Unilateral Pleural Effusion Research Articles

Clinical diagnostic algorithm in defining tuberculous unilateral pleural effusion in high tuberculosis burden areas short of diagnostic tools.

BackgroundEmpirical treatment was introduced when pathological or microbiological results of tuberculosis (TB) were not available. This report was designed to evaluate an algorithm based on empirical treatment in defining tuberculous pleural effusion (TPE) in high burden areas but short of diagnostic tools.MethodsIn this retrospective study, a total of 924 eligible patients were enrolled and 203 (22.0%) were primarily diagnosed as TPE by our diagnostic algorithm based on effusion characteristics [adenosine deaminase (ADA) and exudate] and immunoassays [purified protein derivative (PPD), M. tuberculosis antibody (TB-Ab) and interferon-gamma release assay (IGRA)]. All diagnosed cases received World Health Organization (WHO) standard anti-TB treatment and 187 of them had at least one year of follow-up. The final diagnosis and prognosis of these patients were traced and recorded.ResultsA total of 177 (94.65%) cases benefited from standard treatment, 5 (2.67%) failed due to early termination or drug resistance, and 5 (2.67%) were finally confirmed as misdiagnosis. Regarding diagnostic efficacy, 72 (30.13%) patients received four TB tests, and the combination of the four tests could increase the diagnosis of TPE. Besides, receiving operating characteristics curve (ROC) analysis revealed that our algorithm was the best method to differentiate TPE from malignant pleural effusion (MPE) with higher sensitivity and specificity than other serum markers.ConclusionsThis clinical diagnostic algorithm was an efficient and available method for the diagnosis of TPE. This diagnostic algorithm should be implemented in regions with high TB prevalence but short of diagnostic tools.

THE STUDY OF PLEURAL FLUID LACTATE DEHYDROGENASE /ADENOSINE DEAMINASE RATIO TO DIFFERENTIATE BETWEEN TUBERCULOUS AND PARA PNEUMONIC PLEURAL EFFUSION

Background: Pleural Effusion is a commonly observed clinical manifestation which is associated with more than 50 recognized diseases and disorders. Pleural uid lactate dehydrogenase (LDH) and adenosine deaminase (ADA) levels are often used to distinguish between tuberculous pleural effusion (TPE) and para pneumonic pleural effusion (PPE). This is challenging as the LDH level varies from normal to severely increased in PPE and a signicantly elevated ADA is frequently measured in both conditions. In this study, we evaluated use of the pleural uid LDH/ADA. Material and Methods:This was a prospective observational case study. this study included 51 cases more than 18 years of age; presenting with unilateral pleural effusion meeting criteria of exudative pleural effusion to the OPD & IPD of Department of Medicine and Department Pulmonary Medicine S.R.N. Hospital Prayagraj, U.P. Following allotment, Pleural uid aspiration was done, and patients were divided into 2 groups: tubercular and parapneumonic pathology. Pleural uid sent for analysis (cytology, microbiology, and biochemistry). Pleural uid LDH and ADA levels and LDH/ADA ratios were compared between two groups and results were obtained. Results: out of 51 study subjects , 27 were diagnosed to have Tubercular pleural effusion and 24 were found to have parapneumonic pleural effusion .The median pleural uid LDH,ADA and LDH/ADA ratio in TPE group were found to be 293.8 U/L ,59.8 U/L & 6.1 where as in PPE group it was found to be 503.3 U/L , 12.6 U/L and 40.Using LDH/ADA ratio as indicator of TPE an area under the ROC curve of 0.998 was obtained at cutoff value of 16.465.The sensitivity ,specicity , positive predictive value and negative predictive value was found to be 96.4%,100%,100% and 95.8%. Conclusion: The pleural uid LDH/ADA ratio at cut-off level of 16.465 is highly effective in differentiating between TPE and PPE and can be used as a useful diagnostic aid for the clinicians and thus improving patient care.

12 - A single-centre review of unilateral pleural effusions: are we escalating patients appropriately?

12 - A single-centre review of unilateral pleural effusions: are we escalating patients appropriately?

Pleuropulmonary pathologies in the early phase of acute pancreatitis correlate with disease severity.

