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Case history

image A 50-year-old man presented to hospital with a 4 week history of increasing shortness of breath. He had had some weight loss over a slightly longer period and also reported an occasional hot sweat at night. He had no relevant medical history. He was a lifelong smoker of between 10 and 20 cigarettes a day and had previously worked in the construction industry as a roofer. Initial observations revealed a heart rate of 90 beats/min, respiratory rate 26 breaths/min, BP 110/72 mmHg, oxygen saturation 94% on room air, and a temperature of 37.9°C. He was given supportive oxygen. He had to work with his breathing to hold a conversation.

On examination, there was nicotine staining to the fingers, but no clubbing. His jugular venous pressure was not raised and his heart sounds were normal. There was no peripheral oedema. The left lung had normal breath sounds, whereas the right lung had decreased air entry and was dull to percussion at the base. Initial investigation with a chest X-ray showed a massive pleural effusion.

What is the differential diagnosis for massive pleural effusion?

What is the immediate management for this patient?

How might this man be managed in the future, should his pleural effusion return?

What are the possible complications of massive pleural effusions and how are these managed?

What is the differential diagnosis for massive pleural effusion?

The pleural space is a potential space between the visceral and parietal pleurae. The pleural space usually contains approximately 10 ml of fluid. Pleural effusion is an increased volume of fluid within the pleural space. A pleural effusion is usually caused by excess fluid production and/or decreased lymphatic drainage.1 The exact pathophysiology is determined by the underlying cause.

Pleural effusions are categorized into transudates or exudates, using Light’s criteria to narrow the differential diagnosis.2 Blood (haemothorax), pus (empyema) or chyle (chylothorax) may also accumulate in the pleural space. Fluid is considered exudative if one of the following criteria is present:

  • pleural fluid to serum protein ratio >0.5; or

  • pleural fluid to serum lactate dehydrogenase (LDH) ratio >0.6; or

  • pleural fluid LDH concentration more than two-thirds the upper limit of normal for serum LDH.

The patient’s history and examination findings direct the clinician as to whether the effusion is likely to be a transudate or an exudate and, therefore, guide further investigation. In this case there were several features to suggest an exudative effusion (Figure 31.1). The smoking history, weight loss and night sweats were all concerning for malignancy, while the employment history also raised the possibility of occupational lung disease, including mesothelioma. This, coupled with the absence of cardiac features, should strongly point the clinician to a provisional diagnosis of exudative pleural effusion. A comprehensive list of causes of transudates and exudates is given in Table 31.1.3

Figure 31.1

Chest ...

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