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History
Mrs. B is a 66 year old Caucasian woman who was treated with Celebrex for joint pain. Ten days after starting therapy she developed a diffuse, pruritic, erythematous rash and was admitted to the hospital. Dermatology consult and skin biopsy were obtained. Pathology was consistent with a drug eruption. The rash improved with intravenous steriods. On hospital day #3 she complained of dyspnea. A chest x–ray showed a new large left pleural effusion.
Past Medical History
“Arthritis” since the age of 13; treated only with intermittent NSAIDS and steroids.
Right–sided empyema one year ago treated with prolonged antibiotics and chest tube drainage.
History of coronary artery disease (CAD), non–insulin dependent diabetes mellitus (NIDDM), chronic obstructive pulmonary disease (COPD), depression, diverticulitis
Medications
Cardizem, Pepcid, Premarin, Remeron, Darvocet
Social History
She worked as a typist but quit because of arthritis when she was in her 20’s. She smoked 1–2 packs of cigarettes a day for 40 years.
Review of Systems
Diffuse joint pain and stiffness, worse in the morning, lasting all day, denies joint swelling or warmth. She is able to do all of her activities of daily living.
Denies constitutional symptoms
Mild sicca symptoms, no history of sinusitis or otitis
Denies prior history of rash, photosensitivity, alopecia, oral ulcers, Raynaud’s, paresthesias, myalgias, weakness
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Physical Examination
The patient was frail, somewhat anxious and confused.
BP 130/60, pulse 70, afebrile.
HEENT — no alopecia, conjunctivae were clear, no nasal or oral ulcers. Lungs — decreased breath sounds at left base, no crackles or wheezes; surgical scar over right posterior chest. Cardiac and abdominal exams were unremarkable. Neurological exam was nonfocal. The skin showed diffuse erythematous macules over her trunk and extremities.
Musculoskeletal exam was notable for the following:
cervical spine — mildly diminished range of motion
shoulders, elbows — full range of motion without synovitis, tenderness, or deformity
MCPs — synovial thickening with minimal tenderness, slight ulnar deviation, subluxations of the IPJs
PIPs — no synovitis, deformities, or tenderness
DIPs — Heberden nodes
hips, knees, ankles — full range of motion without synovitis, deformities or tenderness
feet — hallux valgus, no synovitis
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Laboratory Studies
Hematocrit 37.5%; WBC 6,800; platelets 674,00; ESR 35; electrolytes normal; BUN 25; creatinine 0.9; glucose 193; calcium 9.1; albumin 2.7; total protein 5.6; liver function tests normal; uric acid 5.5 urinalysis negative for blood or protein. ABG on room air: pH 7.42 pCO2 35 p02 61, 93% saturation
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Clinical Course and Radiology Studies
Chest x–ray one year prior to admission showed clear lung fields following drainage of the empyema.
Chest x–ray taken on hospital day #3 shows a large left pleural effusion.
(click on image for larger view)
On hospital day #3 thoracentesis produced 540cc of turbid fluid: WBC 2025, 6% neutrophils, 42% lymphocytes, 52%; reactive mesothelial cells; LDH 9638; glucose 133; total protein 4.6
On hospital day #4, the left pleural effusion rapidly re–accumulated, requiring a repeat thoracentesis WBC 1346,; LDH 7579; glucose 139; total protein 4.7; pH 7.1
Pleural fluid showed no malignancy on cytology; a negative AFB and fungal smear; a negative Gram’s stain and routine culture.
The patient’s dyspnea improved after the thoracentesis. She remained clinically stable with minimal joint pain throughout her hospitalization.
On hospital day #5, a chest CT scan showed a 2.0 x 1.5 cm lung mass at the right posterior base with right hydropneumothorax and a left pleural effusion. Multiple lung nodules were present in both lung fields.
(click on image for larger view)
A CT–guided transthoracic needle biopsy was performed on both the right lower and upper lung masses. Biopsy results were non–diagnostic showing only necrotic debris and inflammatory cells.
On hospital day #12, thoracoscopic biopsy of the left lower lung mass was performed.
A Rheumatology consult was obtained.
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Differential Diagnosis
Differential Diagnosis of Exudative Pleural Effusion
1.[ ]Infection (parapneumonic, tuberculosis, fungi)
2.[ ]Malignancy (bronchogenic, metastatic)
3.[ ]Pulmonary Embolism
4.[ ]Gastrointestinal disease
5.[ ]Rheumatic Conditions (rheumatoid arthritis, systemic lupus erythematosus)
Differential Diagnosis of Pulmonary Nodules
1.[ ]Infection (tuberculosis, fungi, pyogenic abscess)
2.[ ]Malignancy (bronchogenic, lymphoproliferative, metastatic)
3.[ ]Benign tumors
4.[ ]Arteriovenous malformations
5.[ ]Rheumatic conditions (rheumatoid arthritis, Wegener’s granulomatosis, Churg–Strauss, sarcoidosis, amyloidosis
History
Mrs. B is a 66 year old Caucasian woman who was treated with Celebrex for joint pain. Ten days after starting therapy she developed a diffuse, pruritic, erythematous rash and was admitted to the hospital. Dermatology consult and skin biopsy were obtained. Pathology was consistent with a drug eruption. The rash improved with intravenous steriods. On hospital day #3 she complained of dyspnea. A chest x–ray showed a new large left pleural effusion.
