Transcript Case Presentation

Case Presentation
Teaching Presentation
Mr. MX
• 55 years old
• Presents to ED with:
• 6/52 worsening SOB and LOW (about
10kg)
• 2/52 cough occasionally productive of
yellow sputum
• General malaise, fatigue.
• No chest pain, palpitations, fevers, night
sweats, rigors.
• PHx
• Asthma
• Treated with Ventolin only.
• No previous admissions.
• No serious attacks for years.
• Smoker
• 40 year history. Quit 6/12 ago.
• Drinker
• Heavy drinker, hasn’t had drink for three
weeks.
• Nil other medications and NKDA
Differentials?
Differential Diagnosis
•Respiratory
•Airways
•Chronic bronchitis
•Bronchiectasis
•Asthma
•Parenchymal
•Pneumonia (atyp)
•Fibrosis
•Granulomatous Disease
•Pulmonary
•Chronic PE
•Chest Wall/Pleura
•Effusion
•Massive Ascites
•Fractures Ribs
•Neuromuscular
•Cardiac
•Congestive Cardiac
Failure
•Mitral Valve Disease
•Cardiomyopathy
•HOCM
•Dilated
•Pericardial effusion
•Haematological
•Anaemia
•Non-Cardiorespiratory
•Acidosis
•Hypothalamic Lesion
•Anxiety
Further History
SOB
• Gradual Onset OE.
• Neither orthopnoea nor PND.
• First noticed at rest 2/52 ago
LOW
• ~10kg in 6/52
LOA
• last 10/52
Denies ankle swelling or pain, chest pain.
Denies wheezing, haemoptysis, travel, CP,
palpitations, syncope.
No abdominal or urinary symptoms.
Further History
• Social History
• lives with wife who suffers from
psychiatric illness and acts as carer
• doesn’t own birds
• no known asbestos exposure
• Family History
• father died at 65yo from heart troubles
• mother died from breast cancer at 76yo
• no strong family history
Examination
• Vital Signs
•
•
•
•
•
•
HR 145
BP 108/88
RR 24
SatO2 97% on 35%O2
Temp 36.4˚C
GCS 15
• General Appearance
• Cachectic, pale, speaking full
sentences, slightly disheveled.
• Not cyanotic.
Respiratory Examination
• Mild-mod clubbing
• Left pupil dilated
• Trachea deviated to R)
• Reduced chest
expansion on L)
• Stony dull percussion
on L) to apex
• Absent breath sounds
on L)
Further Examination
• Cardiovascular
• Apex beat displaced R)
• No heaves or thrills.
• Dual heart sounds with nil added. Tachycardia.
• Abdo
• Soft, non-tender, non-distended abdo.
• Palpation difficult but ?hepatomegaly of 15cm
by percussion.
• Nil other organomegaly or masses.
• Bowel sounds present.
• Lower Limbs
• No pitting, swelling or tenderness.
• Rheum
• no noticeable rashes or joint disease
Impression?
• Large left pleural effusion.
• Causes?
Causes of Pleural Effusion
Transudates
•LVF
•Hypoproteinaemia
•Constrictive
Pericarditis
•Hypothyroidism
•Meig’s Syndrome
•Ovarian fibroma
•R) sided pleural
effusion and
•Ascites
Exudates
•Para-pneumonic
•Bronchial Carcinoma
•Pulmonary Infarction
•Tuberculosis
•CTD
•Acute Pancreatitis
•Post-MI
•Mesothelioma
•Sarcoidosis
Bloods
•
•
•
•
•
•
•
•
•
•
ECG
ABG
FBE/UECr/LFT/Ca2+
Coags
TSH
BSL
G&CM
LDH
CRP
BC
FBE
Hb
84
g/L
[125-175]
WCC
12.0
x 109/L
[4-11]
Plts
1177
x 109/L
[150-450]
RCC
3.43
x 1012/L [4.2-6.2]
Hct
0.26
L/L
[0.38-0.54]
MCV
77
fL
[78-98]
MCH
24.5
pg
[27-34]
MCHC
320
g/L
[310-355]
RDW
20.8
%
[<15]
MPV
6.5
fL
[6.5-12]
Neutrophils
10.08 x 109/L
[2.0-8.0]
Lymphocytes
1.2
x 109/L
[1.0-4.0]
Monocytes
0.72
x 109/L
[0.0-1.0]
Eosinophils
0.0
x 109/L
[0.0-0.5]
Basophils
0.0
x 109/L
[0.0-0.2]
FBE
Hb
84
g/L
[125-175]
WCC
12.0
x 109/L
[4-11]
Plts
1177
x 109/L
[150-450]
RCC
3.43
x 1012/L [4.2-6.2]
Hct
0.26
L/L
[0.38-0.54]
MCV
77
fL
[78-98]
MCH
24.5
pg
[27-34]
MCHC
320
g/L
[310-355]
RDW
20.8
%
[<15]
MPV
6.5
fL
[6.5-12]
Neutrophils
10.08 x 109/L
[2.0-8.0]
Lymphocytes
1.2
x 109/L
[1.0-4.0]
Monocytes
0.72
x 109/L
[0.0-1.0]
Eosinophils
0.0
x 109/L
[0.0-0.5]
Basophils
0.0
x 109/L
[0.0-0.2]
