A 45 year old non-smoker female presented with complaints of dyspnea, dry cough and left sided chest pain for the past one and a half years. She gave history of recurrent refilling and multiple thoracentesis over this period. There was no past history of tuberculosis. There was no history of fever, joint pains and weight loss. There was no history suggestive of chronic use of any medications. She was housewife by occupation. On examination, her vitals were normal. Respiratory system examination showed findings suggestive of left sided bulging with decreased movements of left side, stony dull note on percussion and decreased vocal resonance suggesting left sided effusion. Her chest radiograph was suggestive of massive left pleural effusion with left upper zone rounded opacity (Fig 1). Pleural fluid aspiration was done which was straw colored and had a cell count of 150 cells/cubic mm, 60%polymorphonuclear cells and 40% mononuclear cells, glucose-131 mg/dl, protein-4400 mg/dl, ADA-7.72U/L, LDH-98U/L. Gram's and ZN stains were negative for bacteria and acid fast bacilli. Cytology for malignant cells was negative. Computed tomography revealed a well defined heterogeneously enhancing mass lesion along the posterior chest wall in left upper hemithorax with massive left sided effusion (Fig 2) MRI was done to rule out chest wall origin or invasion and it suggested a well defined lesion in the D4, D5 paravertebral region?neurogenic tumor with massive left side pleural effusion with left lower lobe collapse.
Thoracoscopy was done using a rigid thoracoscope (Karl Storz). A large tumor arising from the posterior chest wall of the apical region was seen. The tumor was highly vascular and bled on touch. (Fig. 3) Biopsy from the tumor was taken with electrocautery assistance to prevent excessive bleeding. Biopsy was suggestive of pleural hemangioma. (Fig. 4).
Patient was referred for surgical management. Left posterolateral thoracotomy with excision of the tumor was done and intercostal drain was placed. The drain was removed after 4 days of surgery when any fluid ceased to drain through it. There was no re-accumulation of pleural fluid on follow-up chest skiagram after 14 days (Fig. 5). Patient is in our regular follow up and she is absolutely normal.
Chest computed tomogram showing heterogeneously enhancing mass lesion along posterior chest wall in left upper lobe and left sided moderate pleural effusion.