A CASE OF BILATERAL PLEURAL EFFUSION SECONDARY TO OVARIAN TUMOR

A 45 year old female daily wage labourer by occupation came to the opd with chief complaint of shortness of breath since 2 days.

Patient was apparantly asymptomatic 2 days ago then she developed shortness of breath which is insidious in onset gradually progressive from grade 1 to grade 3.It is aggrevating on supine position and reliwved on sitting position . Sob is not associated with chest pain , chest tightness, palpitations ,fever , cold , cough , nausea, vomitings , loose stools , PND , sore throat , decreased urine output.

H/o exposure to smoke from fossil fules since 30 years and patient husband is a known smoker who smoker 4-5 beedis per day.

PAST HISTORY

- No similar complaints in the past .

- Not a k/c/o DM, HTN, TB, ASTHMA, EPILEPSY,CAD, CVA.

- Tubectomy was done 20 years ago.

MENSTRUAL HISTORY

PAST MENSTRUAL HISTORY

- Age of menarche - 11 years .

- Regular cycles 5-6 days / 30 days.

- No pain , No clots

- Uses 2-3 pads per day.

PRESENT MENSTRUAL HISTORY

- LMP - 4/1/22

- Regular cycles , 2-3 days / 30 days

- No pain , No clots

- Uses 2-3 pads per day .

MARITAL HISTORY

- Age of patient at time of marriage - 15 years

- Age of husband at time of marriage - 20 years

- Marital life - 30 years

- Non consanguinous marriage

OBSTETRIC HISTORY

- Conseived spontaneously 2 months after marriage .

- P1L1 - Male ,FTNVD , 25 Years

Patient gave a history of loss of significant amount of blood during delivery of first child.

- P2L2 - Female , FTNVD ,23 Years

- P3L3 - Female, FTNVD , 20 Years

PERSONAL HISTORY

- DIET - MIXED

- APPETITE - NORMAL

- BOWEL AND BLADDER MOVEMENTS - REGULAR

- SLEEP - ADEQUATE

- Takes toddy ocassionally .

- Non smoker .

FAMILY HISTORY

- No family h/o DM, HTN, TB, ASTHMA, EPILEPSY.

DRUG AND ALLERGIC HISTORY

- No known drug allergies .

- No significant family history .

PATIENT DAILY ROUTINE

She wakes up at 4 am daily and completes her daily house hold chores then takes bath and around 9 am in the morning she eats rice along with some pickle and goes to work in the fields . Around 1pm she will have her lunch consisting of rice, some curry , pickles prefer to eat spicy foods and later again goes to work at around 5 pm she comes back home and compleates her daily household chores and taker dinner around 8pm consisting of rice , pickle and goes to bed around 9pm.

2 days ago around 11am while she was cooking something she felt shortness of breath and she went to local hospital from there she was referred to KIMS , Narketpally.

GENERAL EXAMINATION

Patient is conscious , coherant , cooperative

No pallor , icterus, cyanosis , lymphadenopathy, edema .

VITALS

TEMP - 98.6 F

BP - 130/90 MMHG

PR - 110/ MIN

RR - 24 / MIN

SPO2- 96 % ON RA

SYSTEMIC EXAMINATION

CVS : S1, S2 +

RS :

INSPECTION :

- SHAPE OF CHEST : SYMMETRICAL

- TRACHEA APPEARS TO BE CENTRALLY LOCATED

- NO SCARS, SINUSES , ENGORGED VEINS OVER THE CHEST WALL .

PALPATION :

- NO TENDERNESS AND LOCAL RAISE OF TEMPRATURE

- TRACHEA CENTRALLY LOCATED

- VOCAL FREMITUS REDUCED IN B/L IMA, IAA, ISA .

PERCUSSION

- DULL NOTE IN B/L IMA, IAA , ISA

ASCULTATION :

- BAE +

- DECREASED BREATH SOUNDS IN BILATERAL LOWER INTERSCAPULAR AREA AND RIGHT ISA , IAA

- ABSENT BREATH SOUNDS IN LEFT ISA, IAA.

P/A :

SOFT, NON TENDER

NO GAURDING AND RIGIDITY

ILL DEFINED MASS PALPABLE IN EPIGASTRIC AND PELVIC REGIONS .

BOEWL SOUNDS +

CNS : NO FND

REFERRALS :

GENERAL MEDICINE REFERRAL

GM referral was taken i/v/o HbsAg positive and Spikes of BP

Adviced : Repeat HbsAg (ELISA) after 6 months and BP monitering

OBG REFERRAL

OBG referral taken i/v/o CT findings .

Examination findings P/S :

- Cervix - hypertrophied ,bleeds on touch

- Vagina - healthy.

B/E -

Uterus - Anteverted , bulk size , mobile, nontender . Right fornix free , Left fornix fullness present .

GROOVES SIGN - POSITIVE .

Cervical motion tenderness - Present .

Advice : CA -125 , CEA

GENERAL SURGERY REFERRAL

GS referral was taken i/v/o CT findings

Examination findings :

P/A :

Soft, nontender , no gaurding and rigidity.

