Wednesday, February 01, 2006

Pleural effusion

49 year old woman with a year of dyspnea on exertion. She came to us for a second opinion. She was diagnosed with sarcoidosis approximately 12 months ago. No biopsies and radiographs not available.
She has multinodular goiter diagnosed also about a year ago, actually had a biopsy on the left neck for this that she states was benign. Her meds include Quinapril,
Chlorthalidone, Metformin, Tamoxifen (don't know why) and prednisone 5 mg QD.
She is a lifelong nonsmoker.

On exam, she has a very large goiter, and dullness to percussion over the left chest.



Her pleural fluid is shown here:

Thoughts?

6 comments - CLICK HERE to read & add your own!:

Baleeiro said...

The fluid looks chylous. Maybe the tamoxifen was for a breast Ca and all that soft-tissue density in the CT are mets to nodes with lymphatic compression and a chylothorax.

Baleeiro said...

Sarcoidosis and even the goiter itself can also cause chylothoraces.
I guess the first step of course is to get the chemical studies and cell analysis on the fluid.

Jennings said...

The WBC's in the fluid were 2800 with 95% lymphocytes.
pH 7.79, LDH 126 (serum 155), protein 5.5 (serum 8.6), glucose 148.
Trigylycerides pending.

Baleeiro said...

The pic of the fluid is pretty cool. I guess an empyema could look like that on a posted pic but the numbers don't support that. I will take my chances with a chylothorax for now.

Jeff H said...

I agree-it looks chylous. The CT shows enlargement of some pre-vascular/peri-aortic nodes, and there's increased soft tissue in the superior mediastinum. Sarcoid is possible, but I'd be more concerned about a malignancy. I think a mediastinoscopy or even a Chamberland procedure is necessary to get tissue.

DKeena said...

I agree that the fluid looks chylous and that malignancy is a possibility given the abnomal soft tissue density in the mediastinum. It looked to me like there might be some calcium deposits in the mediastinum as well. How was the diagnosis of sarcoid made?

Maybe this is chronic histo leading to fibrosing mediastinitis and chylothorax.