BackgroundRespiratory failure worsens the outcome of acute pancreatitis (AP) and underlying factors might be early detectable.AimsTo evaluate the prevalence and prognostic relevance of early pleuropulmonary pathologies and pre-existing chronic lung diseases (CLD) in AP patients.MethodsMulticentre retrospective cohort study. Caudal sections of the thorax derived from abdominal contrast enhanced computed tomography (CECT) performed in the early phase of AP were assessed. Independent predictors of severe AP were identified by binary logistic regression analysis. A one-year survival analysis using Kaplan-Meier curves and log rank test was performed.Results358 patients were analysed, finding pleuropulmonary pathologies in 81%. CECTs were performed with a median of 2 days (IQR 1–3) after admission. Multivariable analysis identified moderate to severe or bilateral pleural effusions (PEs) (OR = 4.16, 95%CI 2.05–8.45, p<0.001) and pre-existing CLD (OR = 2.93, 95%CI 1.17–7.32, p = 0.022) as independent predictors of severe AP. Log rank test showed a significantly worse one-year survival in patients with bilateral compared to unilateral PEs in a subgroup.ConclusionsIncreasing awareness of the prognostic impact of large and bilateral PEs and pre-existing CLD could facilitate the identification of patients at high risk for severe AP in the early phase and thus improve their prognosis.

Spectrum and outcome in patients with unilateral pleural effusion admitted in a tertiary care hospital

Background: Unilateral pleural effusion is a challenge for a physician as the differential diagnosis is varied; sparse epidemiological data are available from India on this subject.Methods: We prospectively studied consecutive adult patients (aged >18 years) presenting with unilateral pleural effusion who underwent thoracocentesis with or without radiological guidance for diagnostic workup.Results: Over a period of 1 year, 116 patients admitted with unilateral pleural effusion were included, majority (63.8%) were in the age group of 20–60 years. Most common presenting symptoms were shortness of breath (56%), fever (53.4%), cough (52.5%), chest pain (35.3%), anorexia (34.5%) and weight loss (18.9%). Ninety-nine patients (85.3%) had exudative and 17 patients (14.6%) had transudative pleural effusion. Amongst exudative, tuberculosis (TB) pleural effusion was the most common cause (45.7%) followed by para-pneumonic (12.9%), malignant (10.3%), among others. TB (44.8%) and malignancy (10.3%) were common aetiologies among the lymphocyte-predominant effusions, whereas para-pneumonic effusion (11.2%) and empyema (4.3%) were common aetiologies amongst the neutrophil-predominant effusions. Pleural fluid lymphocyte-to-neutrophil ratio >0.75 increased the sensitivity and specificity to diagnose TB pleural effusion.Conclusions: Patients with TB pleural effusion were comparatively younger as compared to patients with malignant and para-pneumonic pleural effusion. Most pleural effusions resolved with treatment of underlying cause.

Response to Chemical Pleurodesis in Children with Frequent Relapsing Nephrotic Syndrome Having Refractory Unilateral Pleural Effusion.

Idiopathic nephrotic syndrome is one of the most common chronic renal disorders in children. Associated bilateral pleural effusion is common due to the transudative process as a result of hypoalbuminemia. However, unilateral pleural effusion is a rare phenomenon and at times, unresponsive even when the patients are in remission. Here, we report two cases of frequent relapse nephrotic syndrome presented as persistent unilateral pleural effusion responsive to chemical pleurodesis, which was done with bleomycin along with normal saline.

Bipolaris infection presenting as granulomatous pleuritis and mediastinal mass in a young immunocompetent man: a case report

Background: Bipolaris species are dematiaceous fungi that originally are plant pathogens but have been reported to cause a wide spectrum of diseases in both immunocompromised and immunocompetent human hosts. Case Presentation: We report a case of a young immunocompetent man who presented with fever, dry cough, and malaise. He had unilateral pleural effusion with mediastinal mass. Histopathology of pleura and mediastinal mass revealed granulomatous inflammation with fungal pseudohyphae. Tissue cultures grew Bipolaris species. He is on itraconazole with significant clinical improvement. Conclusion: This clinical presentation of Bipolaris infection has not been previously described. In Pakistan, where tuberculosis pleuritis is frequently encountered, this case highlights that other rare causes of granulomatous pleuritis can also present in a similar fashion.

