76y/M ex smoker, COPD, CAD with history of fever appetite loss 15days . pleural fluid- lymphocytic exudative, low ADA, no malignant cells CT chest finding ? DD ? next sequence of diagnostic investigations and treatment?



with this kind of presentation this should turn out to be malignant ... mostly adenoca . CT reveals massive effusion on left with collapsed underlying lung with mdstnl shift to right ... on right side just below the fissure there is nodule with irregular margins mostly metastatic with surrounding ground glass around that nodule . left bronchus main stem is compressed although any endobrnchial or parenchymal mass is not obvious cz of massive effusion and no cntrast scan available . Insert a 14/16 F pigtail catheter for therapeutic drainage of fluid wich will relieve the dyspnea and patient will require pleurodesis later on . Do a CT guided biopsy of right lung nodule ( looks too small for a USG guided ). Pleural fluid atleast 100ml and heparinised send again for cytology ... Twice it should be sent . after fluid decreases repeat a CT thorax with contrast ... followed by bronchoscopy in a stable state to look for endobronchial mass . treat for copd / vaccination / all rehab . This would turn out to be a stage 4 disease so only palliation can be offered . rarely tuberculosis can cause this presentation ... so send pleural fluid for AFB cultures . pleural biopsy can be done if above procedures don't yield answer . Don't probe patients with thoracoscopy unncesrly when so many simpler diagnostic invstgns are available .

Very well and to the point explained.

- Medical thoracoscopy will be ideal as it will help both the ways - diagnostic and therapeutic - if available at your set up. - In case of non-availability, do therapeutic pleural tapping from left side. Right lung also has a peripheral lesion in lower lobe, I think CT/USG guided biopsy of right sided lesion will give you the diagnosis. - Also look for evidence of metastasis. (Liver and peripheral lymphnodes) - Determine performance score and accordingly plan palliative care as this will be stage IV lung Ca.

Very well description given by Dr chaudhary. there is endobronchial growth in 4th row second column Cut . ideal would we to do therapeutic tap for relieve of dyspnea and look for lung expansion , go for FOB and biopsy of intraluminal growth to clinch the diagnosis no need to do anything on right side. nodule on contralateral lung make it stage lV anyways. if lung expand do pleurodehesis else indwelling catheter is required if it refills.

First need a therapeutic thoracentesis, as there is massive effusion with near total lung collapse. Let the patient get relief from gross effusion, while the work up to get diagnosis continues.

we all know its malignancy. but its a fact that the guys left lung is serving him no good. what he has is the right. doing any poking stuff on right and causing pneumothorax will be catastrophic . its like giving him 2 tubes instead of 1. whatever u wanna find stick to the left...

Only thing I wud like to add ... It is recommended to do a contraltrl lung nodule biopsy and not just assume it to be malignant !! we had patients harbouring dual pathology ... I.e. cntralteral lung nodule turned out to be tubercular While having a malignant endobrnchial growth . This is a rare scenario but it changes the staging altogthr specially wen plural fluid also is negative for malignant cells !!! Our patient survived for more than 3 yrs post treatment with all rehab !!! without treatment he would have survived hardly 6 mnths ... but in resource limited settings we can avoid investigating also .!! thanks

I would do pleuroscopy with this much fluid easy to perform with pleural biopsy. With lymphocyte rich effusion with low Ada ... mostly it should be metastatic, lymphoma or r/o ctd ( rare)....once lungs expanded repeat ct chest to see what's left lung has been hiding

sir kindly check any peripheral lymphnodes on clinical examination followed by pleural fluid analysis for malignant cells on at least 3 days ...later on u can do a bronchoscopy to rule out trapped lung followed by thoracoscopy and pleurodesis...if facility of thoracoscopy not available than a closed blind pleural biopsy may also be done

pleural effusion massive L side..... ?tuberculosis. adv. culture &sensitivty & empirically AKT

pleural effusion massive L side..... ?tuberculosis. adv. culture &sensitivty & empirically AKT

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