Thoracentesis (See )
History of Present Illness
A 60-year-old Caucasian man presented to the hospital with shortness of breath and right lateral chest pain. These symptoms had begun about a month earlier, after a flu-like episode with cough and low-grade fever, and had progressively worsened. Chest radiography, requested by the primary care physician, had revealed right-sided pleural effusion, without shift of the mediastinum ( Fig. 1.1 ). Consequently an urgent referral to the pulmonology department was made.
Past Medical History
The patient was a truck driver, current smoker of about 40 cigarettes a day, with a 70-pack-year history of smoking. He had not had any asbestos exposure, no known risk factors for tuberculosis, and no history of drug abuse, weight loss, or anorexia. He had never undergone pulmonary function tests. He took daily medications for hypercholesterolemia (simvastatin).
Physical Examination and Early Clinical Findings
At the time of the visit to the pulmonologist, the patient was afebrile (body temperature 36.7° C [98.06 °F]), alert, and cooperative. Oxygen saturation measured by pulse oximetry was 97% on room air, heart rate was 80 beats/min, respiratory rate was 23 breaths/min, and blood pressure was 130/85 mm Hg.
On chest examination, the breath sounds were absent in the infrascapular and infra-axillary areas on the right side, and decreased fremitus and dullness to percussion were observed. No pallor, clubbing, and peripheral edema were apparent. Chest ultrasonography showed large, hypoechoic, right-sided pleural effusion, with a flattened diaphragm and paradoxical diaphragmatic motion.
Recent blood tests had shown a hemoglobin level of 15.4 g/dL and total leukocyte count of 9,720 cells/mm 3 , with a normal differential count. The platelet count was 150,000 cells/μL, the international normalized ratio (INR) was 1.06. After injection of a local anesthetic (2% lidocaine), right thoracentesis was performed by inserting a 15-gauge Verres needle catheter connected to a tube with a three-way stopcock and a 2-L collecting bag. Hemorrhagic pleural fluid came out and was retained for analysis ( Fig. 1.2 ). The procedure was well tolerated: the patient had no cough, and oxygen saturation increased to 99% during the thoracentesis. Thus a large amount of fluid (1500 mL) was extracted with the aim of achieving alleviation of symptoms and getting a better view of the lung parenchyma at the subsequent chest computed tomography (CT) scan. To facilitate removal of the liquid, slight suction was applied by means of a syringe. Toward the end of the procedure, however, the patient reported some mild, anterior chest discomfort, and after removal of another 120 mL of fluid, free aspiration of air was obtained in the syringe. Ultrasonography after the procedure revealed right-sided hydropneumothorax ( Fig. 1.3 ), which was confirmed with chest radiography ( Fig. 1.4 ).
A 14-French (Fr) chest drainage tube was inserted through the right fourth intercostal space. Subsequent chest CT before and after administration of iodinated contrast medium ( Fig. 1.5 ) confirmed the presence of right hydropneumothorax that had not resolved despite placement of the chest tube. A parenchymal hypodense area suggestive for pathological solid tissue was detected in the right lower perihilar area, in correspondence with the apical segment of the inferior lobe. Some mediastinal lymph nodes were detected in the right hilar area, with a maximum diameter of about 8 mm. Finally, the postcontrast phase revealed multiple thromboembolic defects at the branches of the left pulmonary artery. This finding led to the initiation of anticoagulant injection therapy (enoxaparin subcutaneously 6000 units two times daily). The patient was admitted to the pulmonology department.
Clinical Course
Pleural fluid analysis was consistent with exudative effusion: total protein was 4.5 g/dL, and lactate dehydrogenase (LDH) was 911 units/L. Patient risk factors, in particular the strong exposure to cigarette smoke, together with the appearance of the pleural fluid, were highly suspicious of malignant effusion. The hydropneumothorax was thought to be the consequence of a tumor that caused difficulty in reexpansion of the lung.
2-Deoxy-2-[fluorine-18]fluoro-D-glucose ( 18 F-FDG) PET/CT was performed ( Fig. 1.6 ) and showed significant FDG uptake in the right hilar area, corresponding to the lesion in the apical segment of the inferior lobe (maximum standard uptake value [SUV] 8.2) and uptake in the right hilar lymph node (maximum SUV 5.2). These findings supported the hypothesis of cancer in the lower lobe of the right lung, with ipsilateral hilar lymph node metastasis.
