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Case reportPleural effusion

By :Ade Sabryla

Eka Aprillia Arum Kanti

Perceptor : Dr. Dedy Zairus, Sp.P


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IDENTITY

Initial Name : Mr. M

Sex : Male

Age : 24th Nationality : Javanese

Marital status : Single

Religion : Islam

Occupation : - Educational background : Junior high school

Address : Tanggamus


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ANAMNESIS

Taken From :

Auto & alloanamnesis November 9th2012 01.30 p.m.

Chief complain :

Breathlessness

Additional complains :fever, cough with sputum, chest pain.


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History of the Illness :

Breathlessness since 4months ago. breathlessness every day

and all day long,

Patient also has cough, fever, chest pain on the right chest

He never got night sweat, nausea, and vomit. He admitted thathe got the appetite loss


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Neither history of asthma nor consuming anti tuberculosis drugwas admitted.


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RESUME

Breathlessnesssince 4 months

ago before cameRSAM.

cough with thickyellow sputum andbad smellsputum.

chest pain, thepain was not likestabbing,

fever.

He never got nightsweat, nausea,

and vomit.


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RESUME

General Check up

Height : 160 cm.

Weight : 48 kg

Blood Pressure : 140/ 80 mmHg

Pulse : 80 x/minute

Temperature : 37,2 C


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RESUME

Lung

Inspection : Left : hemithorax movement symmetrical

Right : hemithorax movement symmetrical

PalpationLeft and right : tactil and vocal fremitus symmetrical

Percussion : Right : Sonor

Left : Sonor

Auscultation : Left : Vesicular, Ronchi (-), Wheezing (-)

Right : Vesiculer, Ronchi (-), Wheezing (-)


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RESUMELABORATORY

(RSAM November 10th 2012)

Hb : 10,4 gr % (N : 13,518 gr%)

LED : 87 mm/hour (N : 0-10 mm/hour)

WBC : 7500 mm (N : 450010.700/ul) Dif. Count

Segment : 79% (50 70 %)

Lymphocyte : 18% (20 40 %)

SGOT : 63 (6-25 u/l) SGPT : 22 (6-35 u/l)

Ureum : 31 (10-40 mg/dl)

Creatinin : 0,5 (0,7-1,3 mg/dl)


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RESUME

Thorax X-ray

November 9th2012 (before thoracocentesis)Pulmo dexter and sinister show increase bronchovascular,

radioopaque appearance at the right pulmo


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RESUMEThorax X-ray

November 20

th

2012 (after thoracocentesis)There is a homogeneous radiopaque appearance at the right

pulmo


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RESUME

Cytology of pleural fluid:

November 20th2012

There is no sign of malignancy. Conclusion Supuratif chronic

inflammationColour : Yellow

Purity : Turbid

Microscopic

There are many PMN, MN, and little of limfosit cell anddegenerative mesothel cell.


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DIAGNOSE

Working diagnosisPleural effusion et causa suspect intrathoracic mass

Differential diagnosis

Pleural effusion et causa suspect pneumonia

Pleural effusion et causa suspect TB

Basic Diagnostic

Anamnesis :breathlessness

cough

chest pain


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MANAGEMENT

Starxon 2 gr drip on 0,9% NaCl, 100cc/ day

Thymelon 125 mg/12 hr, after starxon therapy

Epexol 3 dd C1

Suggestion/Counselling

Bronchoscopy

BTA

Thorax foto Analysis pleural fluid

CEA


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prognose

Prognosis

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam Quo ad sanationam : dubia ad bonam


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FOLLOW UP
http://localhost/var/www/apps/conversion/tmp/scratch_2/FOLLOW%20UP.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_2/FOLLOW%20UP.docx


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DISCUSSION

In this case, the patient had been diagnosed with Pleural

Effusion e.c. suspect intrathoracic mass, based on history of

illness, the clinical appearance, thorax x-ray.

