Case History

A 32-year-old lady was referred to me for a second opinion. She had been BCG-vaccinated, but believes that she might have been exposed to clients who had active pulmonary tuberculosis. She presented with a three-month history of cough, dyspnoea, night sweats and weight loss. She stopped smoking four years ago, and there was no other family history of note. She had been prescribed courses of Augmentin, Amoxicillin, and Clarithromycin, but her cough persisted. Indeed, her cough worsened after her return from the Caribbean.

On examination, there were obvious signs of weight loss, but examination of the fingers, neck and mouth was normal. Cardiovascular examination was normal. Oxygen saturation was 98% on room air, and breath sounds were reduced bilaterally, with some crackles at the right base. The rest of the examination was normal.

Results

Her CT scan of the thorax showed bilateral pleural effusions (larger on the left), bi-basal atelectasis and a small pericardial effusion. Blood tests revealed a microcytic anaemia (haemoglobin 103, MCV 69); CRP 42, ESR 20. Urea and electrolytes were normal, as were autoantibodies, complement, liver function tests and blood cultures.

Questions: What would you do next?

1. Give a further course of antibiotics?

2. Refer to a thoracic surgeon?

3. Refer to a chest physician?

Discussion

She had recently returned from the Caribbean, where there was an outbreak of chikungunya. Chikungunya is a mosquito-borne infection which can be associated with malaise, lethargy, and can persist for between four to six weeks. It is usually self-limiting, and is not often associated with cough and weight loss. Tuberculosis was unlikely and HIV test was negative.

Connective tissue disorders enter the differential diagnosis, but blood tests excluded this. She had already undergone pleural fluid cytological examination, which revealed an exudate, but the pleural fluid cytology was negative for malignant cells.

Therefore I organised for her to undergo a right surgical pleural biopsy (rather than a repeat ultrasound-guided pleural sampling) as surgical biopsies allow for direct viewing of the pleura to see if there is any evidence of malignancy with seeding, as well as for allowing biopsies of the pleura and lung and further pleural fluid sampling.

Histopathology revealed a mucinous cystic adenocarcinoma. This was subsequently also found on the left. She underwent a left-sided talc pleurodesis, and is currently undergoing chemotherapy.

Discussion Points

1. This woman looked unwell, and her symptoms did not respond to multiple courses of antibiotics that were appropriate for a community acquired pneumonia. She therefore required further investigation to obtain a definitive diagnosis.

2. Thoracentesis only revealed an exudate. Pleural fluid cytology is dependent upon the cellularity of the specimen, and often it takes two or three specimens to obtain a diagnosis. Negative pleural fluid specimens can lead to false reassurance.