Case Presentation

1
Case Presentation

• Teaching Presentation

2
Mr. MX

• 55 years old
• Presents to ED with
• 6/52 worsening SOB and LOW (about 10kg)
• 2/52 cough occasionally productive of yellow
  sputum
• General malaise, fatigue.
• No chest pain, palpitations, fevers, night
  sweats, rigors.

3

• PHx
• Asthma
• Treated with Ventolin only.
• No previous admissions.
• No serious attacks for years.
• Smoker
• 40 year history. Quit 6/12 ago.
• Drinker
• Heavy drinker, hasnt had drink for three weeks.
• Nil other medications and NKDA

4
Differentials?
5
Differential Diagnosis

• Respiratory
• Airways
• Chronic bronchitis
• Bronchiectasis
• Asthma
• Parenchymal
• Pneumonia (atyp)
• Fibrosis
• Granulomatous Disease
• Pulmonary
• Chronic PE
• Chest Wall/Pleura
• Effusion
• Massive Ascites
• Fractures Ribs
• Neuromuscular

• Cardiac
• Congestive Cardiac Failure
• Mitral Valve Disease
• Cardiomyopathy
• HOCM
• Dilated
• Pericardial effusion
• Haematological
• Anaemia
• Non-Cardiorespiratory
• Acidosis
• Hypothalamic Lesion
• Anxiety

6
Further History

• SOB
• Gradual Onset OE.
• Neither orthopnoea nor PND.
• First noticed at rest 2/52 ago
• LOW
• 10kg in 6/52
• LOA
• last 10/52
• Denies ankle swelling or pain, chest pain.
• Denies wheezing, haemoptysis, travel, CP,
  palpitations, syncope.
• No abdominal or urinary symptoms.

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Further History

• Social History
• lives with wife who suffers from psychiatric
  illness and acts as carer
• doesnt own birds
• no known asbestos exposure
• Family History
• father died at 65yo from heart troubles
• mother died from breast cancer at 76yo
• no strong family history

8
Examination

• Vital Signs
• HR 145
• BP 108/88
• RR 24
• SatO2 97 on 35O2
• Temp 36.4C
• GCS 15
• General Appearance
• Cachectic, pale, speaking full sentences,
  slightly disheveled.
• Not cyanotic.

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Respiratory Examination

• Mild-mod clubbing
• Left pupil dilated
• Trachea deviated to R)
• Reduced chest expansion on L)
• Stony dull percussion on L) to apex
• Absent breath sounds on L)

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Further Examination

• Cardiovascular
• Apex beat displaced R)
• No heaves or thrills.
• Dual heart sounds with nil added. Tachycardia.
• Abdo
• Soft, non-tender, non-distended abdo.
• Palpation difficult but ?hepatomegaly of 15cm by
  percussion.
• Nil other organomegaly or masses.
• Bowel sounds present.
• Lower Limbs
• No pitting, swelling or tenderness.
• Rheum
• no noticeable rashes or joint disease

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Impression?

• Large left pleural effusion.
• Causes?

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Causes of Pleural Effusion

• Transudates
• LVF
• Hypoproteinaemia
• Constrictive Pericarditis
• Hypothyroidism
• Meigs Syndrome
• Ovarian fibroma
• R) sided pleural effusion and
• Ascites

• Exudates
• Para-pneumonic
• Bronchial Carcinoma
• Pulmonary Infarction
• Tuberculosis
• CTD
• Acute Pancreatitis
• Post-MI
• Mesothelioma
• Sarcoidosis

13
Bloods

• ECG
• ABG
• FBE/UECr/LFT/Ca2
• Coags
• TSH
• BSL
• GCM
• LDH
• CRP
• BC

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FBE
Hb 84 g/L 125-175
WCC 12.0 x 109/L 4-11
Plts 1177 x 109/L 150-450
RCC 3.43 x 1012/L 4.2-6.2
Hct 0.26 L/L 0.38-0.54
MCV 77 fL 78-98
MCH 24.5 pg 27-34
MCHC 320 g/L 310-355
RDW 20.8 lt15
MPV 6.5 fL 6.5-12
Neutrophils 10.08 x 109/L 2.0-8.0
Lymphocytes 1.2 x 109/L 1.0-4.0
Monocytes 0.72 x 109/L 0.0-1.0
Eosinophils 0.0 x 109/L 0.0-0.5
Basophils 0.0 x 109/L 0.0-0.2
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FBE
Hb 84 g/L 125-175
WCC 12.0 x 109/L 4-11
Plts 1177 x 109/L 150-450
RCC 3.43 x 1012/L 4.2-6.2
Hct 0.26 L/L 0.38-0.54
MCV 77 fL 78-98
MCH 24.5 pg 27-34
MCHC 320 g/L 310-355
RDW 20.8 lt15
MPV 6.5 fL 6.5-12
Neutrophils 10.08 x 109/L 2.0-8.0
Lymphocytes 1.2 x 109/L 1.0-4.0
Monocytes 0.72 x 109/L 0.0-1.0
Eosinophils 0.0 x 109/L 0.0-0.5
Basophils 0.0 x 109/L 0.0-0.2
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Interpretation

