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A CASE OF BILATERAL PLEURAL EFFUSION SECONDARY TO OVARIAN TUMOR

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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.



TUMOR MARKERS 

CA125 -  1949.1 IU/L ( normal value - 0-35 IU/L)

CEA - 1.57 ng/ ml ( 0-3.0 ng/ml)


CHEST X RAY 




5:30 pm


10:40pm










8:00am


9:00pm


20/1/22




ECG




2D ECHO


USG 





CT THORAX AND ABDOMEN


PLURAL FLUID CYTOLOGY



DIAGNOSIS

BILATERAL MILD TO MODERATE PLEURAL EFFUSION WITH BILATERAL OVARIAN MASSES ? MALIGNANCY WITH MILD TO MODERATE ASCITIS WITH HbsAg POSITIVE.


Treatment Given

 1. INJ . CEFTRIAXONE 1 GM IV BD

 2. INJ . PAN 40 MG IV OD BBF SYRINGES - 50 ML [HI-TECH]

3. O2 INHALATION 2 @ 2-4 LTS / MIN TO MAINTAIN SATURATIONS >95%

4. INJ. ENOXAPARIN 40 MCG SC OD 

5. TAB. PCM 650 MG PO SOS

6. SYP. GRILLINTUS DX 2 TABLE SPOONS PO TID.











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