Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
r/o abdominal mass
- peter lener (25 March 2004)
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Tb,malignancy and others
- Asif raheem (26 March 2004)
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A 66 year old lady with shortness of breath,part two
- Marin Marinovic (26 March 2004)
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Exclude Meigs and beware lymphoma
- Bruce Lennox (26 March 2004)
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-PLEURAL EFFUSION-THE GREAT MIMIC
- Abdullah Mohammed (26 March 2004)
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Malignacy-Primary Focus to be detected
- Ganapathy Chidambaran (26 March 2004)
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pleural effusion II
- Cornelis K. van Sichem (26 March 2004)
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Pleural exudate- ankle oedema- and dyspnoea
- johan rigobert boie (27 March 2004)
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in addition to abdomen, autoimmune diseases need to be exluded
- ramakant sharma (27 March 2004)
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"Cardiopulmonary Syndrome"
- Ahmad R Tarakji (27 March 2004)
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Pleural effusion - causes
- Koteshwara S Muralidhara (27 March 2004)
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Diagnostic tests
- Nicola Cooper (28 March 2004)
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Clinical Reasoning - an interactive medical education.
- Ed Peile (28 March 2004)
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Combination of diastolic Heart failure syndrome and other disease
- Muntasir Abo Al Hayja (28 March 2004)
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Primary effusion lymphoma
- Marco Cei, Nicola Mumoli (29 March 2004)
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Exudative effusion - What should have been the initial best investigation?
- Malvinder S. Parmar (29 March 2004)
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New diagnosis to be considered
- José M Porcel (29 March 2004)
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Is it an exudate or not?
- Nicola Cooper (30 March 2004)
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More than one or one for all?
- Camilla Alderighi, Raffaele Rasoini, Resident in Cardiology, Florence (30 March 2004)
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Clinical Case-Pleural Effusion
- Rodrigo S Cavallazzi (2 April 2004)
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? Intra abdominal pathology
- Batool F Aly (4 April 2004)
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Pleuro Pulm ; abdominal or pelvic mass to exclude
- Amine Boualem (5 April 2004)
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Intresting Case
- Zaki Hussain Khan (6 April 2004)
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pleural effusion II
- Cornelis K. van Sichem (7 April 2004)
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66 Year Old with breathlessness.
- Alan Williams, BH7 7DW (7 April 2004)
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infective cause/malignancy
- prashanth Manjanabail (17 August 2004)
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peter lener, retired 10467
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i would add that she check her weight every other day and keep a chart of the values. i would order an abdominal sonogram to r/o abdominal pathology-- info to gp--we are still working up her pleural effusion and treating her edema with diuretics.. her echocardiogram was read as normal info to family physician--echocardiogram was read as normal--pleual tap dx effusion no malignat cells ,cultures sterile. continue rx with diuretics, encourage low salt diet and have her check weight every other day and keep record--consider having district nurse pay a visit Competing interests: None declared |
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Asif raheem, emergency care physician saudi arabia
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In view of the elderly pt and the pleural fluid cell picture, extra pulmonary tb, should be kept in mind, followed by, occult malignancy primary or secondary and needs to be investigated further if tuberculosis can be ruled out. The third possibility is a connective tissue diseases. Competing interests: None declared |
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Marin Marinovic, SKMC Abu Dhabi 51900,UAE
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Well,not surprisingly ECHO is basically normal.The pleural tap as well as more detailed history point towards malignancy as the most likely cause. 1.What are the possible causes of the pleural effusions? A/.Malignancy/ Lymphoma,Ca ovary,Ca lung,Ca breast/.At this stage Lymphoma and Ca ovary seems to be most likely.Mature lymphoid cells point towards lymphoma but feeling of abdominal fullness may come from either of them.Mature lymphoid cells plus abdominal fullness plus hematolgy registrar involvement in this case makes hematological malignancy very likely.I do not think we need Sherlock Holmes for this conclusion. B/.Systemic infection or autoimmune disease/unlikely/. 