Atypical chest radiological feature in a patient with nCOVID-19

Classical high-resolution computed tomography (HRCT) pattern in nCOVID-19 pneumonia is bilateral, basal, peripheral, subpleural, bronchopneumonia. Ground-glass opacities and consolidation are the most common initial radiological findings. However, chest computed tomography (CT) should not be used as an independent diagnostic tool to exclude or confirm COVID-19. CT is not a standard diagnostic tool for the diagnosis of COVID-19, but CT findings help to suggest the diagnosis in the appropriate setting. Chest CT findings should be correlated with epidemiologic history, clinical presentation, and reverse transcriptase–polymerase chain reaction (RT-PCR) test results. Many other diseases can mimic nCOVID-19 in HRCT and vice versa. We report an atypical radiological feature in RT-PCR-confirmed nCOVID-19 pneumonia case. HRCT showed unilateral peripheral ground-glass opacity. Atypical HRCT features in nCOVID-19 described in literature include central involvement, peribronchovascular involvement, isolated upper lobe involvement, nodular opacities, lobar consolidation, solitary opacity, unilateral lung involvement, mediastinal adenopathy, cavitory lesions, pleural and pericardial effusion, and subpleural sparing. When radiological manifestations are atypical, diagnosis of nCOVID-19 pneumonia should be by exclusion of other causes for the radiological abnormality.

Unilateral pleural effusion secondary to Takayasu arteritis: a case report and literature review.

Takayasu arteritis (TA) is a chronic, nonspecific inflammatory disease of large and medium-sized vessels that primarily involves the aorta and its branches. TA involving the pulmonary arteries has a prevalence ranging from 14% to 86%, which can lead to pulmonary hypertension, a progressive increase in pulmonary artery pressure, and eventually death from right heart failure. The presentation of pulmonary arteritis (PA) is very nonspecific, with a reported misdiagnosis rate of up to 60% and a diagnosis time ranging from 1 month to more than 10 years. The clinical manifestation of pleural effusion is very rare in both TA and PA cases. Based on our literature review, this is the 6th reported case of TA with pleural effusion, and the specific mechanism of TA with pleural effusion is still unclear. The characteristics of this case and the previously reported cases are summarized in this article to improve the understanding of TA and PA and reduce the misdiagnosis rate.

A ten-year retrospective analysis of nocardiosis in a tertiary care center of South-coastal India.

Nocardiosis is an uncommon life-threatening infection caused by Nocardia spp. This study aimed to review the distribution of risk factors, clinical characteristics, microbiological findings, treatment and outcome of patients diagnosed with nocardiosis. This study was a retrospective case record review of all nocardiosis cases that were diagnosed at our tertiary care hospital from January 2008 to December 2019. A total of 48 patients with a mean age of 52.2±16.28 years were included. Out of which forty one (85%) were diagnosed as pulmonary nocardiosis and seven (14.6%) as disseminated disease. Chronic lung disease 25 (52.1%), long term steroid use 22 (45.8%) followed by diabetes mellitus 11 (22.9%) were common predisposing factors. The common symptoms were fever (87.5%), cough (79.2%) and breathlessness (52.1%). The most frequent radiologic finding included consolidation in 38 (79.1%), cavitation with thickened wall in 2 (4.1%), reticulonodular shadows in 2 (4.1%), and unilateral pleural effusion in 5 (10.4%). Nocardia otitidiscaviarum (22.9%) was frequently isolated from cultures. Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was observed in 21% cases. Mortality was noted in 6 (12.5%) patients and all were with pulmonary involvement. The percentage of death among those with and without pulmonary tuberculosis was 33.3% and 5% respectively. Patients affected by pulmonary nocardiosis with previous history of pulmonary tuberculosis showed significant association with poor outcome (p-value=0.05). In conclusion, nocardiosis mainly affects patients with structural lung disease or immunocompromised hosts with adverse outcome. Awareness of this infection is crucial for a clinician, and any suspicion should lead to make an early diagnosis and choose an appropriate empirical treatment to improve the outcome in this population.

