A 17-year old male patient was admitted to our hospital on June 2015. He had smoked tobacco and marijuana cigarettes for three months the previous year, as well as moderate alcohol consumption. The patient was diagnosed with allergic rhinitis and bronchial hyperreactivity at the age of 12 years old without regular treatment. At hospital admission, he had 7 days with fixed moderate dyspnea, fever, right-sided pleuritic chest pain, headache, cough and no weight loss. Physical examination revealed a pleural effusion syndrome on the same side. No other associated clinical finding was described. Chest x-ray showed a homogenous opacity in lower right hemithorax (Fig. 1). A chest tube was inserted and 1600 ml of hemorrhagic/turbid pleural fluid was drained. After we diagnosed complicated parapneumonic pleural effusion, Clindamycin and ceftriaxone were given. Several biochemical and microbiological analyzes were performed.
The next day, the patient had relief of symptoms, reporting mild pain only at the chest-tube insertion site. A second chest X-ray showed a fully re-expanded left lung (Fig. 2). For the next 7 day at least 750 ml daily of clear pleural fluid was drained. Biochemical analysis of pleural fluid demonstrated an exudate with very low glucose level 0.20 mg/dl. Pleural fluid cultures were negative. Because of the increase of pleural fluid drainage up to 800 ml daily, we decided to perform a closed pleural biopsy, which reported negative results for tuberculosis and malignancy.
At admission, the adenosine deaminase (ADA) level was 34.3 U/L in two weeks it decreased to 19.02 U/L. Acid-fast bacilli (AFB) for pleural fluid was negative, and culture for Mtb remained negative.
In spite of antibiotics, pleural fluid drainage did not decrease after 3 weeks, thus we decided to begin the anti-TB treatment. However, after another week, no decrease in pleural fluid drainage was observed. Therefore, we decided to perform an open pleural biopsy. During surgery, pleural thickening and multiple pale yellow nodules in the lung were seen. After a diagnosis of malignancy, pleurodesis was done twice with povidone-iodine but no decrease in pleural fluid drainage was obtained.
Unfortunately, the patient did not receive other treatment such as pemetrexed, gemcitabine because they were not available at that moment, and extrapleurectomy is not a common surgical procedure in our media.
Immunohistochemistry revealed tumor cells to be immunoreactive for calretinin (clone Z11-E3, Dako) cytokeratin 7 (BC-1, BIOCARE MEDICAL) and negative for WT1 (BC.6F-H2, BIOCARE MEDICAL) NAPSIN A (TMU-Ad 02, BIOCARE MEDICAL). Based on these findings; the cause of pleural effusion was diagnosed as MPM. With this diagnosis, a chemotherapy regimen with cisplatin was initiated. After two cycles, there was no clinical and radiological improvement. The patient is currently under regular follow up.