History of Present IllnessA 60-year-old man presented to the general practitioner for breathlessness and dry cough. The symptoms had arisen a few months earlier and had gradually worsened. Chest radiography revealed complete opacification of the right hemithorax, suggestive of massive pleural effusion ( Fig. 5.1 ). Therefore he was urgently referred to an outpatient pulmonary clinic.
Past Medical History
The patient was a former smoker with a 15-pack-year history (about 10 cigarettes a day for 30 years) and had been exposed to asbestos 40 years earlier, when he started working as a bricklayer. He had never been hospitalized and did not take medications routinely.
Physical Examination and Early Clinical Findings
During pulmonary evaluation, the patient was alert and cooperative. He was afebrile and had mild hypoxemia (oxygen saturation [SpO 2 ] 92% on room air), tachycardia (heart rate 95 beats/min at rest), tachypnea (respiratory rate 25 breaths/min), and normal blood pressure (125/80 mm Hg). On chest examination, breath sounds were absent in all the right hemithorax, with dullness on percussion. No pallor, clubbing, and peripheral edema were observed. Chest ultrasonography confirmed the presence of massive right pleural effusion, with floating particles inside the fluid and a poorly moving collapsed lung ( Fig. 5.2 ). The patient was admitted to the pulmonology department for further workup.
Clinical Course
Blood test results were within normal limits. Hemoglobin was 14.6 g/dL, total leukocyte count was 8.660 cells/mm 3 , platelet count was 180.000 cells/μL, and international normalized ratio (INR) was 1.12. Electrocardiography (ECG) showed sinus rhythm.
Medical thoracoscopy (See )
On the day of admission, medical thoracoscopy was performed. The patient received moderate sedation (intravenous 5 mg of midazolam and 50 μg of fentanyl) and local anesthesia (10 mL of 2% lidocaine), followed by analgesics (paracetamol 1000 mg three times daily and tramadol as needed).
Oxygen via nasal cannula was administered with 3 to 4 L/min to maintain SpO 2 values greater than 94%. A small incision (about 1 cm, parallel to the upper margin of the rib) was made in the fifth intercostal space along the midaxillary line. After penetration of the parietal pleura with a clamp, a trocar was introduced, and a rigid thoracoscope was placed through the trocar. A high amount of orange pleural fluid (2.8 L) was immediately drained. Visceral and parietal pleura were covered with easily desquamating yellow tissue. Many particles of similar tissue were floating in the pleural fluid as well ( Fig. 5.3 ).
The lesions were extensively involving diaphragm, pulmonary apex, pericardium, and subclavian vessels.
Multiple biopsies were performed on the parietal pleura, and samples were sent for histopathological and microbiological examinations. At the end of the procedure, an attempt at talc poudrage was made, then a 24-French (Fr) chest tube was inserted through the same entry port and connected to a three-chamber unit. Suction (−20 cm H 2 O) was applied for 3 days.
Chest radiography performed after thoracoscopy ( Fig. 5.4 ) demonstrated right hydropneumothorax, with nonexpanded right lung. Chest computed tomography (CT) with contrast medium ( Fig. 5.5 ) confirmed the radiographic findings. Both the parietal and visceral pleurae were thickened at the costal, mediastinal, and diaphragmatic levels. Lymph node enlargement was present in the right tracheobronchial angle, right hilum, mediastinum, and subpleural fatty tissue. Some subcutaneous emphysema was present on the right side. Abdominal CT showed no metastatic lesions in the liver, spleen, pancreas, adrenals, kidneys, or bladder.