Unilateral Pleural Effusion in a Pediatric Patient: A Case of T-Cell Acute Lymphoblastic Leukemia Complicated with COVID-19

Unilateral Pleural Effusion in a Pediatric Patient: A Case of T-Cell Acute Lymphoblastic Leukemia Complicated with COVID-19

A CASE OF HÜRTHLE CELL CARCINOMA PRESENTING WITH MALIGNANT PLEURAL EFFUSION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hürthle cell carcinoma (HCC) is uncommon, accounting for 3% of thyroid neoplasms. It is more clinically aggressive compared to other differentiated thyroid cancers. Though thoracic involvement has been reported, it has rarely caused malignant pleural effusion. Here, we describe a case of metastatic HCC presenting with dyspnea and recurrent unilateral pleural effusion. CASE PRESENTATION: A 73-year-old male presented with dyspnea. His past medical history was significant for thyroid HCC diagnosed in 2005. He had undergone thyroidectomy, which was consistent with widely invasive HCC with clear cell change, and radioactive iodine ablation in 2006. He followed with his endocrinologist and oncologist, and was disease free on regular scans. However, his serum thyroglobulin levels continuously rose, prompting a PET scan in 2013 which demonstrated 2 new nodules in the left lower lobe of the lung. Patient had thoracotomy with left lower wedge resection in 2014; pathology was consistent with atypical carcinoid of uncertain source. He remained asymptomatic until he developed dyspnea in 2015; CT chest showed an increase in size of his pulmonary nodules. Biopsy revealed metastatic poorly differentiated thyroid cancer. He underwent right upper lobe radiation and left chest wall mass resection. He continued to have pleuritic chest pain and imaging in 2018 showed a recurrent large left pleural effusion, requiring thoracentesis with symptomatic relief. Cytology was negative at the time. He was then treated with several chemotherapy agents, complicated by side effects. He was diagnosed with left loculated pleural effusion in late 2020, and again pleural fluid was negative for malignancy. He continued to have episodes of desaturation and cardiothoracic surgery was consulted for video-assisted thoracoscopic surgery-guided left indwelling pleural catheter placement. However, he suddenly became hemodynamically unstable and was diagnosed with ST-elevation myocardial infarction. He refused left heart catheterization and continued to deteriorate, ultimately pursuing inpatient hospice. DISCUSSION: Hürthle cell carcinoma is a rare, aggressive form of cancer with high rates of recurrence. Local occurrence and metastatic disease could be found in 30% patients over 20 years after total or subtotal thyroidectomy. Pulmonary metastasis has been reported to be the most common site, though its incidence is significantly less in patients who were treated by total thyroidectomy. Nevertheless, it is imperative to consider HCC recurrence in patients presenting with dyspnea and pleural effusion despite interventions and being disease-free. CONCLUSIONS: Though this patient had negative cytopathologic studies, the recurrence of his unilateral pleural effusion accompanied by progression of his cancer without any other obvious cause cause makes malignant pleural effusion due to HCC the most likely diagnosis. REFERENCE #1: Ahmadi, S., Stang, M., Jiang, X. S., & Sosa, J. A. (2016). Hürthle cell carcinoma: current perspectives. OncoTargets and therapy, 9, 6873–6884. https://doi.org/10.2147/OTT.S119980 REFERENCE #2: Bagherzadegan, N., Feller-Kopman, D., Ernst, A., Haerle, S., & Lunn, W. (2009). An unusual case of hürthle cell carcinoma presenting as metastatic pleural disease 16 years after thyroidectomy. Journal of bronchology & interventional pulmonology, 16(3), 204–206. https://doi.org/10.1097/LBR.0b013e3181b01521 REFERENCE #3: Besic, N., Schwarzbartl-Pevec, A., Vidergar-Kralj, B., Crnic, T., Gazic, B., & Marolt Music, M. (2016). Treatment and outcome of 32 patients with distant metastases of Hürthle cell thyroid carcinoma: a single-institution experience. BMC cancer, 16, 162. https://doi.org/10.1186/s12885-016-2179-3 DISCLOSURES: No relevant relationships by Saloni Goyal, source=Web Response No relevant relationships by Dimitry Petrenko, source=Web Response No relevant relationships by Cleo Zarina Reyes, source=Web Response No relevant relationships by Joseph Schellenberg, source=Web Response