Interpretation
Moderate anaemia with microcytic
hypochromic blood picture. Marked
thrombocytosis. Suggest ____ ______ and
__ __________ and ___/_____ studies.
Interpretation
Moderate anaemia with microcytic
hypochromic blood picture. Marked
thrombocytosis. Suggest iron studies and
Hb electrophoresis and B12/folate studies.
Which poikilocytoses would you expect?
• elongated cells
• target cells
Also Had
• hypogranular neutrophils
• hypersegmented neutrophils
• giant platelets
Other Bloods
UECr
Iron Studies
Na+
124
mM
[135-145]
Fe
1
µM
[13-35]
K+
4.0
mM
[3.5-5.0]
Transfrr
1.3
g/L
[2.0-3.6]
Cl-
90
mM
[101-111]
FE Bind
33
µM
[46-76]
HCO3-
23
mM
[22-32]
Ferritin
1227
µg/L
[20-300]
Urea
3.0
mM
[2.5-9.6]
Arterial Blood Gases
Creat
62
mM
[40-120]
pH
7.43
Ca2+
2.23
mM
[2.2-2.6]
pCO2
32.0
mmHg
[36-46]
pO2
51.4
mmHg
[75-100]
LFTs
[7.35-7.45]
Alb
18
g/L
[35-45]
BE
-2.6
[-3-+3]
ALP
115
U/L
[30-120]
INR
1.9
[0.8-1.2]
ALT
27
U/L
[7-56]
APTT
33
secs
[23-34]
Tot Bili
18
U/L
[<17]
CRP
303
mg/L
[0]
GGT
34
U/L
[7-64]
PGL
8.0
mM
[3.3-7.7]
LDH
187
U/L
[100-200]
B12/RCF NAD
TSH
2.31
mU/L
[0.3-5.0]
BC
[PENDING]
Other Bloods
UECr
Iron Studies
Na+
124
mM
[135-145]
Fe
1
µM
[13-35]
K+
4.0
mM
[3.5-5.0]
Transfrr
1.3
g/L
[2.0-3.6]
Cl-
90
mM
[101-111]
FE Bind
33
µM
[46-76]
HCO3-
23
mM
[22-32]
Ferritin
1227
µg/L
[20-300]
Urea
3.0
mM
[2.5-9.6]
Arterial Blood Gases
Creat
62
mM
[40-120]
pH
7.43
Ca2+
2.23
mM
[2.2-2.6]
pCO2
32.0
mmHg
[36-46]
pO2
51.4
mmHg
[75-100]
LFTs
[7.35-7.45]
Alb
18
g/L
[35-45]
BE
-2.6
[-3-+3]
ALP
115
U/L
[30-120]
INR
1.9
[0.8-1.2]
ALT
27
U/L
[7-56]
APTT
33
secs
[23-34]
Tot Bili
18
U/L
[<17]
CRP
303
mg/L
[0]
GGT
34
U/L
[7-64]
PGL
8.0
mM
[3.3-7.7]
LDH
187
U/L
[100-200]
B12/RCF NAD
TSH
2.31
mU/L
[0.3-5.0]
BC
[PENDING]
Which blood results are
characteristic of an acute
phase response?
CRP 303.8
Platelets 1177
Ferritin 1100
Albumin 18
? others
ECG
CXR
Next relevant
investigation?
USS
Why an USS if total white out?
The CXR does not indicate whether the
lung is adherent to posterior parietal
pleura (eg. if the effusion is loculated).
If it is and you attempt to drain it you’ll
give the patient a pneumothorax.
USS
• The effusion is present to the apex
and is not loculated.
• Distance from parietal pleura to lung
was 10cm where marked.
Issues?
• Large L) pleural effusion - ?
