Symptoms to Diagnosis

Rapidly progressive pleural effusion

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Release date: January 1, 2019
Expiration date: December 31, 2019
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A 33-year-old male nonsmoker with no significant medical history presented to the pulmonary clinic with severe left-sided pleuritic chest pain and mild breathlessness for the past 5 days. He denied fever, chills, cough, phlegm, runny nose, or congestion.

Five days before this visit, he had been seen in the emergency department with mild left-sided pleuritic chest pain. His vital signs at that time had been as follows:

  • Blood pressure 141/77 mm Hg
  • Heart rate 77 beats/minute
  • Respiratory rate 17 breaths/minute
  • Temperature 36.8°C (98.2°F)
  • Oxygen saturation 98% on room air.
Figure 1. Chest radiography in the emergency department (A) showed a mild left-sided pleural reaction (arrow). Computed tomography (B) showed a mild pleural reaction (arrow) and parenchymal atelectatic and fibrotic changes.

Figure 1. Chest radiography in the emergency department (A) showed a mild left-sided pleural reaction (arrow). Computed tomography (B) showed a mild pleural reaction (arrow) and parenchymal atelectatic and fibrotic changes.

No abnormal findings on physical examination were noted at that time. Radiography and computed tomography (CT) (Figure 1) showed inflammatory and atelectatic changes in the left lower lobe, with mild pleural reaction, and results of laboratory testing were:
  • White blood cell count 6.89 × 109/L (reference range 3.70–11.00)
  • Neutrophils 58% (40%–70%)
  • Lymphocytes 29.6% (22%–44%)
  • Monocytes 10.7% (0–11%)
  • Eosinophils 1% (0–4%)
  • Basophils 0.6% (0–1%)
  • Troponin T and D-dimer levels normal.

DIFFERENTIAL DIAGNOSIS OF PLEURITIC CHEST PAIN

1. What is the most likely cause of his pleuritic chest pain?

  • Pleuritis
  • Pneumonia
  • Pulmonary embolism
  • Malignancy

The differential diagnosis of pleuritic chest pain is broad.

The patient’s symptoms at presentation to the emergency department did not suggest an infectious process. There was no fever, cough, or phlegm, and his white blood cell count was normal. Nonetheless, pneumonia could not be ruled out, as the lung parenchyma was not normal on radiography, and the findings could have been consistent with an early or resolving infectious process.

Pulmonary embolism was a possibility, but his normal D-dimer level argued against it. Further, the patient subsequently underwent CT angiography, which ruled out pulmonary embolism.

Malignancy was unlikely in a young nonsmoker, but follow-up imaging would be needed to ensure resolution and rule this out.

The emergency department physician diagnosed inflammatory pleuritis and discharged him home on a nonsteroidal anti-inflammatory drug.

CLINIC VISIT 5 DAYS LATER

At his pulmonary clinic visit 5 days later, the patient reported persistent but stable left-sided pleuritic chest pain and mild breathlessness on exertion. His blood pressure was 137/81 mm Hg, heart rate 109 beats per minute, temperature 37.1°C (98.8°F), and oxygen saturation 97% on room air.

Auscultation of the lungs revealed rales and slightly decreased breath sounds at the left base. No dullness to percussion could be detected.

Because the patient had developed mild tachycardia and breathlessness along with clinical signs that suggested worsening infiltrates, consolidation, or the development of pleural effusion, he underwent further investigation with chest radiography, a complete blood cell count, and measurement of serum inflammatory markers.

Figure 2. Chest radiography 5 days after the emergency department presentation showed development of a left-sided pleural effusion.

Figure 2. Chest radiography 5 days after the emergency department presentation showed development of a left-sided pleural effusion.

Radiography revealed a left-sided pleural effusion (Figure 2). Laboratory testing results:
  • White blood cell count 13.08 × 109/L
  • Neutrophils 81%
  • Lymphocytes 7.4%
  • Monocytes 7.2%
  • Eeosinophils 0.2%
  • Basophils 0.2%
  • Procalcitonin 0.34 µg/L (reference range < 0.09).

Bedside ultrasonography to assess the effusion’s size and characteristics and the need for thoracentesis indicated that the effusion was too small to tap, and there were no fibrinous strands or loculations to suggest empyema.

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