2.What investigations would you do next ? Before ordering any investigation I would like to get hematologist or clinical pathologist opinion on presence of many mature lymphoid cells with macrophages and a few mesothelial cells in pleural tap. I will not be surprised if they suggest possibility of hematological malignancy/most probably lymphoma/. Hence,the next logical investigation is CT of the chest and abdomen.This will definitely help a lot in assessing lymphoid tissue in the thorax,mediastinum and abdomen, and also rule out any other possible growth. CT of pelvis is also necessary to rule out Ca ovary and to evaluate lymphoid tissue in the pelvis.I will not be surprised if based on the history of abdominal fullness CT of abdomen and pelvis show presence of fluid there as well. Bone marrow biopsy may be indicated,but I would definitely discuss this with hematologist. 3.What information should the hospital pass back to the General Practitioner at this stage ? That this lady does not have cardiac failure.The most probable diagnosis at this stage is malignancy and further tests are necessary to prove or rule out this suspicion.Her family doctor should be fully aware that pleuritic tap was only temporary therapeutic and she may develop more shortness of breath. 4.What action may be appropriate for the family doctor? If this lady is still at home awaiting for further investigations,her GP should be clearly told to refer her to hospital immediately if she develops more shortness of breath or temperature.He should monitor her renal function and be careful with any further increase of diuretics and ACE inhibitors. Competing interests: None declared |
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Bruce Lennox, Retired GP Scotland
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Cardiac failure was never likely. In the real world few 66 year olds without risk factors present with 2/12 cardiac failure severe enough to cause pleural effusions. Don't be reluctant to change the provisional diagnosis, beware of tunnel vision. The echo rules out a primary cardiac cause. So don't blame the patient and ask about her "adherence" to medication. It is time to stop and think. Think about alternatives, there are lots of them. Listen to her history (you can't "investigate" it), she is losing weight and has lethargy and abdominal fullness. Examine her again. Make a differential diagnosis and prioritise investigation. And consider draining her effusions and tapering off her medication so she feels better while you are thinking. Of course cancer is high in the differential of pleural effusions at her age. Breast, ovary, or lung (and as she is in the BMJ ask if she has been exposed to asbestos). Lymphoma seems most likely. But let's be optimistic, somethings are benign and curable. The history suggests the possibility of Meigs' or pseudo-Meigs' syndrome. The GP should do a careful bimanual examination. If no ovarian mass is palpable check CA125 and request an urgent pelvic ultrasound. And if these are normal be prepared to retreat to square one, re-take the history, re-examine, CT her belly and ask for a second opinion. Competing interests: None declared |
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Abdullah Mohammed, Clinical Research Registrar The Cardiothoracic Unit, Northern General Hospital Herris Rd,Sheffield S4 ,UK
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The initial clinical findings seem contradictory. The impression of a lady with raised venous pressures, with fluid overload features including peripheral oedema now retrospective history shows weight loss pointing towards a malignant process. The echocardiogram showed good left ventricular systolic function no comments given about diastolic function, right ventricular function, or features of restrictive or constrictive cardiomyopathy, which can cause pleural effusions and ascites, although these diagnoses are much less likely in view of the exudative nature of the pleural effusion. Exudative pleural effusion of that nature aetiology include infective, inflammatory, malignant, drug-induced or rare miscellaneous causes such as sarcoidosis, yellow nail syndrome ,familial Mediterranean fever non- of which seems likely in the absence of their clinical features given so far. The abdominal distension, in a middle age lady with pleural effusion raises the suspicion of ovarian pathology. Although no mention of ascites or masses on abdominal examination, this could be missed if they are of small size. The next line of investigation should aim to image the chest, pelvis, and abdomen with a CT scan. In light of the findings it seems inappropriate to delay the investigations any further, it is more appropriate to admit the lady discontinue her diuretics, monitor her renal function and perform the CT as soon as possible as in-patient. If the CT doesn’t clarify the diagnosis, a thoracoscopy and pleural biopsy is necessary, as it is more sensitive than fluid cytology to diagnose pleural -based disease. If the diagnosis is still not established a revisit to the heart is indicated with a view to assess the right ventricle, diastolic function and exclude constrictive or restrictive cardiomyopathy despite the low probability with exudative type effusion. The general practitioner should be communicated with regarding stopping the diuretics and monitoring renal function unless the patient is being admitted on that day as suggested. Competing interests: None declared |