The anamnesis : Breathlessness since 4months ago, also has

cough, fever, chest pain on the right chest


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DISCUSSION

Chest examination :On inspection, hemithorax movement was asymmetrical,

sinister hemithorax was left.

On palpation, tactil fremitus on the right lung was

decreasedOn percussion, dullness on the right lung

On auscultation, vesicular on the right lung was decreased.

Thorax X-ray PA shows radioopaque appearance at right

pulmonary. After therapy and thoracocentesis, thorax photo

shows deterioration.


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DISCUSSION

Treatment

Thoracocentesis:

a valuable diagnostic and therapeutic procedure.

When the findings of thoracic auscultation or percussion are

suggestive of pleural effusion, thoracocentesis can beperformed to confirm the presence of pleural effusion, provide

a specimen for examination which provide a diagnosis or guide

the therapeutic plan, therapeautically drain a large volume of

pleural fluid.


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DISCUSSION

DrugsCeftriaxone

For the treatment of the infections (respiratory, skin, soft tissue,

UTI, ENT) caused by S. pneumoniae, H. influenzae, staphylococci, S.

pyogenes (group A beta-hemolytic streptococci), E. coli, P. mirabilis,

Klebsiella sp, coagulase-negative staph. Ceftriaxone works by inhibitingthe mucopeptide synthesis in the bacterial cell wall.

Thimelon

A steroid medication used to treat inflammatory disorders. Methyl

prednisolone decreases inflammation by acting within cells to prevent

the release of certain chemicals that are important in the immune

system and also decreased the number of white blood cells circulating

in the blood.


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DISCUSSION

Epexol

Ambroxol is a secretolytic agent used in the treatment

of respirtory disease associated with viscid or excessive mucuc. It is the

active ingredient of Mucosolvan, Mucobrox, Lasolvan, Mucoangin,Surbronc and Lysopain. The substance is a mucoactive drug with

several properties including secretolytic and secretomotoric actions

that restore the physiological clearance mechanisms of the respiratory

tract, which play an important role in the bodys natural defence

mechanisms.


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DISCUSSION Prognosis is dubia ad bonam because the patient has intrathoracic

mass that cause the obstruction of lympe drainage though the mass issuspected teratoma or hamartoma which is a benign tumour of

mediastinum based on cytology of pleural fluid, which is curable with

chemotherapy and radiation treatment so the lymph drainage may not

be obstructed no more.


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PLEURA EFFUSION

Pleuraare the membranes that surround both lungs. They aremoistened with a thin fluid, which reduces friction during

respiratory movements of the lungs.

Pleural Effusion is a collection of fluid into a part of the pleural

cavity, which is Abnormal conditions that can fill the pleural

space are air (pneumothorax), blood (hemothorax), plasma,

serum or lymph (hydrothorax), or pus (pyothorax, empyema).


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Anatomy of Pleura

The pleural space is bordered by the parietal and visceral

pleurae.

The pleural space plays an important role in respiration by

coupling the movement of the chest wall with that of the

lungs in 2 ways.

1. Keeps the visceral and parietal pleurae in close

proximity

2. Serves as a lubricant to facilitate movement of the

pleural surfaces against each other in the course of

respirations


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Etiology

The normal pleural space contains approximately 1

mL of fluid, representing the balance between

(1) Hydrostatic and oncotic forces in the visceral

and parietal pleural vessels(2) Extensive lymphatic drainage.

Pleural effusions result from disruption of thisbalance.


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Although the etiologic spectrum of pleural effusion is

extensive, most pleural effusions are caused by congestive

heart failure, pneumonia, malignancy, or pulmonary

embolism.


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Clinical Manifestation

Dyspnea

Cough

Chest pain

Additional symptoms


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DIAGNOSTIC

Patients with pleural effusions usually have dyspnea,cough, and occasional sharp nonradiating chest pain that isoften pleuritic.

Hemoptysis may be associated with a malignant neoplasm,pulmonary embolism, or severe tuberculosis.