UNPLEASANT SURPRISE: A CASE OF SPONTANEOUS TUMOR LYSIS SYNDROME FROM EXTRANODAL DIFFUSE LARGE B-CELL LYMPHOMA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Approximately a third of the patients with diffuse large B-cell lymphoma present with extranodal involvement.[1] Pleural effusion in diffuse large B-cell lymphoma (DLBCL) foreshadows a poor prognosis.[2] We present a rare case of spontaneous tumor lysis in extranodal DLBCL with unknown primary source, presenting with pleural effusion. CASE PRESENTATION: A 76-year-old man with history of hypertension, diabetes, chronic kidney disease, peripheral vascular disease with bilateral below-knee amputation and stroke, presented with 2 weeks of worsening weakness, decreased appetite, right-sided facial droop, difficulty speaking & trouble urinating; denied hematuria, dysuria, cough, chest pain, abdominal symptoms or history of HIV. On admission, he was hypothermic. Vital signs were stable otherwise. He was a&ox1 and somnolent. Labs remarkable for Na 131mmol/L, bicarbonate 15mmol/L, BUN 84.3mg/dl, creatinine(Cr) 3.72mg/dl, pro-BNP 21699pg/ml, hemoglobin 7.3g/dl, procalcitonin 1.34ng/ml. CT head showed no acute intracranial pathologies. Chest X-ray showed moderate right pleural effusion with partial loculation and right base patchy airspace opacity. Chest CT showed moderate-sized loculated right pleural effusion and small left pleural effusion. He was admitted for community-acquired pneumonia and was started on IV ceftriaxone and azithromycin. On day 2, thoracentesis was done and pleural fluid sent for analysis. On day 5, he was more somnolent and hyperkalemic to 6.8 with anion gap 24, BUN 84mg/dl, Cr 4mg/dl & bicarb 9mmol/L. EKG noted prolonged PR interval. He was started on aggressive IV fluids and sodium bicarbonate drip. Potassium remained elevated despite treatments with calcium gluconate, insulin, dextrose and potassium binders. Uric acid was 31mg/dl, phosphorus 15mg/dl and lactate dehydrogenase 882U/L. Given the lab abnormalities suspicious for tumor lysis syndrome, oncology was consulted. CT abdomen showed nonspecific thickening of the terminal ileum and bladder wall but no lymphadenopathy nor splenic enlargement. Urine cytology negative for malignant cells. Final pathology of pleural fluid showed diffuse large B cell lymphoma with Ki-67 of 80-90%. Rasburicase was given urgently for tumor lysis syndrome. Uric acid became undetectable the next day but Cr was 5.4. After discussion with family, the patient was placed under comfort-care measures as chemotherapy wouldn't be well-tolerated. He passed on day 13. DISCUSSION: Spontaneous tumor lysis syndrome is a rare oncological emergency with multiorgan failure, characterized by an elevation of uric acid, hyperphosphatemia, hypocalcemia, hyperkalemia with no active chemotherapy[3]. Our patient presented with unilateral pleural effusion without detectable lymphadenopathy or hepatosplenomegaly: an extremely rare presentation. CONCLUSIONS: If Cairo-Bishop definition is met, there should be high suspicion for spontaneous tumor lysis syndrome as early treatment can be life-saving. REFERENCE #1: Castillo JJ, Winer ES, Olszewski AJ. Sites of extranodal involvement are prognostic in patients with diffuse large B-cell lymphoma in the rituximab era: an analysis of the Surveillance, Epidemiology and End Results database. Am J Hematol. 2014 Mar;89(3):310-4. doi: 10.1002/ajh.23638. Epub 2014 Feb 19. PMID: 24273125. REFERENCE #2: Porcel, J.M., Cuadrat, I., García-Cerecedo, T. et al. Pleural Effusions in Diffuse Large B-Cell Lymphoma: Clinical and Prognostic Significance. Lung 197, 47–51 (2019). REFERENCE #3: Hsu HH, Chan YL, Huang CC. Acute spontaneous tumor lysis presenting with hyperuricemic acute renal failure: clinical features and therapeutic approach. J Nephrol. 2004 Jan-Feb;17(1):50-6. PMID: 15151259. DISCLOSURES: No relevant relationships by Ahmed Al-Ghrairi, source=Web Response No relevant relationships by Jini Hyun, source=Web Response No relevant relationships by Phyu Thin Naing, source=Web Response No relevant relationships by Rohan Paramesh, source=Web Response