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Ganapathy Chidambaran, Hon.Med.Officer VHS,Adayar,Chennai
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Sir, In view of her BL Pleural Effusion,Wt loss Lethergy, Fruency of urination,urogenital pathology has to ruled out.US abdomen CAT of Lung & abdomen has to be done. Dr.Chidambaran Competing interests: None declared |
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Cornelis K. van Sichem, GP Santpoort-Noord Netherlands
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It seems that we have entered the realm of the red herring. Obviously we need to keep an open mind of causes non related to pulmonary / cardiac causes. The pleural tap was consistent with an exudate. Cultures were negative. Positive cultures are diagnostic, negative cultures exclude nothing. There was a slight increase in pulmonary artery pressure. Therefore the adagium " common things occur commonly" still holds. Possible causes, pulmonary emboli, inflammation of the pleuri bacterial or auto-immune such as TB, lupus erythematodus. Malignancies, mesothelioma, pleural metastasis. Extra-thoracical causes are ovary tumors, although one would expect ascites to be part of the presentation in such case. Investigation proposed would be pleural biopsy, ventilation-perfusion scan of the lung. Communication to the GP should inform him about the pleural effusion of unknown cause which is under inevstigation and to inform him about the possibilities of aggarvation of symptoms. as a GP I would like to pay her a visit to inform myself about the present complaints about dyspnea and physical handicaps in daily matters as walking stairs/housekeeping. shopping and social back-up, e.g. neighbours/family Competing interests: None declared |
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johan rigobert boie, Pneumologist 9620 zottegem
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Differential diagnosis with this symptoms: Amyloïdosis Hypothyreosis Tuberculosis Systemic lupus erythematosus Competing interests: None declared |
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ramakant sharma, halton general hospital runcorn wa7 2da
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my friends have already outlined the correct management, ie US/CT of abdomen and possible CT chest to rule out some parenchymal lung lesions. the other possibilty is autoimmune diseases, with a predominant left pleural effusion. i will also re-emphasize my earlier point of view, the examination given in the summary was misleading. how can you explain raised JVP now? now its the turn of abdomen. are we not totally dependant on investigations? Competing interests: None declared |
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Ahmad R Tarakji, Internist, Nephrologist, Geriatric Fellow University of Missouri-Columbia, One Hospital Dr, Columbia, MO 65212, USA
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The clinical picture of this patient points toward the heart which could be a secondary manifestation of a pulmonary process. She has a right side heart failure component (elevated JVD, high pulmonary pressure) which can decrease the filling to the left side of the heart and causes dyspnea on exertion. The increase in blood pressure could be a compensatory sympathetic process to heart failure. I thought her EKG shows some intraventricular conduction defect (IVCD) but it's not a clear one on the website. The exudative type of pleural effusion with the severity of her dyspnea with "mild" echocardiographic evidences point toward a pulmonary process (?inflammatory, chronic pulmonary embolisms, malignancy). Taking the weight loss and fatigue into consideration, I would look for an interstitial lung disease (ILD) and it will be a good decision to do Pulmonary Function Test (PFT) and CT scan of chest with IV contrast. As a geriatrician and nephrologist, I would check thyroid stimulating hormone (TSH), PPD (for TB) and urinalysis (UA). As a GP, I would get a travel history and ask about food intolerence (? TB or worm disease causing lymphatic obstruction and fatty food intolerence). I would also ask about snoring and sleep apnea symptoms. Breast exam/mammogram and colonoscopy should be done as part of health maintenence by GP. Don't forget that old patients present with uncommon manifestations of common diseases and they can have more than on explanation (multifactorial) of their diseases. A very detailed history taking with patience will uncover a lot of hidden but very helpful red flags. Thanks. DART. Competing interests: None declared |
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Koteshwara S Muralidhara, SHO Central Middlesex Hospital, London, NW10 7NS