Fever occurs in tuberculosis, empyema, and pneumonia.

Weight loss can be associated with a malignant neoplasmand tuberculosis.

Physical findings such as ascites may indicate cirrhosis,

ovarian cancer, or Meig syndrome. Bilateral leg swelling is associated with transudates such as

those caused by heart or liver failure.


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Physical Examinations

Physical findings in pleural effusion are variable and depend

on the volume of the effusion. Generally, there are no

physical findings for effusions smaller than 300 mL.


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With effusions larger than 300 mL, findings may include the

following:

Dullness to percussion, decreased tactile fremitus, and

asymmetrical chest expansion, with diminished or delayed

expansion on the side of the effusion, are the most reliablephysical findings of pleural effusion.

Diminished or inaudible breath sounds

Egophony ("e" to "a" changes) at the most superior aspect of

the pleural effusion

Pleural friction rub


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Mediastinal shift away from the effusion - This is observed

with effusions of greater than 1000 mL; displacement of the

trachea and mediastinum toward the side of the effusion is

an important clue to obstruction of a lobar bronchus by an

endobronchial lesion, which can be due to malignancy or, lesscommonly, to a nonmalignant cause, such as a foreign body.


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WORKUP

Thoracocentesis

Thoracentesis with analysis of the fluid can quickly

narrow the differential diagnosis of an effusion.

Most aspirates consist of a straw-yellow fluid; thisfinding is nonspecific because it occurs in many

types of pleural effusion.


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Pleura Fluid Analysis

When the thoracentesis is done, the fluid should be

analyzed in a systematic manner. Color, odor and character

of the fluid should be noted. The following laboratory tests

are commonly carried out on pleural fluid: leukocyte count

and differential, erythrocyte count, total protein, glucose,lactate dehydrogenase (LDH), amylase and pH

determinations; Wright, Gram and AFB stains; aerobic,

anaerobic, tuberculosis and fungal cultures; and cytology.


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LEUKOcytes

Neutrophils predominate early ininflammatory effusions due to pneumonia,pulmonary infarction, pancreatitis, tuberculosisor lupus. Several days after the acute insult to the

pleura, mononuclear cells predominate in theeffusion.

Mononuclear cells predominate intransudative pleural effusions and chronic

exudative effusions (caused by, for example,tuberculosis, lymphoma, carcinoma, uremicpleurisy or rheumatoid pleurisy).


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Glucose

A normal pleural fluid glucose value (more

than 60 mg per dl, or a pleural fluid-to-serum

ratio of over 0.5) is not particularly helpful;

however, a low pleural fluid glucose level (lessthan 60 mg per dl or a pleural fluid-to-serum

ratio of under 0.5) will help narrow the

differential diagnosis of the exudative pleuraleffusion.


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Lipids

Chylous effusions (chylothorax) occur when the contents of

the thoracic duct empty into the pleural space. The most

common cause is malignancy, usually lymphoma, which

causes a rupture of the thoracic duct, drainage into the

mediastinum and then extension into the pleural space.


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pH

The finding of a low pleural fluid pH (less than 7.30) provides aclinician with the following information:

The fluid is always an exudate

The differential diagnosis of the exudate is narrowed toempyema, malignancy, rheumatoid pleurisy, lupus pleuritis,tuberculosis and esophageal rupture

A parapneumonic effusion is either an empyema or willbehave clinically like

An empyema and usually requires chest tube drainage

The finding has diagnostic, prognostic and therapeuticimplications in malignant effusions


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Radiography

Effusions of more than 175 mL are usually

apparent as blunting of the costophrenic angle

on upright posteroanterior chest radiographs.
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Treatment

The treatment of a pleural effusion should be directed at theunderlying cause.

