also outlines the importance of multidisciplinary approach to avoid unnecessary procedures with better outcomes for patients with this condition. Reference #1: Mei-Lin S, Bin S, Jian-hua G & Shu-juan J. Rare case of primary lymphoma presenting with pleural effusion. Thoracic Cancer 7. 2016. 145-150 Reference #2: Vega F, Padula A, Valbuena JR et al. Lymphomas Involving the pleura. Arch Pathol Lab Med. 2006;130.1497-1502 DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Response No relevant relationships by Kathlyn Camargo Macias, source=Web Response No relevant relationships by Abed Madanieh, source=Web Response No relevant relationships by Chirin Orabi, source=Web Response No relevant relationships by jorge otoya, source=Web Response

A Cyst Close to the Heart

A 49-year-old Lebanese man presented to the hospital with right-sided pleuritic chest pain without associated respiratory or systemic symptoms. His vitals on presentation were stable, and examination was unremarkable. He had mild leukocytosis with 9.8% eosinophils. Imaging including cardiac magnetic resonance imaging with and without contrast revealed an extra pericardial, multiloculated anterior mediastinal cyst (Figure 1). A diagnosis of hydatid cyst was suspected based on epidemiologic history and radiologic appearance. Echinococcus serology was found to be positive. Patient was started on empiric anthelminthic treatment followed by surgical excision. Intraoperatively, the wall of the excised cyst showed calcification and sebaceous contents (Figure 2). Histopathologic exam showed multilocular cyst lined by squamous epithelial cells and foci of mature bone tissue (Figure 3), pancreatic acini, and ciliated columnar epithelial ducts consistent with a diagnosis of benign mature cystic teratoma. No parasite was seen. Anthelminthic therapy was discontinued, and the patient reported to be doing well on the follow-up visit. Similar cases have been reported in the past.1Patel I.J. Hsiao E. Ahmad A.H. Schroeder C. Gilkeson R.C. AIRP Best Cases in radiologic-pathologic correlation: mediastinal mature cystic teratoma.RadioGraphics. 2013; 33: 797-801Crossref PubMed Scopus (19) Google Scholar, 2Jaakik B. Benjelloun H. A Rare pericardial cyst resembling hydatid cyst on echocardiography.Intern Med. 2010; 49: 1673-1674Google Scholar, 3Montebello A. Mizzi A. Cassar P.J. Cassar K. Benign cystic mediastinal teratoma presenting as a massive pleural effusion in a 17-year–old boy.BMJ Case Reports. 2017; 2017 (bcr2016217439)Google ScholarFigure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3View Large Image Figure ViewerDownload Hi-res image Download (PPT) The authors wish to acknowledge Dr Khushi Nagori, MBBS, Department of Pathology, Ascension St John Hospital, Detroit, Michigan.

Hemothorax caused by vertebral exostoses.

Spontaneous hemothorax is a rare condition and sometimes occurs during anticoagulant therapy for venous thromboembolism. Other causes of the condition are bleeding disorders, complication of spontaneous pneumothorax and pleural malignancy. Vertebral exostosis represents an exceptional etiology of hemothorax, as a result of direct traumatic injury of the pleura or diaphragm by the intrathoracic tumour. Exostosis often occurs in hereditary multiple exostoses, but can also be isolated. We present a case of spontaneous hemothorax in a patient with vertebral exostoses and propose a new etiology of hemothorax. A 22-year-old man with no specific history elements and no previous trauma presented has been experiencing a right-sided pleuritic chest pain and respiratory discomfort for 6 days. Physical examination revealed dullness to percussion and decreased breath sounds on the right side of the chest. Chest x-ray showed right pleural effusion and diagnostic thoracocentesis revealed gross blood. Pleural effusion's hematocrit was 52%, while that of the peripheral blood was 39%. Hemothorax was diagnosed. Thoracic Computed tomography scan (CT-scan) (A and B, arrows) followed by magnetic resonance imaging (MRI) showed the presence of two vertebral exostoses arising from the right transverse processes of the 10th and 11th thoracic vertebrae (C and D, arrows). These, encroached on the 11th intercostal space. The hemothorax was managed successfully with chest-tube insertion. However, surgical resection of exostoses was indicated in our patient given the risk of loco-regional complications, and the recurrence of the hemothorax. The postoperative course was uneventful and the patient was followed without recurrent hemothorax for two years.

Peripheral pulmonary embolism: A missed entity

Pulmonary embolism (PE) is common, but often under-diagnosed or misdiagnosed entity. Pulmonary infarct is often caused by embolus in the peripheral branches, and timely diagnosis is often more challenging. Although peripheral pulmonary infarct is not fatal, it can be misdiagnosed as pneumonia or pleural effusion. Accurate diagnosis is also essential not only to rule out risk factors and prothrombotic states but also to prevent future thrombotic events. We report a case of 35-year-old male who presented with a history of isolated right-sided pleuritic chest pain of 1-week duration, diagnosed as a case of PE with a peripheral infarct. After 3 months of anticoagulation, he underwent screening for thrombophilia and detected to have factor V Leiden mutation. This case report highlights the fact that PE should be considered in the differential diagnosis of pleuritic chest pain.