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Bilateral pleural effusions can be exudative or transudative. Common causes of bilateral pleural effusions include: 1.Transudative: a. Cardiac failure, b.nephrotic syndrome, c.anasarca due to any protein deficiency state or fluid overload. 2. Exudative: a.Infections: Tuberculosis and rarely other infections b. Neoplasms: Malignancy - primary and metastatic pleural malignancy, bronchogenic Ca,lymphomas etc. c. Immunological diseases: Mixed connective tissue disease, Rheumatoid arthritis, SLE and others. d. Long standing cardiac failure or liver failure (on diuretics) e. Hypothyroidism (chronic) f. Drug induced - methotrexate etc This lady has history of progressive disease with weight loss and vague abdominal symptoms. One has to rule out a chronic infective process like tuberculosis and underlying neoplasm. CT chest and abdomen, Heaf test, autoimmune screen, tumour markers will be of help in making a diagnosis. Pleural fluid Adenosine DeAminase, lysozyme and gammainterferon levels have high sensitivity and specificity for tuberculosis. High amylase level in pleural fluid may indicate pancreatic pathology. Salivary amylase may be increased in Small Cell Ca of Lung. Pleural biopsy is another useful investigation in getting a proper tissue diagnosis. Competing interests: None declared |
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Nicola Cooper, SpR medicine / elderly The Leeds Teaching Hospitals NHS Trust
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This case raises several points about the use of diagnostic tests. First: pleural effusions. Historically, the cut-off of 30g/L protein has been used to differentiate exudates from transudates. But this misclassifies 15-20% effusions, especially in treated heart failure. Light's criteria is the gold standard for evaluating pleural effusions. An exudate is diagnosed when one of three of the following occur: pleural protein to serum protein ratio >0.5, pleural LDH to serum LDH ratio >0.6, or pleural LDH > two-thirds the upper limit of normal for blood LDH. These criteria are 98% sensitive for diagnosing an exudate - but in treated heart failure 10-20% transudates are misdiagnosed (because the diuretics "thicken up" the remaining pleural fluid). In this situation, the serum-effusion albumin gradient has a sensitivity of 87% and specificity of 92% and prevents patients with transudates on diuretics being subject to unecessary investigations. (An exudate has a gradient of 12g/L or less and a transudate is higher). Others use the pleural effusion cholesterol level. Second: echocardiography is quite operator dependent, and in the UK is usually performed by technicians, as opposed to cardiologists. From the American College of Cardiology guidelines on echocardiography: ‘In clinical practice the visual estimation of ejection fraction from two- dimensional echocardiography is common. Ejection fraction may be reported quantitatively or qualitatively as increased, normal, or mildly, moderately, or severely reduced. When performed by skilled observers, ejection fraction by visual estimation corresponds closely to that obtained by angiography. However, because of its subjective nature, a visual estimate of ejection fraction is less reproducible than quantitative methods. Optimally, its use should be restricted to those practitioners with considerable experience in echocardiography who can periodically compare their visual estimates to those obtained with a non echocardiographic method. If the Echo result does not fit with the patient, it may be wrong. Particularly as the ACC points out that diastolic dysfunction, defined as heart failure in the presence of an ejection fraction greater than 40%, is common. However, ‘observations concerning the utility of echocardiography in patients with congestive heart failure were investigated by Aguirre et al, who prospectively studied 151 consecutive patients undergoing Doppler echocardiography who had a clinical diagnosis of congestive heart failure. A normal ejection fraction (greater than 55%) was observed in 34% of patients. More recent data from population studies confirm the high prevalence of normal ejection fraction in older patients hospitalised for congestive heart failure.’ This leads to a change in management in a significant number of patients. Third: pre-test (or clinical) probability is extremely important and is based on a good, through history and examination. All diagnostic tests can only be interpreted in the light of pre-test probability, because there is no such thing as a perfect test. In a patient at high risk of cardiovascular disease, the findings so far have not ruled out congestive cardiac failure. But in a patient with no risk factors for cardiovascular disease, the findings so far have virtually ruled it out. So the next step is to start with a thorough history and examination. Finally, this is why I constantly tell junior doctors: “Tests so not make a diagnosis; doctors do.” Refs: Burgess LJ, Maritz FJ, Taljaard FJJ. Comparative analysis of the biochemical parameters used to distinguish between pleural transudates and exudates. CHEST 1995; 107 (6): 1604 - 9 American College of Cardiology website acc.org Black ER, Bordley DR, Tape TG, Panzer RJ [eds]. Diagnostic strategies for common medical problems. American College of Physicians 1999. Competing interests: None declared |
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Ed Peile, Professor of Medical Education Warwick Medical School CV4 7AL
