Left Pleural Effusion e.c Suspect Lung Carcinoma

Disusun Oleh :Fahmi Aulia, S.Ked(0918011110)

Intan Putri Prayitno, S.Ked(0918011118)Rahma Putri Kinasih, S.Ked (0918011127)

Perseptor :dr. Dedy Zairus, Sp.P

SMF PARU RSAM BANDAR LAMPUNGUNIVERSITAS LAMPUNG

2014

Medical Record Number : 22907/ 96.44.49

Admission Date : 06 Januari 2014

Admission Time : 09.00 WIBName : Mrs. SGender : FemaleAge : 43 years old Occupation : FarmerAddress : Pringsewu

Anamnesis (Date: 23 December 2013, 06.00WIB)

Chief Complaint : progressive shortness of breatheSecondary Complaint : chest pain , cough, heartburn pain,

insomnia, loss of appetite which cause significant weight lost, vomitus and epigatric pain.

History of Present Illness 

The patient came to the hospital with shortness of breathe he already felt for about 3 days. The shortness of breathe occured gradually then suddenly developed rapidly into severe breathlessness and get worse for the 2 days before admission. She also felt chest pain, the pain is not radiating to the shoulder, arm, nor the neck. She also had productive cough for the last 2 months. He also had insomnia, heartburn pain, loss of appetite which cause significant weight lost. Before came to RSUAM hospital, patient treated in Mitra Husada Hospital Pringsewu, in there the patient has proofpuncture (pleura puncture) and got serohemorrhagic fluid ± 300cc. The patient felt for the whole day, and there is no marked became better in any particular time of the day and then the patient moved to RSUAM hospital. The patient always cook with firewood.

• History of Past IllnessHer past illness is unremarkable. He never had asthma or severe breathlessness before. She also never took any 6 months regiments / antituberculosis drug. She never had heart dissease and Diabetes mellitus.

 • History of Family Illness

There was no family member who diagnosed as tuberculosis, having wet cough more than 2 weeks, nor present any symptoms like the patients.

• Physical Examination

General appearance: Looks illConsciousness : Compos mentis, E4V5M6Height : 150 cmWeight : 45 kgBlood Pressure: 140/90 mmHgPulse : 76 bpm , regularTemperature : 36.20 CRespiration Rate : 28x/minuteHead : Normocephali, atraumatic,

normal hair distribution, hair not easily revokedEye : isochor pupils, anemic conjuctiva -/-, icteric sclera -/-

visual field intact.Nose: Symmetrical, septum deviation (-), discharge (-), concha oedem (-)

Mouth : sianosis (-), caries , stomatitis (-)

Throat : tonsil T1-T1 calm, hyperemis pharing (-)

Neck : thyroid gland normal size, lymph nodes not palpable, deviation oftrachea (-)

Thorax :Lung

Inspection : symmetrical shape, asymetrical chest movement, accessory

muscle use (-),Palpation : weakened fremitus on the right hemithorax, no tenderness.Percussion : Right : Sonor, Left : Dim Auscultation : absent breathe sounds of the left hemithorax, vesicularbreath sound on the right hemithorax. Wheezing (-/-), Crackles (-/-)

AbdomenInspection : abdomen flat, no tension, no dilated veinsPalpation : no percussion pain, no defense muscular, no enlarged liverPercussion : timpanic, percussion pain (-), shifting dullness (-)Auscultation : bowel movement (+), normal

Extremity : warm , oedem (-), cyanosis (-)

•Laboratory Findings

HematologyHemoglobin : 12,7r %WBC counts : 8600 μlDiff-count : 0 / 0 / 2/ 74/

20/4Platelet counts : 227.000/ulSGOT : 15 U/LSGPT : 13 U/LRandom blood glucose : 230 mg/dlUreum : 13 mg/dlCreatinin : 0,5 mg/dl

Chest X-Ray

•DIAGNOSISLeft pleural effusion e.c Suspect Lung Carcinoma

 •DIFFERENTIAL DIAGNOSIS

▫Left pleural effusion e.c Suspect Lung Carcinoma

▫Left pleural effusion e.c tuberculosis

•Management▫Bed rest▫Pharmacological Intervention :▫IVFD RL xx gtt/minute▫Roborantia▫Antibiotic▫Expectorant▫Non Pharmacological Intervention▫Bedrest▫Oxygen 2L/minute

•Another WorkUp (Recommended)▫Pleural fluid cytology▫Pleural fluid analysis

•PROGNOSISQuo ad vitam : dubia ad malamQuo ad functionam : dubia ad malamQuo ad sanationam : dubia ad malam

(Date : 7 Januari 2014, 13.30 WIB)

The patient has proofpuncture (pleural puncture) and got serohemorrhagic fluid ± 350cc. Then pleural fluid has sent to Patologi Anatomi Laboratorium for cytology pleural fluid and to Patologi Klinik Laboratorium to analysis pleural fluid.

(Date : 8 Januari 2014. 10.00 WIB)

Analysis pleural fluid :

• Macroscopic: yellow to redClarity: cloudy

• Microscopic:Number of cells: >1000 cells / ULGlucose: 241 mg/dLProtein: 3,1 g/ULPMN : 9%MN : 91 %Rivalta Test : + (Positif)pH : 8LDH : 406 mg/dL

(Date : 11 Januari 2014. 09.00 WIB)

•Cytology pleural fluid :Positive malignant cell c/w Squamous cell Carcinoma, poorly diff.

PLEURAL EFFUSION

•DEFINITION

Pleural effusion is a condition of buildup of fluid in the pleural cavity. Pleural effusion can be either a transudate or exudate.

•INCIDENCY

▫In Indonesia pulmonary tuberculosis is the leading cause of pleural effusion , followed by malignancy

▫Pleural effusion found more in women than men .