Indications for urgent drainage of parapneumonic effusionsinclude:

frankly purulent fluid

a pleural fluid pH of less than 7.2

loculated effusions

bacteria on Gram stain or culture

Patients with parapneumonic effusions who do not meet thecriteria for immediate tube drainage should improve clinicallywithin 1 week with appropriate antibiotic treatment.


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PathogenesisThe pathogenesis of a tuberculous pleural effusion is thought to

be related to the rupture of a subpleural caseous focus in the lung intothe pleural space. The hypersensitivity reaction is initiated when

tuberculous protein gains access to the pleural space.

The tuberculous pleural effusion develops when the delayed

hypersensitivity reaction increases the permeability of the pleuralcapillaries to protein and then the increased protein levels in the

pleural fluid result in a much higher rate of pleural fluid formation. In

addition, the lymphocytic pleuritis obstructs the lymphatics in the

parietal pleura, which leads to decreased pleural fluid clearance from

the pleural space. The pleural effusion results from the combination of

the increased pleural fluid formation and the decreased pleural fluid

removal.


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INCIDENCE

The percentage of patients with TB who have pleural effusions hasvaried markedly from county to country. In Burundi more than 25% of

patient with TB ave tuberculous pleural effusions while in South Africa

20% of TB patients have tuberculous pleural effusions. In contrast only

35% of patients in the USA are reported to have tuberculous pleural

effusions.

In patients with AIDS and TB it appears that the incidence of

pleural effusions is higher than in immunocompetent patients. In other

series of immunocompromised hosts without AIDS, the percentage of

TB patients with pleural effusions has been less.


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CLINICAL MANIFESTATIONSTuberculous pleuritis usually presents as an acute illness. Upon

presentation symptoms in one series had been present for less than 1week in 25/71 patients (35%) and had been present for less than a

month 50/71 patients (71%).19 The most frequent symptoms are

cough (~70%), which is usually nonproductive and chest pain (~70%),

which is usually pleuritic in nature.

If both cough and pleuritic pain are present, the pain usually

precedes the cough. Most patients are febrile but approximately 15%

will be afebrile. Patients with tuberculous pleural effusions may be

dyspneic if the effusion is large.

On occasions the onset of tuberculous pleuritis is less acute with

mild chest pain, at most a low grade fever, a non-productive cough,

weight loss and easy fatigability.


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Continue....

The pleural effusions secondary to tuberculous pleuritis are usually

unilateral and can be of any size. In one series of 254 patients the

effusions occupied more than two-thirds of the hemithorax in 18%,

between one-third and two-thirds of the hemithorax in 47%, and less

than one-third of the hemithorax in 34%.

TB was the third leading cause of large or massive pleural effusion

(12%) after malignancy (55%) and pneumonia (22%)22 Approximately

20% of patients with tuberculous pleural effusions have coexisting

parenchymal disease on chest radiograph.


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Pleural fluid characteristicsThe pleural fluid with tuberculous pleuritis is invariably an

exudate. Indeed, the pleural fluid protein level frequently exceeds 5g/dL and this finding suggests tuberculous pleuritis. Most patients with

tuberculous pleuritis have more than 50% small lymphocytes in their

pleural fluid and many have more than 90%.

Patients with symptoms less than 2 weeks in duration are more

likely to have predominantly polymorphonuclear leucocytes in their

pleural fluid.

The pleural fluid glucose level with tuberculous pleural effusions

may be reduced but it usually is similar to the serum level. The pleural

fluid pH is usually above 7.30, but it also may be reduced. The pleural

fluid lactic acid dehydrogenase (LDH) level is usually higher than the

serum LDH level.


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Continue...

One characteristic of pleural fluid from patients with tuberculous

pleuritis is that it rarely has more than scattered mesothelial cells.Mesothelial cells are the cells that cover both the visceral and parietal

pleura.

Transudative pleural fluids contain any mesothelial cells.

The absence of mesothelial cells is not diagnostic of tuberculous

pleuritis because any condition in which the pleural surfaces are

extensively involved by an inflammatory process will be associated

with a paucity of mesothelial cells in the pleural space.