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Interactive case reviews are showing an interesting and welcome progression. Only about 15% of the responses to the two instalments in this case have been the sort of quiz response which just offers a 'right or wrong' answer. The vast majority now are reflective exposures of the respondents' clinical reasoning processes. Most people responding to the initial case presentation offered heart failure as the most likely condition, but the interest for me lay in their defining the causes for uncertainty, and the appraoches to reducing uncertainty. Again, following the case progression, there is some really thought- provoking clinical reasoning contributed by way of response. Let's take this process further - I would like to encourage contributors to interact with each other's reasoning and to develop approaches to these complex clinical problems that are generalisable. Those of us involved in undergraduate or postgraduate education are only too well aware of the difficulties in training medical learners in clinical reasoning, and it seems that a wonderful oportunity is developing here. Good to see medical students taking part. Competing interests: I am an editorial adviser to BMJ and have received fees from BMJ for work on interactive case reviews |
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Muntasir Abo Al Hayja, ST laekare Sweden (Registrar Level) 79252 Mora / Sweden
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This lady has a hypertensive blood pressure, accelerated heart rhythm, mitral regurgitation and mild pulmonary hypertension. All these data indicate that she has a diastolic heart failure. So Doppler Echocardiography, M-Mode colour doppler, isovolumic relaxation time and pulmonal vein pulsed-wave doppler registration should be able to demonstrate this clearly. In doubt the B-type natriuretic peptide can be measured to confirm the diagnosis heart failure. Arterial blood gas analysis should be taken before and after exercise. Pulmonary function tests are not useful at this stage because of the persistent of the bilateral pleural effusion but could be considered after aspiration of the fluid. So Thoracocentesis could be repeated once again and a larger volume should be sent for cytology. The main causes of exudative pleural effusions are inflammatory, neoplastic, Tuberculosis pleurisy and meigs syndrome. Pulmonary embolism has already been excluded. Further investigation should include the following: Thorax and abdominal CT, mammography, gynaecological investigation. Competing interests: None declared |
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Marco Cei, Hematologist Ospedale Civile Livorno, Italy, Nicola Mumoli
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Primary effusion lymphoma is an attractive hypothesis, although not very probable. Primary effusion lymphoma (also known as body cavity-based lymphoma) usually presents without detectable tumour mass or marrow involvement; however lymphocytes in exudates are often described as atypical. We would know something about immunophenotyping, HIV (Human Immunodeficincy Virus) status and polimerase chain reaction for HHSV-8 (Human Herpes Virus-8). Competing interests: None declared |
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Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
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The patient has exudative effusion and the possibilities include 1. A neoplastic process – primary or secondary – lymphoma, mesothelioma are the ones to consider. 2. Meig’s syndrome is still a possibility as mentioned in my response to part 1 of this case [http://bmj.bmjjournals.com/cgi/eletters/328/7441/698#53889]. 3. Infectious process that needs to consider would be tuberculosis. 4. Autoimmune process would be a remote possibility. The question is not what investigation to do next but as a teaching or learning process with these interactive cases, it is important to highlight which investigations should be done first. In clinical practice, multiple investigations are performed at the same time and some of those are futile. In this time of financial restraints on healthcare systems around the world, it is important to discuss what investigations, when and in what order those investigations should be performed. Although, clinically it was felt that patient may have heart failure (common diagnosis) but the lack of vascular redistribution with bilateral pleural effusion, as mentioned in my previous response [http://bmj.bmjjournals.com/cgi/eletters/328/7441/698#53889] suggested the moderate likelihood of a non-cardiac cause, but I along with others treated her as ‘heart failure.’ However, I did not elect Echocardiogram to be my initial investigation and instead thoracocentesis was my test of choice both for diagnostic and ‘therapeutic’ purpose(s). Now as the thoracocentesis has shown the effusion to be exudative, an echocardiogram might have been avoided. Although it is a non-invasive test but still increased the cost of care. Now, the question should be, in retrospect would you have done Echocardiogram as an initial test? I think one purpose of such discussions is to avoid "Reflex action medicine." Similarly, as suggested by some respondents, CT scan of chest, abdomen and pelvis should be the next step. The question should be Would you do CT of all cavities [chest, abdomen and pelvis] or would you select a particular cavity first? It would be important to know more details on the pleural fluid – like pleural fluid glucose [as low levels would indicate infectitious or a rheumatological process], LDH, amylase and complement levels, if done, although these may not be available at all places. As the revised history now indicates, abdominal symptoms of fullness and the first test that I would consider would be a bimanual examination by a gyanecologist to assess her ovaries for enlargement (Meig’s syndrome) and if there is suspicion then would do CT of pelvis and then abdomen if pelvic CT is negative and in the last would be CT of chest. If all these are negative then pleural biopsy. Competing interests: None declared |