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

A CURIOUS CASE OF URINOTHORAX

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Urinothorax (UT), is a rare cause of pleural effusion caused by accumulation of urine in the pleural space. It is usually the result of trauma or obstruction of the urinary tract. We present a case of a tension UT developed due to accidental displacement of a ureteral stent. CASE PRESENTATION: 80-year-old male with medical history significant for chronic kidney disease stage III, nephrolithiasis, prostate cancer status post prostatectomy and hospitalizations for obstructive uropathy requiring ureteral stent placement presented with progressively worsening dyspnea and acute encephalopathy. He was hypotensive and hypoxic requiring admission to the intensive care unit. Of note, patient was discharged 2 days ago after exchange of double J ureteral stent and removal of nephrostomy tube. Physical examination revealed a confused elderly male in respiratory distress. Patient had absent breath sounds and dullness on percussion of the right chest. Laboratory investigations were consistent with acute kidney injury. His imaging showed complete opacification of right hemithorax, consistent with large right sided pleural effusion and mediastinal shift to the left. Commuted tomography (CT) of the chest showed proximal aspect of the ureteral stent had migrated into the right pleural space. A chest tube was placed with drainage of yellow colored fluid and resolution of hypotension and hypoxia. On analysis, pleural fluid was transudative in nature with creatinine of 10.5 mg/dl. The findings of pleural fluid analysis including serum creatinine ratio greater than 1 and imaging confirmed the diagnosis of UT. The chest tube was kept in place for the drainage of urinoma and J-stent was removed under general anesthesia with repeat imaging showing resolution of the pleural effusion. DISCUSSION: UT usually presents as unilateral or bilateral pleural effusion usually due to trauma or obstruction of urinary tract. It has a male predominance and can occur at any age. Traumatic etiologies including surgical injuries, blunt trauma, medical procedures etc. are common causes of UT. Less commonly, UT can be due to obstructive causes due to prostate disease, left renal vein obstruction etc. Patients usually present with symptoms of flank pain, shortness of breath, or decreased urine output. Diagnosis is made on pleural fluid analysis with pleural fluid to serum creatinine ratio greater than 1 with associated obstructive or traumatic uropathy. Treatment of UT is by draining the pleural fluid and correcting the underlying etiology. To our knowledge, this is the first case reported of urinothorax secondary to ureteral stent displacement into the pleural space. CONCLUSIONS: UT is a rare but curable cause of pleural effusion. Though there is paucity of data, however, according to the reported causes patients have favorable prognosis if diagnosed early. REFERENCE #1: Toubes ME, Lama A, Ferreiro L, Golpe A, Álvarez-Dobaño JM, González-Barcala FJ, San José E, Rodríguez-Núñez N, Rábade C, Lourido T, Valdés L. Urinothorax: a systematic review. Journal of thoracic disease. 2017 May;9(5):1209. REFERENCE #2: Garcia-Pachon E, Romero S. Urinothorax: a new approach. Current opinion in pulmonary medicine. 2006 Jul 1;12(4):259-63. REFERENCE #3: Stark DD, Shanes JG, Baron RL, Koch DD. Biochemical features of urinothorax. Archives of internal medicine. 1982 Aug 1;142(8):1509-11. DISCLOSURES: No relevant relationships by Dheera Grover, source=Web Response No relevant relationships by Prashant Grover, source=Web Response No relevant relationships by Simrina Sabharwal, source=Web Response