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DIAGNOSIS

The diagnosis of tubeculous pleuritis depends upon the

demonstration of tubercle bacilli in the sputum, pleural

fluid, or pleural biopsy specimens, or the demonstration

of granulomas in the pleura. The diagnosis can also beestablished with reasonable certainty by demonstrating

elevated levels of adenosinedeaminase (ADA) or g-

interferon in the pleural fluid.


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1. Mycobacterial stain and culture

One test that is frequently overlooked in the diagnostic work-up of

patients with an undiagnosed pleural effusion is examination of the

sputum for mycobacteria.

2. Skin tests

This is primarily because a negative test does not rule out the diagnosis

of tuberculous pleuritis.

3. Adenosine deaminase

ADA, a predominant T-lymphocyte enzyme, catalyses the conversion of

adenosine and deoxyadenosine to inosine and deoxyinosine,

respectively.


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4. Gamma interferon

The level of pleural fluid g-interferon is also very efficient at

distinguishing tuberculous from nontuberculous pleural effusions.Gamma interferon is a cytokine released by activated CD4 + T

lymphocytes that increases the mycobactericidal activity of

macrophages.

5. Gamma interferon release assaysThe g-interferon release assays (IGRA) are T cellbased in vitro assays

that measure g-interferon release by sensitized T cells from peripheral

blood or pleural fluid in response to highly Mycobacterium

tuberculosis-specific antigens such as early secretory antigen (ESAT)-6

and culture filtrate protein (CFP)-10.


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7. Nucleic acid amplification tests

Nucleic acid amplification (NAA) assays amplify M. tuberculosis-specific

nucleic acid sequences with a nucleic acid probe. This allows directdetection of M. tuberculosis in clinical specimens like pleural fluid

within hours of their receipt.

8. Pleural biopsy

The most common way to make the diagnosis of tuberculous pleuritisover the past 50 years has been with a blind needle biopsy of the

pleura.


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TREATMENT

The treatment of tuberculous pleuritis has three goals:

1. to prevent the subsequent development of active TB

2. to relieve the symptoms of the patient

3. to prevent the development of a fibrothorax.

Chemotherapy

Corticosteroids


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LUNG CANCER

Lung cancer is the number one cancer killer of men and

women. Over 165,000 people die of lung cancer every year

in the United States. Lung cancer rates among Southeast

Asians are 18% higher than among White Americans.

Smoking rates are significantly higher among Southeast

Asian populations, like Vietnamese and Cambodian.


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Symptoms And Their Causes

There are two main types of lung cancer: non-small cell andsmall cell. Non-small cell lung cancer is more common, slow

growing, and does not spread to other organs rapidly. Small

cell lung cancer is not as common as non-small cell. But it is

fast growing, and spreads very rapidly to other organs.Cigarette smoking or exposure to second-hand smoke

causes the majority of lung cancer cases.

Cigarettes contain over 4000 chemicals; 40

of these chemicals can cause cancer.


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Some of the symptoms of lung cancer include the following:

Chronic cough, or cough w/ bloody sputum.

Hoarseness

Shortness of breath, chest pain, or wheezing Weight loss or loss of appetite


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Other symptoms of lung cancer include:

Swelling in the face or neck

Repeated lung infections or bronchitis

Fever General weakness - specifically in shoulder, arm,

or hand.


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DIAGNOSIS

Chest x-rays

A CAT scan of the lung

Biopsy

MRI


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Treatment

The treatment of lung cancer depends on how advancedthe cancer is. If the lung cancer has not spread and is

relatively small, surgery may be necessary to take the

cancer out. Radiation therapy and chemotherapy may also

be necessary to either try to cure the cancer or, at least, toslow its growth.


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Radiation therapy

The radiation damages the cells in the path of the beamnormal cells as well as cancer cells. In brachytherapy,

or internal radiation therapy, radioactive material is placed

directly into or near the tumour.