• Moderate anaemia with microcytic hypochromic
  blood picture. Marked thrombocytosis. Suggest
  ____ ______ and __ __________ and ___/_____
  studies.

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Interpretation

• Moderate anaemia with microcytic hypochromic
  blood picture. Marked thrombocytosis. Suggest
  iron studies and Hb electrophoresis and
  B12/folate studies.

• Which poikilocytoses would you expect?
• elongated cells
• target cells
• Also Had
• hypogranular neutrophils
• hypersegmented neutrophils
• giant platelets

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Other Bloods
UECr UECr UECr UECr
Na 124 mM 135-145
K 4.0 mM 3.5-5.0
Cl- 90 mM 101-111
HCO3- 23 mM 22-32
Urea 3.0 mM 2.5-9.6
Creat 62 mM 40-120
Ca2 2.23 mM 2.2-2.6
LFTs LFTs LFTs LFTs
Alb 18 g/L 35-45
ALP 115 U/L 30-120
ALT 27 U/L 7-56
Tot Bili 18 U/L lt17
GGT 34 U/L 7-64
LDH 187 U/L 100-200
TSH 2.31 mU/L 0.3-5.0
Iron Studies Iron Studies Iron Studies Iron Studies
Fe 1 µM 13-35
Transfrr 1.3 g/L 2.0-3.6
FE Bind 33 µM 46-76
Ferritin 1227 µg/L 20-300
Arterial Blood Gases Arterial Blood Gases Arterial Blood Gases Arterial Blood Gases
pH 7.43 7.35-7.45
pCO2 32.0 mmHg 36-46
pO2 51.4 mmHg 75-100
BE -2.6 -3-3
INR 1.9 0.8-1.2
APTT 33 secs 23-34
CRP 303 mg/L 0
PGL 8.0 mM 3.3-7.7
B12/RCF NAD NAD NAD
BC PENDING PENDING PENDING
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Other Bloods
UECr UECr UECr UECr
Na 124 mM 135-145
K 4.0 mM 3.5-5.0
Cl- 90 mM 101-111
HCO3- 23 mM 22-32
Urea 3.0 mM 2.5-9.6
Creat 62 mM 40-120
Ca2 2.23 mM 2.2-2.6
LFTs LFTs LFTs LFTs
Alb 18 g/L 35-45
ALP 115 U/L 30-120
ALT 27 U/L 7-56
Tot Bili 18 U/L lt17
GGT 34 U/L 7-64
LDH 187 U/L 100-200
TSH 2.31 mU/L 0.3-5.0
Iron Studies Iron Studies Iron Studies Iron Studies
Fe 1 µM 13-35
Transfrr 1.3 g/L 2.0-3.6
FE Bind 33 µM 46-76
Ferritin 1227 µg/L 20-300
Arterial Blood Gases Arterial Blood Gases Arterial Blood Gases Arterial Blood Gases
pH 7.43 7.35-7.45
pCO2 32.0 mmHg 36-46
pO2 51.4 mmHg 75-100
BE -2.6 -3-3
INR 1.9 0.8-1.2
APTT 33 secs 23-34
CRP 303 mg/L 0
PGL 8.0 mM 3.3-7.7
B12/RCF NAD NAD NAD
BC PENDING PENDING PENDING
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Which blood results are characteristic of an
acute phase response?

• CRP 303.8
• Platelets 1177
• Ferritin 1100
• Albumin 18
• ? others

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ECG
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CXR
Next relevant investigation?
USS
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Why an USS if total white out?

• The CXR does not indicate whether the lung is
  adherent to posterior parietal pleura (eg. if the
  effusion is loculated).
• If it is and you attempt to drain it youll give
  the patient a pneumothorax.

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USS

• The effusion is present to the apex and is not
  loculated.
• Distance from parietal pleura to lung was 10cm
  where marked.

