Interesting case of pleural effusion
HPI: 47 y/o F, no PMHx, sent in from UC for R sided pleural effusion
3 weeks gradually worsening SOB associated w/ dry cough
Worse with exertion and laying flat
No recent fevers, URIx, weight loss, changes in appetite
BP 143/67 | Pulse 96 | Temp 97.2 °F (36.2 °C) (Oral) | Resp (!) 32 | SpO2 96%
Cardio: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.
Pulm: Moderate respiratory distress w/ increased work of breathing and tachypnea. Decreased breath sounds throughout the entire R lung field. No wheezing or rhonchi
Abd: Soft, non-tender
Portable CXR: Large right pleural effusion with mediastinal shift to the left. Complete opacification of the right hemithorax.
POCUS cardiac / lungs: Large amount of fluid R pleural space
Low risk for PE - PERC negative - and would be unlikely to cause such a large effusion.
No history of CHF or cirrhosis to cause transudate effusion.
No hx trauma to suspect hemorrhage
Work up / Plan:
CBC, BMP, coags, urine preg, EKG
Pigtail catheter for diagnostic and therapeutic pleurocentesis
Procedure: Pigtail catheter placed with immediate drainage of 2L of straw colored fluid
Follow up CXR: Interval placement of a right basilar pigtail catheter. Interval minimal improvement in aeration of the right lung compared to prior study
Further Steps → CT chest w/ contrast
Heterogeneous, predominantly cystic anterior mediastinal lesion containing fluid, fat, soft tissue, and calcium. Findings are compatible with a mature teratoma. Moderate right pleural effusion, which may be seen with ruptured mature teratoma.
CTAP w/ contrast: no evidence of intra-abdominal or ovarian/GYN masses
bHCG and AFP negative. Normal LDH, TSH.
Thoracic surgery - resection of anterior mediastinal mass
Cytology - Mature teratoma
Light’s Criteria - Exudate vs Transudate → 1+ of the below = exudate
Pleural fluid: serum protein > 0.5
Pleural fluid: serum LDH > 0.6
Pleural fluid LDH > ⅔ upper limit normal serum
Exudates: inflammation and increased capillary permeability (ie: PNA, cancer, TB, viral infection, PE, autoimmune)
Transudates: increased hydrostatic pressure OR low oncotic pressure (ie: CHF, cirrhosis, nephrotic syndrome, PE, hypoalbuminemia)