A 74-year-old male with a history of tuberculosis with known cavitary lesion (Fig. 1) and 75 pack-year smoking history presented to a local emergency department with a one-week history of dyspnea on exertion and unintentional weight loss. He was afebrile with sinus tachycardia at 120 beats per minute, respiratory rate of 22 respirations per minute, blood pressure of 166/89 mmHg, and oxygen saturation of 94% on room air. Physical exam revealed scant expiratory wheezing on the left lung field and markedly diminished breath sounds and dullness to percussion on the right posterior thorax. A chest x-ray (CXR) was notable for complete opacification of the right hemithorax (Fig. 2). Computed tomography (CT) of the chest revealed mass effect on right atrium and right paratracheal lymphadenopathy. Point of care ultrasound (POCUS) prior to 14-Fr tube thoracostomy revealed right atrial and ventricular collapse during cardiac cycle and a large volume complex-homogenous pleural effusion with inverted right diaphragm (Fig. 3, Fig. 4A, Suppl 1,2). During the procedure, 3500 mL of bloody-appearing fluid was drained and repeat POCUS revealed normal lung volumes and diaphragm function post-procedure (Suppl 3). Additionally, point of care cardiac ultrasonography immediately post-drainage demonstrated normalization of the pleural fluid compromising right ventricular function (Fig. 4B, Suppl 4). Pleural fluid analysis demonstrated pH 7.34, Glucose 49, lactate dehydrogenase (LDH) 1050 U/L (serum 203), total protein 3.6 g/dL (serum 5.9), white blood count 570 (lymphocytes 82, monocytes 18), adenosine deaminase (ADA) 14 U/L, and cultures with no growth. Sputum acid-fast bacilli (AFB) cultures were negative. Repeat chest CT revealed right sided pleural thickening and nodularity with interstitial septal thickening, as well as paratracheal and periaortic lymphadenopathy.
Pleural cytology was unremarkable, and with an unclear source of the effusion and concern for malignancy, thoracoscopy with right pleural and chest wall mass biopsy was completed. Surgical pathology revealed atypical epithelioid cells consistent with poorly differentiated carcinoma. It was negative for mesothelioma markers calretinin, CK5/6, WT1, D2-40, Germ cell tumor marker SALL4, and other organ or origin specific markers including GATA4, PAX8, TTF-1, Napsin A, NKX3.1, synaptophysin, chromogranin, CK20, and mucicarmine. The patient is currently undergoing further work-up with NextGen sequencing and plans for palliative chemotherapy/immunotherapy.
Supplementary video related to this article can be found at https://doi.org/10.1016/j.rmcr.2023.101868
The following is/are the supplementary data related to this article.
Computed tomography of the chest (coronal view) showing a right upper lobe cavitation and endobronchial spread of pulmonary tuberculosis diagnosis, 7 years prior to presentation.