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José M Porcel, Internist Arnau de Vilanova University Hospital, 25198 Lleida, Spain
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Initially, I considered constrictive pericarditis as a probable diagnosis. I think it cannot be excluded, since echocardiography may be normal and cardiac catheterization may be neccesary to establish the diagnosis. However, other diseases need to be considered at this point. First, malignancy remains the most common etiology of undiagnosed exudative pleural effusions. The sensitivity of pleural cytology is only 60% on average. Thus, a negative result as in the present case does not rule out a malignant effusion. Except for breast cancer, which rarely presents with pleural effusion, a number of solid and hematologic malignancies may be included as potential causes. Second, pulmonary embolism should be pursued in all patients with undiagnosed effusions. This woman had indirect evidence of pulmonary hypertension, although persistence of the effusion for weeks is infrequent in pulmonary embolism. The pleural fluid in this entity is almost always an exudate, not neccesarily blood-tinged. Finally, bilateral effusions and the absence of fever argue against tuberculosis. In my opinion, a second cytologic analysis, measurement of adenosine deaminase in pleural fluid, and a thoracic CT scan should be ordered. Spiral CT can demonstrate not only a pulmonary emboli but parenchymal infiltrates, pleural thickening, pericardial thickening or mediastinal lymphadenopathy. If no diagnosis is obtained after these procedures, a pleural biopsy should be the next study. Competing interests: None declared |
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Nicola Cooper, SpR medicine / elderly The Leeds Teaching Hospitals NHS Trust
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All the respondents seem sure this effusion is an exudate on the basis of protein level alone (see previous rapid response). This is the first question to answer. Competing interests: None declared |
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Camilla Alderighi, Resident in Cardiology Florence, Raffaele Rasoini, Resident in Cardiology, Florence
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The apparent incoherence of Mrs Dempsey's symptoms/signs raises the possibility that more pathological conditions could simultaneously be present but the concomitant onset of her problems two months before presentation is much more suggestive of an isolated underlying ethyology, perhaps leading to heterogeneous findings. The good systolic function as well as the normal size and thickness of cardiac chambers, the apparent exudative nature of the effusion and the refractoriness to diuretics lower the probability of HF, but do not definitely exclude it. A constrictive pericarditis as a restrictive cardiomyophaty could present with such echographic findings, and a low response to diuretics could be present. Nothing is known about diastolic function and the presence of tachycardia could be the reason for that. Jugular distension and ankle oedema with normal systolic function are in keeping with a constrictive/restrictive pattern but the absence of a detectable liver on examination and ascites seem unusual. Moreover, the characteristics of the effusion (exudate, asymmetric) are not typical for these conditions. The loss of a half stone during the last six months is of course underestimated, because the patient has fluid retention, and marked weight loss should suggest that HF, if present, is secondary to another illness. The characteristics of pleural fluid described could be related, in particular, with tuberculosis and cancer, and both these conditions can involve pericardium and pleura. A diffuse tubercular process which also involves meninges could explain lethargy and negative cultural exams of pleural fluid do not exclude tuberculosis. Nonetheless, the presence of mesothelial cells strongly argues against tuberculosis and moreover, the absence of fever, anemia and lymphocytosis would be very atypical in such a massive presentation. Cancer should be considered the leading hypothesis. A neoplastic process could justify a constrictive heart involvement and an exudative effusion refractory to diuretics. Cancers which are most probably related to this presentation are pulmonary, breast and lymphoma. Pulmonary cancer in non-smokers is more frequently seen in women and it would be interesting to know if the patient's husband is a smoker. Breast cancer often presentates with a metastatic illness and we don't know if Mrs Dempsey has recently performed mammographic screening. The symptoms and signs described are also consistent with lymphoma, particularly a non-Hodgkin disease with extra- lymph nodal involvement. An interesting hypothesis that could explain the jugular veins distension in absence of liver enlargement is an incomplete superior vena cava syndrome due to cancer. Orthopnoea and lethargy can be present in this syndrome even though we don't find a reason for ankle oedema. The chest radiography does not show a mass in the superior