Case report

Pleural effusion

By : Ade Sabryla Eka Aprillia Arum Kanti

Perceptor : Dr. Dedy Zairus, Sp.P

IDENTITY Initial Name Sex Age Nationality Marital status Religion Occupation Educational background Address : Mr. M : Male : 24th : Javanese : Single : Islam :: Junior high school : Tanggamus

ANAMNESIS Taken From : Auto & alloanamnesis November 9th 2012 01.30 p.m. Chief complain : Breathlessness Additional complains : fever, cough with sputum, chest pain.

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 that he got the appetite loss

 Neither history of asthma nor consuming anti tuberculosis drug was admitted.

fever. He never got night sweat, nausea, RESUME and vomit. Breathlessness since 4 months ago before came RSAM. cough with thick yellow sputum and bad smell sputum.

chest pain, the pain was not like stabbing,

RESUME
General Check up

Height Weight Blood Pressure Pulse Temperature

: 160 : 48 : 140/ 80 : 80 : 37,2

cm. kg mmHg x/minute C

RESUME
Lung
Inspection : Left : hemithorax movement symmetrical Right : hemithorax movement symmetrical Palpation Left and right : tactil and vocal fremitus symmetrical Percussion : Right : Sonor Left : Sonor Auscultation : Left : Vesicular, Ronchi (-), Wheezing (-) Right: Vesiculer, Ronchi (-), Wheezing (-)

RESUME
LABORATORY (RSAM November 10th 2012) Hb : 10,4 gr % (N : 13,5 18 gr%) LED : 87 mm/hour (N : 0-10 mm/hour) WBC : 7500 mm (N : 4500 10.700/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)

RESUME
Thorax X-ray November 9th 2012 (before thoracocentesis) Pulmo dexter and sinister show increase bronchovascular, radioopaque appearance at the right pulmo

RESUME
Thorax X-ray November 20th 2012 (after thoracocentesis) There is a homogeneous radiopaque appearance at the right pulmo

RESUME
Cytology of pleural fluid :
November 20th 2012 There is no sign of malignancy. Conclusion Supuratif chronic inflammation Colour : Yellow Purity : Turbid

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

DIAGNOSE
Working diagnosis Pleural 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

DIAGNOSE
Clinical Work Up before thoracocentesis : I : hemithorax deter movement is asymmetrical with sinister hemithorax. P : Vocal and tactil Fremitus R < L P : L= sonor, R= dullness A : Vesicular ( / +), ronkhi (+/+), wheezing (-/-)

Supportive checkup : Laboratorium LED 87 mm/hour, Leucocyte 15800/ul Thorax X-ray Pulmo : Pulmo dexter and sinister show increase bronchovascular, radioopaque appearance at the right pulmo Cytology of pleural fluid There is no sign of malignancy. There are many PMN, MN, little of limfosit cell and degenerative mesothel cell. Conclusion Supuratif chronic inflammation.

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

prognose
Prognosis Quo ad vitam Quo ad functionam Quo ad sanationam : dubia ad bonam : dubia ad bonam : dubia ad bonam

FOLLOW UP

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

DISCUSSION
Chest examination : On inspection, hemithorax movement was asymmetrical, sinister hemithorax was left. On palpation, tactil fremitus on the right lung was decreased On 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.

DISCUSSION
Treatment
Thoracocentesis : a valuable diagnostic and therapeutic procedure. When the findings of thoracic auscultation or percussion are suggestive of pleural effusion, thoracocentesis can be performed 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.

DISCUSSION
Drugs Ceftriaxone 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 inhibiting the 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.

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.

DISCUSSION
Prognosis is dubia ad bonam because the patient has intrathoracic mass that cause the obstruction of lympe drainage though the mass is suspected 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.

 Differential diagnosis is pleural effusion e.c. Suspected infection of TB and pneumonia, because the patient also has fever, cough with sputum and the laboratory examination shows that LED and neutrophil segment level is high which suggests pulmonary TB, and the result of thoracocentesis Pleural fluid appearance grossly seroxantochrome fluid. The cytology of pleural fluid found no sign of malignancy, there are many PMN, MN, and little of limfosit cell and degenerative mesothel cell.

PLEURA EFFUSION
Pleura are the membranes that surround both lungs. They are moistened 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).

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

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 this balance.

 Although the etiologic spectrum of pleural effusion is extensive, most pleural effusions are caused by congestive heart failure, pneumonia, malignancy, or pulmonary embolism.

Clinical Manifestation
Dyspnea Cough Chest pain Additional symptoms

DIAGNOSTIC
Patients with pleural effusions usually have dyspnea, cough, and occasional sharp nonradiating chest pain that is often 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 neoplasm and 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.

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.

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 reliable physical 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

 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, less commonly, to a nonmalignant cause, such as a foreign body.

