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Case 123

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A 65-year-old male patient complains of progressive dyspnea associated with intermittent fever for the last eight weeks. He has a 60-year-pack smoking history and is a heavy alcohol drinker (consumption of half liter of spirits each day). He is tachypneic and presents diminished breath sounds, dullness to percussion and decreased tactile vocal fremitus on the left hemithorax. His breath sounds are normal on the right side. No alterations are found in blood tests performed to evaluate hepatic and renal function or in urinalysis. However, the hemogram reveals normochromic normocytic anemia. Chest radiography is requested and he undergoes a thoracentesis.

Based on the clinical history and image presented, which of the following statements is NOT correct?

a) On the chest radiography, it might be observed a homogenous opacity on the left hemithorax with deviation of the trachea to the right.

25%

b) It is probably an exudative pleural effusion, which might be confirmed by fluid analysis using the Light’s criteria.

25%

c) Water-seal drainage is the prompt treatment of choice. Definitive treatment should be provided after establishing the underlying condition.

25%

d) Tuberculosis and neoplastic diseases are the most probable diagnoses. Thus, Ziehl-Neelsen-stained smears and cytologic examination of the pleural fluid should be the method of choice for determining the exact diagnosis.

25%
   

Comments

– Diagnostic thoracentesis is indicated for most of the patients with pleural effusion. Fluid analysis is useful for establishing the diagnosis in 75% of the cases.
– If a small pleural effusion of known etiology is present, the patient might be treated conservatively with careful observation.
– Routine fluid evaluation includes: cell count, pH, protein, lactate dehydrogenase and glucose.
– Fluid analysis might also include, in selected patients: amylase, cholesterol, triglycerides, adenosine deaminase and cytology.
– Transudates are resultant from imbalances of hydrostatic and oncotic pressures across the vasculature.
– Exudates might occur due to infections, malignancies, immunological responses and inflammatory processes, iatrogenic injuries and fluid movement across the diaphragm.
– If one or more of Light’s criteria are met, the fluid might be categorized as an exudate Diseases.
– Glucose<60mg/dL and pH< 7,3 are suggestive of the following disorders: complicated parapneumonic effusion or empyema, tuberculosis, rheumatoid arthritis, systemic lupus, malignant neoplasm or esophageal rupture.
– Cytology and adenosine deaminase levels are useful for the differential diagnosis between tuberculosis and neoplastic effusion.

References

1. YC Gary Lee. Diagnostic evaluation of pleural effusion in adults: Additional tests for undetermined etiology. Jun 14, 2012. Uptodate. Available at: http://www.uptodate.com/contents/diagnostic-evaluation-of-pleural-effusion-in-adults-additional-tests-for-undetermined-etiology?detectedLanguage=pt&source=search_result&translation=pleural+effusion&search=derrame+pleural&selectedTitle=3~150&provider=google
2. John E. Heffner. Diagnostic evaluation of a pleural effusion in adults: Initial testing. Jun 26, 2013. Uptodate. Available at: http://www.uptodate.com/contents/diagnostic-evaluation-of-a-pleural-effusion-in-adults-initial-testing?detectedLanguage=pt&source=search_result&translation=pleural+effusion&search=derrame+pleural&selectedTitle=1~150&provider=google
3. Hooper C et al. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010; Thorax. 2010 Aug;65 Suppl 2:ii4-17.

Author

Daniel Moore Freitas Palhares – 6th year medical student of UFMG School of Medicine
E-mail: danielmoore2[at]msn.com

Supervisor

Professor Alline Beleigoli – member of the Department of Internal Medicine (UFMG School of Medicine).
E-mail: abeleigoli[at]gmail.com

Reviewers

Glauber Eliazar, Júlio Guerra and professor Viviane Parisotto.

Translated by

Lucas Resende Lucinda– 6th year medical student of UFMG School of Medicine
E-mail: lucasresendebh[at]hotmail.com

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