▫Pleural effusion caused by lung tuberculosis is more prevalent in men than women .

▫Most affected ages are from 21 to 30 years of age

•  EtiologyPleural fluid is divided into :

Transudate

can be caused by :• Congestive heart failure ( left heart failure )• Nephrotic Syndrome• Ascites• superior vena cava syndrome• Tumor• Meig”s Syndrome

Exudate

can be caused by :• Infections : tuberculosis , pneumonia , and other infective disease• Tumor• Pulmonary Infarction• Radiation• Collagen Diseases

Hemorrhagics

effusion , can be caused by :• Tumor• Trauma• Pulmonary Infarction• Tuberculosis

Jenis pemeriksaan Transudate Exudate

Rivalta - / + (weak) +

Berat jenis < 1,016 > 1,016

Protein < 3 gr / dl > 3 gr / dl

Pleural pritein ratio with serum proteins

< 0,5 > 0,5

LDH (Lactic Dehydrogenase)

< 200 IU > 200 IU

Ratio of pleural fluid LDH with serum LDH

< 0,6 >0,6

White blood cells < 1000 / mm3

> 1000 / mm3

Difference between transudate and Exudate

•Pathophysiology

In normal people , the fluid in pleural cavity is as much as 1-20 ml . Amount of fluid

in the pleural cavity is constant because there is a

balance between production by the parietal pleura and absorption by

the visceral pleura

Pleural fluid accumulation can occur if :1 . Colloid osmotic pressure in the blood decreases , for example in hipoalbuminemia .2 . Or condition that cause increase in :• Capillary permeability ( inflammation , neoplasm )• Hydrostatic pressure in the blood vessels to the heart / pulmonary vein ( left heart failure )• Negative pressure inside the pleura ( atelectasis )

Pleural Fluid Analysis

Macam cairan pleura Makroskopis

Transudate Clear, yellowish

Eksudate Yellow to yellow-green

Chylothorax Milky white

Empyema Thick and murky

Anaerobic empyema Foul smell

Malignant mesothelioma Very viscous with hemorrhage

• Cell Count And Cytology▫Leukocytes 25,000 / mm3 : Empyema▫High amount of neutrophils : pneumonia ,

pulmonary infarction , pancreatitis , early pulmonary tuberculosis

▫High amount of of lymphocytes : Tubarkulosis , lymphoma , malignancy

• CHEMICAL TESTGlucose▫Glucose levels < 30 mg / 100 cc : Pleurutis

rheumatoid< 60 mg / 100 cc : Tuberculosis , malignancy , or the empyema▫Decreased glucose levels caused by : Glycolysis

extracellular

• DIAGNOSIS1 . Clinical

Asymmetrical hemithorax movement , decrease of vocal fremitus of the affected area , Barrel chest , egophony ( if the fluid does not fill the entire pleural cavity ) , decreased to absent breath sounds , the deviation of mediastinal organ to healhy side.

2 . RadiologyBlunting of the costophrenic angle and elevated diaphragm .

3 . LaboratoryPleural fluid analysis with clinical chemistry test methods

4 . PathologyObtained from the pleural biopsy and pleural fluid

DIFFERENTIAL DIAGNOSIS

1 . Lung tumors2 . Schwarte or pleural thickening3 . Lower lobe atelectasis4 . Diaphragm high position

• MANAGEMENTManagement of pleural effusion is aimed at treat the underlying disease and to evacuate the excess fluid (by thoracosintesis)

• Indications for thoracocentesis is1 . Eliminate dyspneu caused by fluid accumulation pleural cavity2 . When specific therapy for the primary disease is not effective or fail3 . If there is fluid reaccumulation

At first, evacuate pleural fluid not more than 1000 cc , because the sudden decrease of pleural fluid can cause swollen lungs marked by coughing and tightness .

•Complications1 . Thoracocentesis can causes loss of protein 2 . Infection in the pleural cavity3 . Pneumothorax can occur

CASE ANALYSIS 

•A woman identified as Mrs. S 43 -year -old , MRS Januari 6, 2014 with a chief complaint of shortness of breath since 3 months ago , and intensified since ± 2 weeks SMRS .

•Of these complaints , we can think of is a disorder in the respiratory system / lungs , heart failure , and kidney disorders .

•Based on physical examination , a diagnosis can be established left pleural effusion . The presence of vesicular weakened and dimmed in the left lung may show no abnormalities in his lungs again , especially to suspect neoplasm . Since the number of findings that are often a cause of pleural effusion neoplasms , neoplasms can then be considered as the cause of pleural effusion in this case . The most common neoplasms are metastases originating from primary pleural tumors .

•Based on the results of history, physical examination and investigation , can be enforced type exudate pleural effusion . In pleural fluid cytology obtained metastatic carcinoma

•Treatment was given a high -calorie diet plain rice high in protein and medical. Drug OBH include syrup , antibiotics , corticosteroids , and vitamins . The prognosis of pleural effusion depends on the cause , the age of the patient , and the treatment is done .

REFERENCES • Abrahamian, Fredrick M, DO, FACEP, June 27, 2005.

pleural effusion. www.emedicine.com • Bambang Kisworo, Efusi pleura keganasan in Cermin

Dunia Kedokteran No. 99. 1995. Hal 40 • Hadi Halim. 2006. Penyakit-Penyakit Pleura in Buku Ajar

Ilmu Penyakit Dalam FKUI. Jilid II. Edisi IV. Jakarta. Pp 1066-68.

 • Light, Richard W., 1995. Kelainan pada pleura,

mediastinum dan difragma in Harrison Prinsip-prinsip Ilmu Penyakit Dalam. Volume 3. Edisi 13. Jakarta, Pp1385-87.

  

Thankyou