Ill defined mass palpable in epigatrica and pelvic region ? Deposits in peritoneum ? Omental deposits.

Dx: ? Carcinoma ovary with metastasis .

Adv : refer to surgical oncology and Gynaecology.

SURGICAL ONCOLOGY REFERRAL ()

ADVICE :

- CA -125 , CEA

- MRI PELVIS

- MEDICAL ONCOLOGY OPINION I/V/O CHEMOTHERAPY .

- PLEURAL FLUID FOR CYTOLOGY AND MALIGNANT CELLS .

ASCITIC FLUID FOR MALIGNANT CELLS

COURSE IN THE HOSPITAL:

A 45 YEAR OLD FEMALE CAME TO THE OPD WITH C/O SOB SINCE 2 DAYS AND WAS TREATED WITH ANTIBIOTICS, ANALGESICS, PPI, OXYGEN SUPPLIMENTATION . NEEDLE THORACOCENTESIS WAS DONE ON 13/1/22, 14/1/22, 15/1/22, 18/1/22 , AND ABOUT 2 LITERS PLEURAL FLUID WAS DRAINED FROM LEFT SIDE AND 500ML OF FLUID( HEMORRAGIC FLUID ) WAS DRAINED FROM THE RIGHT SIDE , THE PROCEDURE WAS UNEVNTFUL AND PATIENT WAS STABLE AFTER THE PROCEDURE . ON 18/1/22 SHE UNDERWENT USG CHEST AND ABDOMEN WHICH SHOWED

- Bilteral moderate pleural effusion with mobile internal echos and thin internal septations.

- Omental and mesentric masses .

- Mesentric and iliac lymphadenopathy.

- Mild ascitis

- Surface deposits in liver suggested for CECT.

CECT WAS DONE ON WHICH REVELED

- Bilateral heterogenously enhancing adnexal masses.

- Multiple enhancing nodular masses in omental , mesentry and peritoneal region .

- Moderate ascitis.

- Moderate bilateral pleural effusion.

- Pleural deposits in left lower lobe .

- Retroperitoneal lymphadenopathy

FOR THE ABOVE FINDINGS GYNACECOLOGY , SURGERY AND SURGERY ONCOLOGY REFERRALS WERE TAKEN . PATEINT IS REFERREDTO THE HIGHER CENTRE (ONCOLOGY CENTRE) FOR FURTHER MANAGEMENT.

INVESTIGATIONS

LDH : 455.5 IU/L

PLEURAL FLUID PROTEIN : 4.9 GM/DL PLEURAL FLUID SUGAR : 62 MG/DL

PLEURAL FLUID

RIGHT SIDE

TC : 5100 CELLS /CUMM

DC : 85%LYMPHOCYTES AND 15% NEUTROPHILS

RBC : 10,400 CELLS / CUMM

LEFT SIDE

TC : 1200

DC : 90% LYMPHOCYTES AND 10 % NEUTROPHILS

RBC: 18,000 CELLS /CUMM

2D ECHO( 14/1/22) : EF : 62% FS : 31% TRIVIAL TR + / AR + , NO MR NO RWMA , NO MS/ AS , SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION . DIASTOLIC DYSFUNCTION + , NO PAH.

USG CHEST : E/O Bilateral moderate PLEURAL EFFUSION with consolidation and collapse of underlying lung segments .

USG ABDOMEN : No sonologic abnormality detected.

PLEURAL FLUID PROTEIN : 4.6 GM/DL

PLEURAL FLUID SUGAR : 89 MG/DL

PLEURAL FLUID LDH : 919.8 IU/L

ESR : 55 MM / 1ST HOUR

D - DIMER : 2430

CRP: NEGATIVE

PLEURAL FLUID AMYLASE : 19.5 IU/L

RA FACTOR : NEGATIVE

S. AMYLASE : 25 IU/L

S.LIPASE: 19 IU/L

USG CHEST AND ABDOMEN )- Bilteral moderate pleural effusion with mobile internal echos and thin internal septations.

- Omental and mesentric masses .

- Mesentric and iliac lymphadenopathy.

- Mild ascitis

- Surface deposits in liver suggested for CECT.

CT CHEST (PLAIN) &ABDOMEN AND PELVIS ( PLAIN &IV CONTRAST ) (): IMPRESSION :- Bilateral heterogenously enhancing adnexal masses.- Multiple enhancing nodular masses in omental , mesentry and peritoneal region .

- Moderate ascitis.

- Moderate bilateral pleural effusion.

- Pleural deposits in left lower lobe .

- Retroperitoneal lymphadenopathy .

Above features suggestive of

- Carcinoma ovary with metastatic deposits.

- Chronic granulomatous infection like tuberculosis.

- Primary peritoneal carcinomatosis. Suggested histopathological corelation.

THYROID PROFILE :

T3: 0.88 ng/ml

T4: 14.26 MICRO GRA, /DL

TSH: 1.42 MICRO IU / ML.