Past Medical History
“Arthritis” since the age of 13; treated only with intermittent NSAIDS and steroids.
Right–sided empyema one year ago treated with prolonged antibiotics and chest tube drainage.
History of coronary artery disease (CAD), non–insulin dependent diabetes mellitus (NIDDM), chronic obstructive pulmonary disease (COPD), depression, diverticulitis
Medications
Cardizem, Pepcid, Premarin, Remeron, Darvocet
Social History
She worked as a typist but quit because of arthritis when she was in her 20’s. She smoked 1–2 packs of cigarettes a day for 40 years.
Review of Systems
Diffuse joint pain and stiffness, worse in the morning, lasting all day, denies joint swelling or warmth. She is able to do all of her activities of daily living.
Denies constitutional symptoms
Mild sicca symptoms, no history of sinusitis or otitis
Denies prior history of rash, photosensitivity, alopecia, oral ulcers, Raynaud’s, paresthesias, myalgias, weakness
(top of page)
Physical Examination
The patient was frail, somewhat anxious and confused.
BP 130/60, pulse 70, afebrile.
HEENT — no alopecia, conjunctivae were clear, no nasal or oral ulcers. Lungs — decreased breath sounds at left base, no crackles or wheezes; surgical scar over right posterior chest. Cardiac and abdominal exams were unremarkable. Neurological exam was nonfocal. The skin showed diffuse erythematous macules over her trunk and extremities.
Musculoskeletal exam was notable for the following:
cervical spine — mildly diminished range of motion
shoulders, elbows — full range of motion without synovitis, tenderness, or deformity
MCPs — synovial thickening with minimal tenderness, slight ulnar deviation, subluxations of the IPJs
PIPs — no synovitis, deformities, or tenderness
DIPs — Heberden nodes
hips, knees, ankles — full range of motion without synovitis, deformities or tenderness
feet — hallux valgus, no synovitis
(top of page)
Laboratory Studies
Hematocrit 37.5%; WBC 6,800; platelets 674,00; ESR 35; electrolytes normal; BUN 25; creatinine 0.9; glucose 193; calcium 9.1; albumin 2.7; total protein 5.6; liver function tests normal; uric acid 5.5 urinalysis negative for blood or protein. ABG on room air: pH 7.42 pCO2 35 p02 61, 93% saturation
(top of page)
Clinical Course and Radiology Studies
Chest x–ray one year prior to admission showed clear lung fields following drainage of the empyema.
Chest x–ray taken on hospital day #3 shows a large left pleural effusion.
(click on image for larger view)
On hospital day #3 thoracentesis produced 540cc of turbid fluid: WBC 2025, 6% neutrophils, 42% lymphocytes, 52%; reactive mesothelial cells; LDH 9638; glucose 133; total protein 4.6
On hospital day #4, the left pleural effusion rapidly re–accumulated, requiring a repeat thoracentesis WBC 1346,; LDH 7579; glucose 139; total protein 4.7; pH 7.1
Pleural fluid showed no malignancy on cytology; a negative AFB and fungal smear; a negative Gram’s stain and routine culture.
The patient’s dyspnea improved after the thoracentesis. She remained clinically stable with minimal joint pain throughout her hospitalization.
On hospital day #5, a chest CT scan showed a 2.0 x 1.5 cm lung mass at the right posterior base with right hydropneumothorax and a left pleural effusion. Multiple lung nodules were present in both lung fields.
(click on image for larger view)
A CT–guided transthoracic needle biopsy was performed on both the right lower and upper lung masses. Biopsy results were non–diagnostic showing only necrotic debris and inflammatory cells.
On hospital day #12, thoracoscopic biopsy of the left lower lung mass was performed.
A Rheumatology consult was obtained.
(top of page)
Differential Diagnosis
Differential Diagnosis of Exudative Pleural Effusion
1.[ ]Infection (parapneumonic, tuberculosis, fungi)
2.[ ]Malignancy (bronchogenic, metastatic)
3.[ ]Pulmonary Embolism
4.[ ]Gastrointestinal disease
5.[ ]Rheumatic Conditions (rheumatoid arthritis, systemic lupus erythematosus)
Differential Diagnosis of Pulmonary Nodules
1.[ ]Infection (tuberculosis, fungi, pyogenic abscess)
2.[ ]Malignancy (bronchogenic, lymphoproliferative, metastatic)
3.[ ]Benign tumors
4.[ ]Arteriovenous malformations
5.[ ]Rheumatic conditions (rheumatoid arthritis, Wegener’s granulomatosis, Churg–Strauss, sarcoidosis, amyloidosis
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| AAAAA
Forum Fanatic
Topics: 153
Posts: 1,983
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CXR
Attached Files:
6_case_fig1.jpg (9 KB, 1 downloads)
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| AAAAA
Forum Fanatic
Topics: 153
Posts: 1,983
|
Answer
A. Infection TB
B. Malignancy
C. Benign tumors
D. AV Malformation
E. Rheimatic Disease
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Forum Fanatic
Topics: 153
Posts: 1,983
|
CT Scan of the pleural effusion
Attached Files:
6_case_fig2.jpg (17 KB, 1 downloads)
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