vena cava region even though it might be difficult to detect. Abdominal fullness such as ankle oedema can be related to lymphoma which involves abdominal lymph nodes. The absence of lymphoadenomegaly on examination and the normal blood chemistry are not unusual in non-Hodgkin lymphoma. With regard to the neoplastic hypothesis, lethargy could be related to many paraneoplastic syndromes, including malignant hypercalcemia and inappropriate ADH production, such as with a metastatic involvement of the central nervous system. Another tumor that we must consider is ovarian carcinoma, which usually presents when it's already outside pelvis. An abdominal mass can be failed on examination and ascites can be not detectable. Abdominal fullness is a characteristic presentation, umbilical hernia can develop as well as ankle oedema because of increased abdominal pressure and/or lymph node involvement. Paraneoplastic syndromes, as malignant hypercalcemia, can be one of the first signs of ovarian cancer. Even pleural effusion can be the initial presentation, and differentiation of neoplastic cells from mesothelial cells in pleural fluid may be difficult. Venous jugular distension in not easily explained, even though the association between superior vena cava thrombosis and ovarian cancer has been described. Pulmonary embolism is consistent with right heart involvement, even though many factors are evidence against this diagnosis, as the mild pulmonary hypertension in a patient with jugular veins distension, the large, bilateral, and persistent effusions, the absence of pleuritic chest pain and clinical signs of deep venous thrombosis. However, renal cell carcinoma could extend to the inferior vena cava and determine neoplastic pulmonary embolism, with large effusions. In conclusion, cancer with or without secondary pericardial involvement represents the most probably condition which assembles the majority of the findings in this patient. Lymphoma and ovarian cancer are at the top of the list. Many other neoplasms, particularly pulmonary, breast and renal cancer are also suggestive hypothesis. Incomplete superior vena cava syndrome, although not frequent, may represent an interesting explanation for a pseudo-cardiac involvement. The first investigation that should be made is chest and abdomen-pelvis CT with contrast medium. That's why we need to see everything in chest, including pleural pericardial thickening, mediastinum masses, lymph-nodes, pulmonary parenchyma and pulmonary arteries. Abdomen and pelvis scan should be integrated with transvaginal pelvic ultrasonography which is more sensitive than CT for imaging ovary. Sodium, calcium, beta 2 microglobulin and LDH should be dosed and a tuberculin skin test should be done. CA 125 dosage is not useful in this setting because pleural effusion (as every sierosits) might falsely elevate it. If a second pleural tap is made, pleural fluid pH, cytometry, adenosine deaminase, PCR for micobacteryal DNA must be considered. The next diagnostic steps are largely dependent on CT and laboratory findings. Mrs Dempsey's physician should be informed with caution of cancer hypothesis, underlying the fact that at the moment we have not other results except echocardiography. It could be reasonable to say the general practitioner that her patient should be admitted, in order to complete diagnostic tests rapidly and to receive more intensive care. Don't forget that this patient has dispnoea for very small efforts. Competing interests: None declared |
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Rodrigo S Cavallazzi, Pulmonary physician Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil, 04023-900
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Pleural effusions are divided in transudates and exsudates by biochemical criteria. Most common causes of transudates include heart failure, cirrhosis, nephrotic syndrome, peritoneal dyalysis, myxedema, acute atelectasis, constrictive pericarditis, superior vena cava obstruction, and pulmonary embolism. Most common causes of exsudates include pneumonia; pulmonary embolism; empyema; pleural tuberculosis; connective tissue disease; viral, fungal and parasitic infections; asbestos related disease; Meigs`syndrome; pancreatic disease; uremia; chronic atelectasis; trapped lung; chylothorax; sarcoidosis; drug reaction; and post-myocardial inarction syndrome. Although this lady has a high pleural-fluid protein, which is indicative of a exsudate, it is important to point out that she has been using diuretic for a while. In patients receiving diuretics, sometimes a transudate can be mistakenly assumed as a exsudate when using a single biochemical parameter. Therefore I would like to know if this effusion is still a exsudate if we use the Light´s criteria and, most importantly, the pleural fluid-serum albumin gradient. Assuming it as a exsudate, I believe the most appropiate next step is to ask for the pleural-fluid cell count and differential. The percentage of mesothelial cells is valued here since a high number would decrease the possibility of pleural tuberculosis. At this time, I would also look for pleural-fluid glucose, which is low in parapneumonic effusion, cancer, pleural tuberculosis and rheumatoid disease. Of paramount importance in this case, is the pleural-fluid oncological citology, which depending on the tumor type, has a high yeld. Indeed, a malignancy is a very likely diagnosis in this case. The absence of fever and chest pain, the bilateral compromise and the evolution of this pleural effusion make pleural tuberculosis a less likely diagnosis although it should still be tested for markers of tuberculosis. If all results of the above exams and analyses do not give us a dignosis, the next action would be either a repeated pleural-fluid oncological citology or pleucoscopy with biopsy. As an easy alternative, one could also try a closed pleural biopsy. Competing interests: None declared |