UNILATERAL EXUDATIVE PLEURAL EFFUSION DUE TO CRYPTOCOCCAL INFECTION IN AN IMMUNOCOMPETENT INDIVIDUAL

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion, which can be exudative or transudative as per Light's criteria and has more than 50 recognized cases. It occurs as a result of increased fluid formation and /or reduced fluid resorption. Exudative effusion can be caused by malignancy, tuberculosis, PE, rheumatoid arthritis, pancreatitis, and rarely fungal infections. Cryptococcal infection causing pleural effusion is extremely rare with just 50 reported cases and that too in immunocompromised patients with reduced cellular function. [1]Pulmonary Cryptococcus is seen in immunocompromised patients with reduced cellular function and pleural presentation is rarely seen in pulmonary cryptococcosis. We are presenting a unique case in which this disease was found in an immunocompromised person. CASE PRESENTATION: Our patient is a 58 year old Male who had gone for Pre-op check up for his shoulder surgery where routine chest x-ray showed left sided pleural effusion. On presentation, he denied any complaints of dyspnea, chest pain, or fever. He is a non smoker, works in a plasma center and lives in a basement apartment complex. He further denied owning any pets or any outdoor hobbies such as hiking, camping, or canoeing. Auscultation of chest revealed reduced air entry on left side. Labs works showed serum cryptococcal antigen positive. Rest of the investigations were normal . The patient underwent thoracocentesis which drained out 1200 ml of green colored fluid which was sent for gram stain, AFB stain and culture sensitivity and were negative. Sputum and CSF analysis were negative as well. He was started on Amphotericin B and Fluconazole IV for 2 weeks as induction therapy following which patient improved clinically. Patient was discharged with continuation of consolidation therapy with fluconazole for 8 weeks on outpatient basis. He was followed up at the clinic where Chest X ray showed resolution of the infection. DISCUSSION: Pulmonary cryptococcus is an opportunistic infection usually seen in immunocompromised patients like those with HIV infection, hematological malignancies, immunosuppressive medications etc. Pleural effusion is rare presentation of pulmonary cryptococcus and even rarer in an immunocompetent individual. Only 35% of cases with pulmonary cryptococcal infection were in immunocompetent people and most of them were reported in Asia. Patients with immunocompetent state with cryptococcal infection usually showed pneumonia like manifestations or solitary and well defined nodules. Our case did not show any manifestations other than the pleural effusion. Cryptococcal Antigen(CrAg) testing in body fluids can guide us for confirmation of the disease. 56% of patients with Non HIV related Cryptococcal infection tested positive for CrAg. CONCLUSIONS: This Unique case shows that cryptococcal infection can present in immunocompetent person. That this case was found in North America with no risk factors in the person. REFERENCE #1: [1] Hooper C, Lee YCG, Maskell N Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010Thorax 2010;65:ii4-ii17. REFERENCE #2: Shirley RM, and Baddley JW. 2009. Cryptococcal lung disease. Curr. Opin. Pulm. Med. 15(3):254–260 REFERENCE #3: Zhang Y, Li N, Zhang Y, Li H, Chen X, Wang S, Zhang X, Zhang R, Xu J, Shi J, Yung RC. Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis. Eur Respir J. 2012;40:1191-1200Ye F, Xie JX, Zeng QS, Chen GQ, Zhong SQ, Zhong NS. Retrospective analysis of 76 Immunocompetent patients with primary pulmonary cryptococcosis. Lung. 2012;190:339-346. DISCLOSURES: No relevant relationships by Farhan Ali, source=Web Response No relevant relationships by Sucheta Kundu, source=Web Response

The Effect of Lateral Position with Head Up 45° on Oxygenation in Pleural Effusion Patients

