October 2004 Case Study

October 2004

HISTORY:

A 51-year-old gentleman, nonsmoker, with an unremarkable past medical history who is referred for evaluation of undiagnosed left pleural effusion. On 8/13/2004, the patient had a "heart saver" CT scan which
demonstrated a left pleural effusion and a possible loculated pericardial effusion and a 1-cm AP window lymph node. The patient saw his doctor, who obtained a chest x-ray which confirmed the presence of
a moderate pleural effusion. He subsequently had thoracic CT scan on 8/11/2004 which confirmed the presence of a moderate left pleural effusion. There was focal linear scar / atelectasis in the lingula.
There is mild pericardial thickening and a loculated posterior pericardial effusion. There is no significant hilar or mediastinal lymphadenopathy. Thoracentesis was done which was reportedly "inconclusive". PPD skin test was reportedly negative, and there is no history of exposure to active tuberculosis. Currently, the patient reports that he has had cough for 2-3 months with productive scant amount of white sputum. He denies hemoptysis. He has a wheeze once or twice a day. He reports left-sided chest pressure when he takes a deep breath. He denies exertional breathlessness. He is able to mow his yard, carry groceries from the car into the home, keep up the with his sons. He reports that his energy level is good. He is not having fevers, chills, or night sweats. He denies weight loss, new or worsening neurologic symptoms, bone or joint pains, GI / GU complaints, or voice change. He does note that approximately 30 years ago (~1974) he mixed asbestos for 1.5 to 2 yrs while working at a chemical plant. He wore a paper mask.

PAST MEDICAL HISTORY:
Symptoms of acid reflux, undiagnosed left pleural effusion, see above.

CURRENT MEDICATIONS: Multivitamin.

SOCIAL HISTORY:
Cigarettes 1 pack per week x 10 years, discontinued in 1980s. Alcohol rare. Social drinker. He has been married for 19 years, he has 4 children who are healthy. He is currently a quality engineer at a fabricated metal manufacturing plant. He is intermittently exposed to ferric chlorate, sulfuric acid, and other caustic solutions. He has 3 dogs (2 inside, 1 outside). His hobbies include "mowing his lawn".

DIAGNOSTIC STUDIES:
Chest x-ray 9/2/2004 shows a moderate left lower lobe pleural effusion, nonchanged from 8/17/2004 and 8/11/2004. Thoracic CT scan -see above.

ASSESSMENT AND PLAN:
Left pleural effusion - etiology uncertain. Presumably it is an exudative pleural effusion. Primary diagnostic concerns are infection (fungal/mycobacterial/primary tuberculous effusion - note lack of constitutional or respiratory symptoms) versus malignancy (adenocarcinoma vs mesothelioma - note lack of chest pain and no known primary cancer) versus benign asbestos-related pleural effusion vs.(doubt) collagen vascular disease.

PROCEDURE(S):
1. Video assisted thoracoscopy.
2. CT of the chest, abdomen and pelvis.
3. Hemangioma studies.

Hospital Course:
A 51-year-old white gentleman with no significant past medical history. Initially found to have left sided pleural effusion on a CT scan done at the Heart Hospital for routine evaluation. A thoracentesis done at outside hospital was nondiagnostic. The patient was seen in the pulmonary clinic for a second opinion and had a repeat diagnostic paracentesis. Subsequently the patient developed a large pneumothorax, a result of the tap, and needed to come to the Emergency Room to have a chest tube placed. The pleural fluid was sent for pathology to confirm malignant cells in the pleural fluid. Final pathology on the fluid came out to be mesothelioma.

PRINCIPAL DIAGNOSIS: Mesothelioma.

"Malignant mesothelioma, a rare form of cancer, is a disease in which cancer (malignant) cells are found in the sac lining the chest (the pleura), the lining of the abdominal cavity (the peritoneum) or the lining around the heart (the pericardium).

Most people with malignant mesothelioma have worked on jobs where they breathed asbestos.

The patient was admitted to the medicine service after a chest tube was placed in the left side for the pneumothorax. CT surgery was consulted. Pulmonary was consulted. CT surgery evaluated the patient and VATS was done. Pleural biopsy was taken which came out to be mesothelioma. Pulmonary was following with the patient. Subsequently hematology/oncology was consulted who recommended pan CT, CT of the chest, abdomen and pelvis. The CT scan showed a low density lesion in the liver which is nonspecific. The patient was referred to nuclear medicine for a hemangioma study. For more information about hemangiomas click here.
Radiology Report:

CLINICAL HISTORY: This is a 51-year-old male with a history of low-density lesion at the junction of segment six and seven of the liver seen on recent CT of 9/7/04.

TECHNIQUE: Using in-vitro technique, the patient was injected with 23.3 mCi of Tc-99m tagged red blood cells and planar images as well as SPECT images were obtained.

FINDINGS: There is uniform distribution of radiotracer seen throughout the liver. There is a focal area of blood pooling seen in the posterior aspect of the right lobe of the liver. This correlates with the low-density lesion seen on CT and most likely represents hemangioma. There is physiologic activity noted in the heart, spleen, and kidneys.

IMPRESSION: FOCAL AREA OF BLOOD POOLING IN THE POSTERIOR ASPECT OF THE RIGHT LOBE OF THE LIVER WHICH CORRELATES WITH THE LOW-DENSITY LESION SEEN ON CT AND THIS LIKELY REPRESENTS HEMANGIOMA.


Hematology/oncology came by and we are discussing about the treatment options with the patient however, the patient refused any treatment here and he wanted to take second opinion and he wanted to get his care and treatment options at MD Anderson. The patient was provided with the phone number for the MD Anderson and was discharged from the hospital on 9/8/04.

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Images courtesy of University of Arkansas for Medical Sciences Dept of Nuclear Medicine.