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Issues?

• Large L) pleural effusion - ? Malignancy
• Fluid Balance and Electrolyte Issues
• 100/60 in long term smoker probably low
• Hyponatraemia in a patient likely to be water
  deplete. ?SIADH
• Coagulopathic.
• Microcytic Hypochromic Anaemia with abnormal iron
  studies.
• Acute phase response - ? infectious component

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Management

• Admit Respiratory HDU.
• Drain effusion tomorrow morning
• 10mg of Vitamin K stat and rpt INR in am
• Send fluid for ______________________
• CXR two hours post drainage
• CT Chest with contrast tomorrow afternoon.
• Contrast allows good distinction between vessels
  and lymph nodes (Hint remember this!)
• Fluid replacement with normal saline.
• ? Transfuse
• Commence antibiotics ceftriaxone and
  azithromycin
• Blood cultures if febrile.

- didnt but had matched blood ready if needed
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What do we want to know about the pleural
aspirate?

• Cytology
• Neutrophils
• Lymphocytes
• Abn. Mesothelial Cells
• Giant cells (RA)
• Immunology
• Not performed

• Macroscopic
• Yellow cloudy
• Volume 6.0L
• Biochemistry
• Protein
• Glucose
• pH
• LDH
• amylase

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Biochemical Parameters

• Protein
• lt30g/L
• gt30g/L
• Glucose lt3.3mM
• pH lt7.3
• LDH high
• Amylase high

Transudate Exudate
pancreatitis, carcinoma, bacterial pneumonia,
oesophageal rupture
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Pleural Aspirate

• Protein 42g/L
• Glucose 4.7mM
• pH 8.2
• LDH 511U/L
• Amylase not tested on this occasion

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How do we test for SIADH?

• Serum Osmolality
• Urine Osmolality

283 mOsmol/kg 280-300
753 mOsmol/kg 50-1400
The diagnosis requires concentrated urine (Na
gt20mM and osmolality gt500mOsmol/kg) in the
presence of hyponatraemia (Nalt125mM) or low
plasma osmolality (lt280mOsmol/kg), and the
absence of hypovolaemia, oedema or diuretics.
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CXR
2 hr Post drainage of 6.3L pleural fluid!!
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT Chest
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CT ChestSpot the Lymph Node
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CT ChestSub-carinal LAD
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CT ChestPick the abnormality
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CT ChestSupraclavicular LAD
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Cytology Method

• Pleural fluid spun down and sediment smeared.
• Two stains used.
• Sediment is clotted by addition of plasmin and
  the fixed and sliced in the regular fashion
  permitting the use of immunohistochemistry.
• Calretinin negative in this case indicates
  unlikely to be mesothelioma

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Cytology

• Main features of slide are
• Large (in many cases multinucleated) cells
• Large nuclei and prominent nucleoli
• Cytoplasmic vacuolation (mucin, fat, H2O,
  artifact)
• Generally bizarre looking cells
• Other features not on slide shown
• Mitotic figures
• Acinar structures favours adenocarcinoma

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Cytology

• Hard to diagnose malignancy from cytology
• High sensitivity, low specificity.
• Rarely diagnose mesothelioma based solely on
  cytology because of
• Legal implications
• Difficulty distinguishing benign from malignant
  cells
• Textbook hallmarks of malignant cells can be
  seen in benign cells.
• Better to view cytology like VQ scans, in that
  they give you probabilities of a positive result
  and can be diagnostic only in gross abnormalities.

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Cytology Report

• Numerous individual abnormal cells with large
  vesicular nuclei, prominent nucleoli, moderate
  amount of generally finely vacuolated cytoplasm
  and scattered groups exhibiting glandular
  formation.
• The differential diagnosis is between
  adenocarcinoma and mesothelioma. I favour
  adenocarcinoma on the cytological features
  however immunohistochemistry has been ordered for
  clarification.

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Cytology Report

• Immunohistochemistry demonstrated the that
  tumours cells are strongly positive with EMA and
  negative with calretinin stains supporting
  adenocarcinoma involvement of the pleura.

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Progress

• Sats improved 93 on 3.0L NP
• Drowsy but oriented.
• Pneumocath out.
• Transferred to single room.
• Deceased in am.

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Summary

• 55 year old man
• 40 year smoking history
• malignant pleural effusion
• cytological diagnosis of adenocarcinoma
• compression of L) main bronchus making palliation
  difficult
• deceased within 8 weeks of onset of symptoms and
  within 2 weeks of presentation to ED