Malignancy
• Fluid Balance and Electrolyte Issues:
• 100/60 in long term smoker probably
low
• Hyponatraemia in a patient likely to be
water deplete. ?SIADH
• Coagulopathic.
• Microcytic Hypochromic Anaemia
with abnormal iron studies.
• Acute phase response - ? infectious
component
Management
• Admit Respiratory HDU.
• Drain effusion tomorrow morning:
• 10mg of Vitamin K stat and rpt INR in am
• Send fluid for ______________________
• CXR two hours post drainage
• CT Chest with contrast tomorrow afternoon.
• Contrast allows good distinction between vessels
and lymph nodes (Hint: remember this!)
• Fluid replacement with normal saline.
• ? Transfuse - didn’t but had matched blood ready if needed
• Commence antibiotics: ceftriaxone and
azithromycin
• Blood cultures if febrile.
What do we want to know about the pleural
aspirate?
•Macroscopic
•Yellow cloudy
•Volume ~6.0L
•Biochemistry
•Protein
•Glucose
•pH
•LDH
•amylase
•Cytology
•Neutrophils
•Lymphocytes
•Abn. Mesothelial Cells
•Giant cells (RA)
•Immunology
•Not performed
Biochemical Parameters
• Protein
• <30g/L
• >30g/L
Transudate
Exudate
• Glucose <3.3mM
• pH <7.3
• LDH high
• Amylase high
empyema, malignancy, TB,
RA, SLE
pancreatitis, carcinoma,
bacterial pneumonia, oesophageal
rupture
Pleural Aspirate
•
•
•
•
•
Protein 42g/L
Glucose 4.7mM
pH 8.2
LDH 511U/L
Amylase not tested on this occasion
How do we test for SIADH?
• Serum Osmolality
283 mOsmol/kg [280-300]
• Urine Osmolality
753 mOsmol/kg [50-1400]
The diagnosis requires concentrated urine (Na+ >20mM
and osmolality >500mOsmol/kg) in the presence of
hyponatraemia (Na+<125mM) or low plasma osmolality
(<280mOsmol/kg), and the absence of hypovolaemia,
oedema or diuretics.
CXR
2 hr Post
drainage of
6.3L pleural
fluid!!
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
CT Chest
Spot the Lymph Node
CT Chest
Sub-carinal LAD
CT Chest
Pick the abnormality
CT Chest
Supraclavicular LAD
Cytology Method
• Pleural fluid spun down and
sediment smeared.
• Two stains used.
• Sediment is clotted by addition of
plasmin and the fixed and sliced in
the regular fashion permitting the
use of immunohistochemistry.
• Calretinin negative in this case
indicates unlikely to be mesothelioma
Cytology
• Main features of slide are:
• Large (in many cases multinucleated)
cells
• Large nuclei and prominent nucleoli
• Cytoplasmic vacuolation (mucin, fat,
H2O, artifact)
• Generally bizarre looking cells
• Other features not on slide shown
• Mitotic figures
• Acinar structures – favours
adenocarcinoma
Cytology …
• Hard to diagnose malignancy from
cytology
• High sensitivity, low specificity.
• Rarely diagnose mesothelioma based
solely on cytology because of:
• Legal implications
• Difficulty distinguishing benign from malignant
cells
• Textbook ‘hallmarks’ of malignant cells can be seen
in benign cells.
• Better to view cytology like VQ scans, in
that they give you probabilities of a
positive result and can be diagnostic only
in gross abnormalities.
Cytology Report
“Numerous individual abnormal cells
with large vesicular nuclei, prominent
nucleoli, moderate amount of generally
finely vacuolated cytoplasm and
scattered groups exhibiting glandular
formation.”
“The differential diagnosis is between
adenocarcinoma and mesothelioma. I
favour adenocarcinoma on the
cytological features however
immunohistochemistry has been
ordered for clarification.”
Cytology Report
• “Immunohistochemistry demonstrated
the that tumours cells are strongly
positive with EMA and negative with
calretinin stains supporting
adenocarcinoma involvement of the
pleura.”
Progress
•
•
•
•
•
Sats improved 93% on 3.0L NP
Drowsy but oriented.
Pneumocath out.
Transferred to single room.
Deceased in am.
Summary
• 55 year old man
• 40 year smoking history
• malignant pleural effusion
• cytological diagnosis of
adenocarcinoma
• compression of L) main bronchus
making palliation difficult
• deceased within 8 weeks of onset of
symptoms and within 2 weeks of
presentation to ED