The accumulation of fluid in the pleural cavity will interfere with the restriction process, namely disruption of lung expansion so that the air entering the lungs is less than normal. One of the effects is shortness of breath and a decrease in oxygen saturation. In this case, nursing actions play an important role in inadequate ventilation, namely positioning. The lateral position is one of the recommended positions for patients with unilateral lung disease, one of which is unilateral pleural effusion. Position selection is very important to facilitate adequate breathing, namely one with a head-up of 45°. According to some literature, the 45° head-up position can reduce consumption and maximize lung expansion which will result in greater ventilation. To determine the effect of the lateral position with a head-up 45°on oxygen saturation and respiratory rate in a patient with unilateral pleural effusion at the Dr. H. A. Rotinsulu Lung Hospital Bandung. The research design was a quasi-experimental design with one group pre and post-test design with a sample of 44 people. The sampling technique used consecutive sampling. The results showed that there were differences in median oxygen saturation and respiratory rate before and after the intervention. The results of a comparative study using the Wilcoxon test obtained a p value of 0.0001 (p value&lt;0.05). There is an effect of giving a lateral position with a head-up 45° on increasing oxygen saturation and decreasing respiratory rate. Thus, it is expected for the service unit to establish a lateral position in the direction of the effusion with a head-up of 45°as the operational standard for the management of unilateral pleural effusion impaired oxygenation patients.

A rare presentation of isolated right-sided pleural effusion in the context of ovarian hyperstimulation syndrome: A case report

An isolated pleural effusion as the sole manifestation of early ovarian hyperstimulation syndrome (OHSS) is rare. A 38-year-old woman who had undergone in vitro fertilization presented with OHSS. Six days after transvaginal oocyte pickup, she presented with only an isolated right-sided pleural effusion and restricted respiratory capacity. A thoracentesis was successfull. Clinicians must be aware of unilateral pleural effusion, with a higher incidence on the right side, as a single-symptom presentation of OHSS. The case reported here illustrates the diversity and severity of OHSS.

Unilateral pleural effusion in chronic renal insufficiency: A clinician’s challenge

Pleural effusion is a common clinical presentation of chronic kidney disease (CKD). Pleural effusion secondary to hypervolemia is usually bilateral in nature. We herein report a rare presentation of unilateral massive exudative pleural effusion in a 66-year-old male patient who is a known case of CKD, presented to us with severe dyspnea. On further evaluation, it was found that dyspnea was secondary to massive pleural effusion. After excluding other causes of pleural effusion, the patient was started on renal replacement therapy following which the patient improved markedly, and hence, pleural effusion was considered likely to be secondary to uremia. Uremia as such is a rare cause of pleural effusion and it should be considered as a diagnosis of exclusion.

Value of Bedside Lung Ultrasound in Severe and Critical COVID-19 Pneumonia.

Lung ultrasound (LUS) is an effective imaging modality that can differentiate pathological lung from non-diseased lung. We aimed to explore the value of bedside LUS in patients with severe and critical coronavirus disease 2019 (COVID-19)-associated lung injury. Sixty-three severe and 33 critical hospitalized subjects with COVID-19 were enrolled in this study. Bedside LUS was performed in all subjects; chest computed tomography was performed on the same day as bedside LUS in 23 cases. The LUS protocol consisted of 12 scanning zones. LUS score based on B-lines and lung consolidation was evaluated. The most common abnormality of LUS was the various forms of B-lines, detected in 93 (96.9%) subjects; as the second most frequent abnormality, 80 (83.3%) subjects exhibited lung consolidation, mainly located in the posterior lung region. Twenty-four (25.0%) subjects had pleural line abnormalities, and 16 (16.7%) had pleural effusion; 78 (81.3%) subjects had ≥ 2 abnormal LUS patterns, and 93 (96.9%) had bilateral lung involvement. The proportion of bilateral or unilateral lung consolidation and pleural effusion in the critical COVID-19 group were higher than that in the severe group (P < .05). The lung consolidation of critical subjects showed a marked increase in most lung areas, including bilateral lateral lung, posterior lung, and left anterior-inferior lung area. The median (interquartile range) LUS scores of critical cases were higher than those of severe cases: left: 14 (12-17) vs 7 (5-12); right: 14 (10-16) vs 8 (3-12); bilateral: 28 (23-31) vs 15 (8-22) (P < .001 for all). There was a good correlation between the LUS score and the chest computed tomography score (r = 0.887, P < .001). The most common abnormal LUS pattern in subjects with severe and critical COVID-19 pneumonia was B-lines, followed by lung consolidation. Bedside LUS can provide important information for pulmonary involvement in patients with COVID-19.