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; this finding is nonspecific because it occurs in many types of pleural effusion.

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.

LEUKOcytes
Neutrophils predominate early in inflammatory effusions due to pneumonia, pulmonary infarction, pancreatitis, tuberculosis or lupus. Several days after the acute insult to the pleura, mononuclear cells predominate in the effusion. Mononuclear cells predominate in transudative pleural effusions and chronic exudative effusions (caused by, for example, tuberculosis, lymphoma, carcinoma, uremic pleurisy or rheumatoid pleurisy).

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 (less than 60 mg per dl or a pleural fluid-to-serum ratio of under 0.5) will help narrow the differential diagnosis of the exudative pleural effusion.

Total Protein and LDH, Transudates vs Exudates

If any one of the three following criteria is present, the fluid is usually an exudate: A pleural fluid to serum protein ratio of over 0.5 A pleural fluid ldh level of more than 200 iu and A pleural fluid-toserum ldh ratio of over 0.6.

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.

pH
The finding of a low pleural fluid pH (less than 7.30) provides a clinician with the following information: The fluid is always an exudate The differential diagnosis of the exudate is narrowed to empyema, malignancy, rheumatoid pleurisy, lupus pleuritis, tuberculosis and esophageal rupture A parapneumonic effusion is either an empyema or will behave clinically like An empyema and usually requires chest tube drainage The finding has diagnostic, prognostic and therapeutic implications in malignant effusions

Radiography
Effusions of more than 175 mL are usually apparent as blunting of the costophrenic angle on upright posteroanterior chest radiographs.

Treatment
The treatment of a pleural effusion should be directed at the underlying cause. Indications for urgent drainage of parapneumonic effusions include: 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 the criteria for immediate tube drainage should improve clinically within 1 week with appropriate antibiotic treatment.

TUBERCULOSIS PLEURA EFFUSION

Tuberculosis (TB) is a major public health problem in developing countries. Although the majority of patients with TB have pulmonary TB, extrapulmonary TB affecting mainly the lymph nodes and pleura serves as the initial presentation in about 25% of adults. TB is the leading cause of pleural effusions in some countries. It is important to consider the possibility of tuberculous pleuritis in all patients with an undiagnosed pleural effusion.

Pathogenesis
The pathogenesis of a tuberculous pleural effusion is thought to be related to the rupture of a subpleural caseous focus in the lung into the 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 pleural capillaries 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.

INCIDENCE
The percentage of patients with TB who have pleural effusions has varied 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.

CLINICAL MANIFESTATIONS
Tuberculous pleuritis usually presents as an acute illness. Upon presentation symptoms in one series had been present for less than 1 week 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.

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.

Pleural fluid characteristics

The pleural fluid with tuberculous pleuritis is invariably an exudate. Indeed, the pleural fluid protein level frequently exceeds 5 g/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.

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.

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 be established with reasonable certainty by demonstrating elevated levels of adenosinedeaminase (ADA) or ginterferon in the pleural fluid.

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.

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 assays The 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.

7. Nucleic acid amplification tests Nucleic acid amplification (NAA) assays amplify M. tuberculosis-specific nucleic acid sequences with a nucleic acid probe. This allows direct detection 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 pleuritis over the past 50 years has been with a blind needle biopsy of the pleura.

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

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.

Symptoms And Their Causes

There are two main types of lung cancer: non-small cell and small 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.

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

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.

DIAGNOSIS
Chest x-rays A CAT scan of the lung

Biopsy
MRI

Treatment
The treatment of lung cancer depends on how advanced the 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, to slow its growth.

Radiation therapy
The radiation damages the cells in the path of the beam normal 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 more tired than usual, have some diarrhea, or notice changes to the skin (it may be red or tender) where the treatment was given.

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.

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 <10 gr% is not urgent for transfusion, just give treatment for etiology of anemia). Granulosit 1500/mm3 Trombosit 100.000/mm3 Hepar in good condition

KARNOFSKY PERFORMANCE STATUS

 Some of the more common chemotherapy medicines include the following: Carboplatin Cisplatin Docetaxel Erlotinib Etoposide

Gemcitabine Irinotecan Paclitaxel Pemetrexed Vinorelbine

MALIGNANT PLEURA EFFUSION

Malignant pleural effusions (MPE; those effusions associated with 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 an ultrasound-directed aspiration for diagnosis. In patients with primary lung cancer, such small effusions must be evaluated.

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 to cancer. 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 pathologic examination.

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 examination demonstrates decreased breath sounds, dullnes to percusion, or a pleural rub.

DIAGNOSTIC
Radiologic studies
Standard chest roentgenograms (posterioranterior and lateral) may demonstrate blunting of the costophrenic angle suggestive of a small eusion.

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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