History of Present Illness
A 35-year-old Asian man was referred to the pulmonology department for shortness of breath and a dull pain in his right lateral chest. His symptoms, which had started 3 months earlier, were a nonproductive cough, mild chest discomfort on the right side, and gradually worsened dyspnea on exertion. Chest radiography ( Fig. 6.1 ) revealed large pleural effusion on the right side without contralateral mediastinal shift; the effusion was nonloculated, as seen on chest ultrasonography ( Fig. 6.2 ). The patient underwent thoracentesis, with about 1400 mL of dark straw-colored pleural fluid extracted. Biochemical analysis of the pleural fluid was consistent with exudate: lactate dehydrogenase (LDH) 353 units/L (serum LDH 189 units/L; ratio 1.86) and protein 3.8 g/L (serum protein 3 g/L; ratio 1.26). Cytological analysis showed lymphocyte predominance (71%), with no evidence of malignant cells. The pleural fluid level of adenosine deaminase (ADA) was 22.20 units/mL; and the smear microscopy and nucleic acid amplification test results for Mycobacterium tuberculosis (Xpert MTB/RIF) were negative. Ten days later, ultrasonography showed recurrence of pleural effusion.
Past Medical History
The patient was a goat farmer and a never-smoker. He had had no asbestos exposure, no known risk factors for tuberculosis, and no history of drug or alcohol abuse. The patient denied any recent weight loss or appetite reduction. He was not on any medication at the time of evaluation.
Physical Examination and Early Clinical Findings
The patient was referred directly to the interventional pulmonology department, with a request for medical thoracoscopy–guided biopsy. Upon admission, the patient was alert, cooperative, and afebrile. The room air oxygen saturation measured by pulse oximetry was 96%, heart rate was 70 beats/min, and blood pressure was 130/80 mm Hg. Physical examination revealed decreased movements of the right hemithorax, reduced tactile fremitus, stony-dull percussion in the right pulmonary field, and absent breath sounds. No lymphadenopathy, clubbing, or pallor was evident. Chest ultrasonography showed residual right pleural effusion. Routine blood tests showed hemoglobin (Hb) 15.20 g/dL, and total leukocyte count 7,040 cells/mm 3 , and normal differential count. Platelet count was 298,000 cells/μL, and the international normalized ratio (INR) was 1.16.
Computed tomography (CT) of the chest ( Fig. 6.3 ) showed the presence of large right pleural effusion with mild pleural thickening. Lymph node enlargement was seen (levels 3, 4R, and 7), and no parenchymal abnormalities were evident.
Clinical Course
The patient underwent rigid thoracoscopy under moderate sedation (intravenous midazolam and fentanyl). Thoracoscopic examination revealed a diffuse white, nodular, flat growth on the parietal pleura at the costodiaphragmatic level and flat tumor infiltrations on the visceral pleura among the upper lobe, middle lobe, and lower lobe ( Fig. 6.4 ). Multiple biopsy specimens were obtained from the parietal pleura for histopathological and microbiological examinations. Subsequently, chemical pleurodesis was performed with talc poudrage. A total of 4 g of talc was atomized and insufflated into the pleural space through a catheter placed in the working channel of the thoracoscope. Uniform distribution of the talc on all pleural surfaces was confirmed by direct visualization. At the conclusion of the procedure, a chest tube was inserted to drain residual air and fluid from the pleural cavity. Five days after the procedure, no air leakage was evident, and drained fluid was less than 100 mL per day; therefore the chest tube was removed and the patient discharged.
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