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Case Presentation

Case Presentation. Teaching Presentation. 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. PHx Asthma

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Case Presentation

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  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, hasn’t 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.

  7. Further History • Social History • lives with wife who suffers from psychiatric illness and acts as carer • doesn’t 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 35%O2 • Temp 36.4˚C • GCS 15 • General Appearance • Cachectic, pale, speaking full sentences, slightly disheveled. • Not cyanotic.

  9. 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)

  10. 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

  11. Impression? • Large left pleural effusion. • Causes?

  12. Causes of Pleural Effusion Transudates LVF Hypoproteinaemia Constrictive Pericarditis Hypothyroidism Meig’s 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 • G&CM • LDH • CRP • BC

  14. FBE

  15. FBE

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

  17. 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

  18. Other Bloods

  19. Other Bloods

  20. Which blood results are characteristic of an acute phase response? CRP 303.8 Platelets 1177 Ferritin 1100 Albumin 18 ? others

  21. ECG

  22. CXR Next relevant investigation? USS

  23. 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 you’ll give the patient a pneumothorax.

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

  25. 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

  26. 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. - didn’t but had matched blood ready if needed

  27. 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

  28. Biochemical Parameters empyema, malignancy, TB, RA, SLE • Protein • <30g/L • >30g/L • Glucose <3.3mM • pH <7.3 • LDH high • Amylase high Transudate Exudate pancreatitis, carcinoma, bacterial pneumonia, oesophageal rupture

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

  30. 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+ >20mM and osmolality >500mOsmol/kg) in the presence of hyponatraemia (Na+<125mM) or low plasma osmolality (<280mOsmol/kg), and the absence of hypovolaemia, oedema or diuretics.

  31. CXR 2 hr Post drainage of 6.3L pleural fluid!!

  32. CT Chest

  33. CT Chest

  34. CT Chest

  35. CT Chest

  36. CT Chest

  37. CT Chest

  38. CT Chest

  39. CT Chest

  40. CT Chest

  41. CT Chest

  42. CT Chest

  43. CT Chest

  44. CT ChestSpot the Lymph Node

  45. CT ChestSub-carinal LAD

  46. CT ChestPick the abnormality

  47. CT ChestSupraclavicular LAD

  48. 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

  49. 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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