Radiation side effects are usually mild. You may feel moretired than usual, have some diarrhea, or notice changes to

the skin (it may be red or tender) where the treatment was

given.


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Chemotherapy

Chemotherapy may be given as pills or by injection.Chemotherapy drugs interfere with the ability of cancer cells

to grow and spread, but they also damage healthy cells.

Although healthy cells can recover over time, you may

experience side effects from your treatment like nausea,vomiting, loss of appetite, fatigue, hair loss and an increased

risk of infection.


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Basic criteria before chemotherapy:

Performance status 70-80. If the performance< 70 or long age, can give chemotherapy with

specific regiment or/and specific schedule.

Haemoglobin 10 gr% (mild anemia without

acute bleeding, if Hb


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KARNOFSKYPERFORMANCE

STATUS


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Some of the more common chemotherapy

medicines include the following:

Carboplatin

Cisplatin

Docetaxel

Erlotinib

Etoposide
http://www.webmd.com/cancer/carboplatin-for-cancerhttp://www.webmd.com/cancer/cisplatinhttp://www.webmd.com/cancer/docetaxelhttp://www.webmd.com/lung-cancer/erlotinibhttp://www.webmd.com/cancer/etoposidehttp://www.webmd.com/cancer/etoposidehttp://www.webmd.com/lung-cancer/erlotinibhttp://www.webmd.com/cancer/docetaxelhttp://www.webmd.com/cancer/cisplatinhttp://www.webmd.com/cancer/carboplatin-for-cancer


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Gemcitabine

Irinotecan

Paclitaxel

Pemetrexed

Vinorelbine
http://www.webmd.com/cancer/gemcitabinehttp://www.webmd.com/cancer/irinotecanhttp://www.webmd.com/cancer/paclitaxel-for-cancerhttp://www.webmd.com/cancer/pemetrexedhttp://www.webmd.com/cancer/vinorelbine-tartratehttp://www.webmd.com/cancer/vinorelbine-tartratehttp://www.webmd.com/cancer/pemetrexedhttp://www.webmd.com/cancer/paclitaxel-for-cancerhttp://www.webmd.com/cancer/irinotecanhttp://www.webmd.com/cancer/gemcitabine


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MALIGNANT PLEURA EFFUSION

Malignant pleural effusions (MPE; those effusions associatedwith primary, concurrent, or distant neoplasms) may be more

complex, with frequent recurrence.

Small effusions may occur in association with an intrathoracic

neoplasm. If such effusions occur, the patient should have anultrasound-directed aspiration for diagnosis. In patients with

primary lung cancer, such small effusions must be evaluated.


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DIAGNOSTIC

Etiology

Numerous benign, infectious, and malignant etiologies cause

pleural effusions. Twenty-five percent of all pleural effusions

in a general hospital setting are secondary to cancer. Thirty

percent to 70% of all exudative effusions are secondary tocancer. In patients with cancer, 50% to 60% of MPE are

positive on first thoracentesis. In 25% of patients with

cancer and a recurrent pleural effusion, malignant cells in

the effusion may not be identified by pathologicexamination.


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DIAGNOSTIC

History and Physical Examination

Patient may be diagnosed with MPE by screening chest

radiograph, as happen in patient with small asymptomatic

effusion, or they may have underlying symptoms of cough,

dyspnea, or chest pain. The physical examinationdemonstrates decreased breath sounds, dullnes to

percusion, or a pleural rub.


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DIAGNOSTIC

Radiologic studies Standard chest roentgenograms (posterioranterior and

lateral) may demonstrate blunting of the costophrenic angle

suggestive of a small effusion.


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Treatment of MPE

The treatment of initial and recurrent MPE may be complex.Chest tube drainage, pleurodesis, pleural sclerosis, or

drainage with a chronic indwelling pleural catheter is used

most often for patients who have recurrent MPE.


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THANK YOU

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