A 79-year-old male with PMH of Hypertension and Diabetes presented to the ED after developing progressively worsening shortness of breath and mid sternal pleuritic chest pain during a trans-continental flight, and was in mild respiratory distress by the time EMS evaluation occurred. In the ER chest x-ray suggested a large right hydro pneumothorax with moderate left sided pleural effusion (Fig. 1), which was confirmed by chest CT (Fig. 2, Fig. 3).
Both large-bore and small-bore chest tubes were placed, which resulted in symptomatic improvement. Due to the unclear etiology, the patient was started on broad spectrum IV antibiotics for suspected pneumonia. Pleural fluid analysis was remarkable for an exudative pattern that was negative for malignant cells (Table 1). When infections etiologies as well as a Tuberculosis etiology were ruled out, antibiotics were discontinued. The small-bore catheter was eventually removed, however the chest tube remained due to the recurrence of pneumothorax on imaging studies.
While the patient initially experienced clinical improvement requiring only minimal supplemental oxygen, he soon developed recurrence of bilateral pleural effusions with clinical deterioration. This pattern persisted, and serial pleural cytology samples were remarkable for bloody fluid with elevated cellularity, proteins and LDH, but were negative for malignant cells. As infectious and inflammatory etiologies were ruled out as the cause of recurrent hydro-pneumothorax, video-assisted thoracoscopy (VATS) and pleural biopsy confirmed the diagnosis of malignant pleural mesothelioma-epithelioid variant-in the context of histologic findings (Fig. 4, Fig. 5) and imunohistochemical markers positive for calretinin, CK 5/6, mesothelin and focal Glut-1 and negative for EpCam, CEA, Napsin A, TTF-1, and BerEP4. Interestingly, mesothelial plaques were restricted to the parietal pleural surface without invasion of the chest wall or extension into the contralateral pleura.
Given the imaging and tissue staging, chemotherapy was recommended, however prognosis remained reserved due to the patient's poor functional status. Ultimately, this patient opted not to pursue aggressive measures, and was discharged home with provisions for comfort care, and expired 3 months later.
CT Chest coronal view showing right sided hydro-pneumothorax and left sided pleural effusion.