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Batool F Aly, Clinical Attachae Glan Clwyd Hospital LL18 5UJ
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cannot ignore the posibility of intra abdominal pathology specially ovarian, as she is complaining of abdominal fullness and has an umblical hernia [?increased intra abdominal pressure]with bilateral pleural effusion.Another posibility is lung pathology [? mesothelioma]. Investigations; CT Chest and Abdomen + tumor markers. Results of echo and other investigations should passforward to her GP with further explanation and advice regarding symptomatic support until we reach final diagnosis. At this stage when things are not very clear her GP should aim towards symptomatic and psychological support and ways of improving her daily life. Competing interests: None declared |
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Amine Boualem, PRHO CB2 2 QQ
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Dear Doctors 1/Possible causes: *Malignancy (e.g. Bronch Ca; abdominal or Pelvic tumour with Inferior Vein Cava Obstruction) *Pulmonary Infracts; *Pancreatitis; *Auto-immune disease 2/Investigations: U/S Abdomen (? ascites or mass), Amylase; CT Scan(chest+abdomen+pelvis); antinuclear antibodies 3/tell GP : stop Frusemide and ACE Inh, may consider Spironolactone; useful to do Tuberculin skin test.Do again U/Es; Dipstick Urine. 4/Update the patient with the findings, reassure her and tell her about the plan of investigations and likely causes of her condition. Competing interests: None declared |
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Zaki Hussain Khan, Resident Ziauddin Medical University hospital
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Q1. Possible causes of exudative pleural effusion are many, A. Neoplastic:- breast cancer,ovarian cancer,lymphoma b. Pulmonary embolization c. Infectious:- T.B, Fungal infection., bacterial infection d. Collagen vascular disease:- SLE, RA, etc e. Sarcoidosis f. Asbestos exposure. etc Q2.investigations I like to do diagnositc and therapeutic pleural tap and send pleural fluid for glucose,AFB, repeat cytology, cell count and differential. pleural biopsy. Ultrasound of abdomen and pelvis. repeat X-ray after therapeutic tap and possible ct scan of the chest. Urinalysis. ACE level ANA Q3. should inform the general practioner that these symptoms are unlikely because of heart failiure as proof by the investigation and further evaluation(extensive) is needed to diagnose the case. Q4 Family dr should refer the patient to the appropriate specialist. Competing interests: None declared |
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Cornelis K. van Sichem, gp Netherlands
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Re-reading the article I can't recall whether a tuberculin test has been done. If not, adding to my previous response, this should be done. Cancer should be suspected if the test shows negative. Competing interests: None declared |
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Alan Williams, Consultant Physician Royal Bournemouth Hospital, UK, BH7 7DW
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The race is on to be the first to scoop the diagnosis. A few red herings have been thrown I am sure! The involvement of the haematologist may be one! The level of breathlessness may be disproportionate to the mere physical presence of the bilateral effusions which are probably moderate and which are unlikely to exert a significant physiological effect in the presence of underlying normal lung tissue. The peripheral oedema/ raised JVP still point to a right sided cardiac problem as does the raised pulmonary artery systolic pressure. The oxygen saturation of 93% is not normal. The likeliest diagnosis therefore, is multiple 'silent' pulmonary emboli. This needs to be excluded with CT PA/V/Q lung scanning. In addition, co-existing malignancy should be sought with detailed scanning of abdomen and pelvis. Competing interests: None declared |
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prashanth Manjanabail, sho renal medicine DN25AB
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The echo report virtually excludes LVF as the etiology of breathlessness.The pleural fluid analysis is suggestive of exudate.The couse of which could be 1)tuberculosis 2)Malignancy this is supported by the fact that analysis showed lymphocytes. The next step would be to ask for contrast enhanced CT of the chest.If contrast enhanced ct of the chest is not suggestive of anything a pleural biopsy should be performed. It would also be worth while doing a connective tissue screen(although unlikely but would exclude connective tissue disorder as the couse of effusion) Competing interests: None declared |
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