History of Present Illness
A 35-year-old Caucasian woman went to the emergency room for right chest pain, tachycardia, and low-grade fever (37.5° C [99.5° F]). The symptoms had begun a couple of weeks earlier and had gotten progressively worse.
Past Medical History
The patient worked as a general practitioner, never smoked, and had a history of mammary fibroadenomas and polycystic ovary syndrome. Six years earlier, she had undergone cholecystectomy for gallstones. She had one previous pregnancy with delivery by cesarean birth 2 years earlier, and she breastfed her baby for 15 months.
She probably had a limited amount of exposure to asbestos (it was present in the roof of the home where she had lived in the first 20 years of her life).
Physical Examination and Early Clinical Findings
A reduction in breath sounds and dullness to percussion were found at the right lower part of the chest. Arterial blood gas (ABG) analysis in room air showed hypoxemia and hypocapnia: pH 7.45; partial pressure of oxygen (Pa O 2 ) 65 mm Hg; and partial pressure of carbon dioxide (Pa co 2 ) 29 mm Hg. Chest radiography revealed unilateral right-sided pleural effusion, without pulmonary parenchymal lesions; no left pleural effusion; and no pathological mediastinal findings ( Fig. 8.1 ).
Blood tests showed a slight increase in the inflammation indices (C-reactive protein [CRP]: 32 mg/L; normal values < 5 mg/L), absence of leukocytosis (white blood cell [WBC] count: 8,030 cells/μL).
Well’s criteria for pulmonary embolism were applied, and the patient was determined to be at low risk. Because D -dimer was not negative (644 ng/mL; normal values < 500 ng/mL), the patient underwent computed tomography pulmonary angiography (CTPA), which did not show pulmonary thromboembolism and confirmed right pleural effusion with a maximum thickness of approximately 35 mm ( Fig. 8.2 ). Three very small nodules (maximum diameter approximately 3 mm) along the major fissure were identified. The patient was admitted to the internal medicine unit.
Clinical Course
Empirical therapy, including broad-spectrum antibiotics (piperacillin/tazobactam 4 g/0,5 g intravenously every 8 hours, plus oral levofloxacin 500 mg per day), systemic glucocorticoids (methylprednisolone 20 mg intravenously every 8 hours), and analgesics (paracetamol as needed), was begun.
Bedside thoracic ultrasonography showed only small right pleural effusion, which further reduced in the subsequent days. Therefore thoracentesis was not performed. Further blood tests showed positivity for anti- Mycoplasma pneumoniae immunoglobulin M (IgM). Results of screening tests for autoimmune disorders were negative (absence of antinuclear antigens [ANA], extractable nuclear antigens [ENA], proteinase 3 [PR3] and myeloperoxidase [MPO] anti-neutrophil cytoplasm antibodies [ANCA]).
Some tumor markers were assayed (carcinoembryonic antigen [CEA], cancer antigen [CA] 125, CA 15-3, CA 19-9, cytokeratin fragment [CYFRA] 21.1, neuron-specific enolase [NSE]), with an increase only in CA 125 (121 units/mL; normal values < 35). However, this marker is nonspecific and frequently increased in patients with pleural effusion.
A tuberculin skin test with five tuberculin units produced a reaction of 5 mm of induration after 72 hours. This is usually considered negative in people without known risk factors for tuberculosis (TB). However, QuantiFERON TB GOLD was prudently executed, but the result was not immediately available.
The patient experienced slow but progressive clinical improvement, with normalization of the inflammatory indices, resolution of the hypoxemia, and reduction in the amount of pleural effusion, as demonstrated by chest radiography and ultrasonography.
Recommended Therapy and Further Indications at Discharge
The patient was discharged after 10 days of hospitalization with the diagnosis of right pleuropneumonia caused by Mycoplasma pneumoniae.
The following home therapy was prescribed:
Levofloxacin 500 mg per day until reaching a total of 14 days of therapy.
Methylprednisolone 16 mg per day, with tapering every 3 days and discontinuation in 9 days
Outpatient follow-up after hospital discharge was suggested, with a control chest radiography after 4 weeks.
Follow-Up and Outcomes
Some days before the scheduled control, the patient went again to the emergency room because of high fever with shivering and chest pain. Chest radiography showed recurrence of right pleural effusion. Blood tests showed a WBC count 13,200 cells/μL (neutrophils 88%) and CRP 262.1 mg/L. The previously performed QuantiFERON TB test result was positive. The patient was admitted to the infectious disease unit.
