History of Present Illness
A 47-year-old black woman presented to the emergency room with progressive increase of breathlessness, dry cough, and fever. The symptoms had worsened in the past 3 days. She also complained of neck pain that had been present for several months and episodes of palpitations without chest pain.
Past Medical History
The patient was a never-smoker. She had a family history of malignancy (both mother and grandmother with breast cancer). She had moved from West Africa (Burkina Faso) to Europe 15 years earlier. The patient suffered from meningitis and acute pericarditis 10 and 2 years, respectively, before the current clinical presentation. She was receiving home therapy with only a beta-blocker (bisoprolol 1.25 mg two times daily).
Physical Examination and Early Clinical Findings
The patient had a fever (38.5° C [101.3° F]) and tachycardia (heart rate 129 beats/min). Her oxygen saturation (Sp O 2 ) was 94% while at rest and breathing in ambient air. Arterial blood gas (ABG) analysis showed hypoxemia with pH 7.46, partial pressure of oxygen (Pa O 2 ) 65.4 mm Hg, and partial pressure of carbon dioxide (Pa CO 2 ) 31.5 mm Hg.
Blood pressure was 130/90 mm Hg. Physical examination revealed absence of respiratory sounds in the entire left hemithorax, with dullness on percussion and decreased tactile fremitus.
Chest radiography revealed massive left pleural effusion, with significant contralateral shift of the trachea and the mediastinum ( Fig. 14.1 ). On chest ultrasonography, the pleural effusion was visible over six intercostal spaces along the posterior axillary line. The effusion was not loculated, although it contained minimal fibrinous strands ( Fig. 14.2 ).
Blood tests showed an increase in inflammation indices (C-reactive protein [CRP]: 222.2 mg/L; normal values < 5 mg/L), normal white blood cell (WBC) count (6,810 cells/μL) and normal differential count.
While the patient was still in the emergency room, the thoracic surgeon placed a large-bore chest tube (24-French [Fr]) in the sixth left intercostal space. About 1500 mL of yellowish pleural fluid was immediately evacuated. The tube was then clamped for 2 hours, and then 1400 mL more fluid was gradually drained (at a rate of about 500 mL every 60 minutes). Subsequent chest radiography showed reduction of the left pleural effusion and no more mediastinum shift ( Fig. 14.3 ).
Echocardiography showed normal left ventricular ejection fraction and no evident pericardial effusion.
The patient was admitted to the pulmonology unit. Empiric antibiotic therapy was initiated (piperacillin/tazobactam 4 g/0.5 g intravenously every 8 hours). Urinary antigen tests for Pneumococcus and Legionella were negative. No growth was observed on blood cultures.
CT pulmonary angiography ( Fig. 14.4 ) did not show pulmonary embolism. There was a residual left pleural effusion with an air bubble of about 20 mm inside. CT also documented thickening of the major fissure, intrafissural fluid, and a large area of parenchymal hyperdensity with air bronchogram in the left lower lung lobe. In the mediastinum, several oval-shaped lymph nodes were found (maximum thickness of about 8 mm). Moreover, an enlarged internal mammary lymph node was found ( Fig. 14.5 , A ), which was also visible on chest ultrasonography (see Fig. 14.5 , B ).
Subdiaphragmatic CT showed a left renal cortical lesion of approximately 40 × 37 mm ( Fig. 14.6 ). It had no calcification, and after the injection of the contrast medium, it had density lower than that of the surrounding parenchyma. These findings suggested a solid lesion probably caused by oncocytoma.
After the pleural fluid evacuation, the patient experienced relief from dyspnea, SpO 2 increased to 97% in ambient air, and CRP decreased to 64 g/dL in a week. However, cough, weakness, and a low-grade fever persisted.
The pleural fluid was a lymphocyte-predominant exudate with lactate dehydrogenase (LDH) 648 units/L, proteins 5.6 g/dL, glucose 70 mg/dL, lymphocytes 75%, and eosinophils 3%. Cultures yielded no growth, and cytological examination did not found malignant cells. The results of both microscopy and analysis of ribosomal RNA of Mycobacterium tuberculosis complex (MTC) with ribosomal ribonucleic acid–polymerase chain reaction (rRNA-PCR) on pleural fluid were negative.