A 36-year-old woman from Cameroon (immigrated 10 years ago) with no past medical history presented to the Emergency Department with increasing abdominal swelling over months. She had no respiratory symptoms, no abdominal pain, no constitutional symptoms such as fever or weight loss, and reported prior negative tuberculin skin testing.
Physical exam was notable for normal vitals. She appeared healthy. Heart exam was normal without murmurs, rubs or gallops. She had absent breath sounds on auscultation of the right lung, clear breath sounds on the left, and a distended non-tender abdomen with a fluid wave. She had no edema of her lower extremities.
Complete blood count and basic metabolic profile were remarkable only for a mild anemia (hemoglobin of 11.9 g/dL). A Computed Tomography (CT) scan of the chest (Fig. 1) revealed complete opacification of the right hemithorax with right lung collapse and mediastinal shift to the left consistent with large pleural effusion. CT of the abdomen and pelvis demonstrated extensive abdominal ascites with nodularity of the peritoneum and a left adnexal cystic lesion (Fig. 2). A follow-up ultrasound of the abdomen revealed a complex cystic lesion within the left ovary concerning for a possible ovarian malignancy. Chest tube placement drained dark brown pleural fluid (Fig. 3) that was exudative and negative for bacterial and fungal cultures as well as Mycobacterium tuberculosis. Cell count revealed 490 nucleated cells/high-power field and 59% histiocytes and 273,000 RBCs/HPF (Fig. 4). Cytology was sent and was negative. Notably, there was a markedly elevated ADA of 102.4 IU/L. A paracentesis revealed similar dark brown fluid with comparable cellular characteristics (Fig. 4).
Further work-up including tumor markers (cancer antigen-125, carcinogenic embryonic antigen, and cancer antigen 19-9) were all within normal limits. Interferon gamma release assay assessing for prior exposure to tuberculosis was negative. Patient was subsequently taken for exploratory laparotomy by gynecology-oncology which revealed a large amount of hemorrhagic ascites, multiple endometriotic implants, and a right ovarian endometrioma. Pathology of biopsy specimens from the right ovary, peritoneal implants and left ovarian fossa were consistent with a diagnosis of endometriosis from all samples. The patient was sent for video-assisted thoracoscopy. Decortication was performed on the thin fibrous peel surrounding the left lung. A 2 mm defect in the R medial diaphragm was identified and closed. Pathology of the pleural peel revealed reparative and reactive changes including chronic inflammation and granulation tissue. There was no evidence of malignancy or granulomas. Smears and cultures were negative on all specimens for Mycobacterium tuberculosis.
CT of chest revealing large right pleural effusion with right lung collapse and mediastinal shift to the left.