A 56 Year Old Man with Pleural Effusion

Andrea Glassberg, MD, PhD October 29, 2002

Case Presentation
A 56 year old man presented to the emergency department complaining of pleuritic chest pain and dyspnea on exertion. Three weeks prior to admission he developed left sided pleuritic chest pain, subjective fevers, chills, lightheadedness, and night sweats. He denied cough, wheezing or sputum production. One week prior to admission he noted dyspnea on exertion.

Past Medical History

Erosive arthritis (presumed to be RA) Spinal compression fractures (due to prednisone) Depression Chronic Pain

Physical Exam
Emaciated middle aged WM, NAD. 98.4, 103/61, HR 69, RR 18, O2 sat 98%RA No lymphadenopathy Slightly decreased BS left lower lung field Decreased tactile fremitus left base Single rheumatoid nodule left 3rd toe

Labs
WBC 10.5 (8.18N) HCT 38 PLT 254 Na 137 LFTs WNL Protein 6.2 INR 1.0 Troponin-I negative LDH 119 RF +

Additional Information?

Pleural Fluid
Yellow, hazy WBC 14000 RBC 1900 70% neut 14% eos 1% meso 5% lymph Protein 4.5 Glucose 102 LDH 266 Amylase 42 Chol 84 ADA 4.3 (1.6 to 9.2)

Pleural Fluid
Gram stain negative Culture negative AFB negative Cytology benign

Differential Diagnosis of Pleural Fluid Eosinophilia

Air in pleural space Hemorrhage PE BAPE Infection
Parasitic Fungal

Idiopathic

DDx in this patient:

Malignancy Infection
TB Parapneumonic effusion PCP Parasitic Fungal

RA Drug Reaction PE with infarction Post Traumatic Benign Asbestos Pleural Effusion

Additional Information?

What would you do next?

VATS
Pleural fibrosis. No granulomas. No asbestos bodies or fibers No evidence of vasculitis or tumor. Cultures negative. Stains for AFB and fungi negative.

What does this patient have?

What is the next step?

BAPE:
Benign Asbestos Pleural Effusion

BAPE: What is it?

Initially described 1950s. Most common pleuro-pulmonary asbestos related abnormality during the first 20 yrs after exposure. Exudative pleural effusion. Exposure to asbestos. Exclusion of other causes of effusion. Exclusion of malignancy for two years of follow up.

BAPE, Pathogenesis:
Exact mechanism unknown Hypothesized that submicroscopic asbestos particles in the pleural space induce a constant stimulation to pleural mesothelial cells to release chemotactic factors

BAPE: Who gets it?

Reported to occur in 3% of asbestos exposed workers. Latency period shorter than for other asbestos related disorders, ranges from 1 to 58 years, mean of 20 to 30 years. Prevalence dose related with 7.0% direct exposure, 3.7% indirect, and 0.2% peripheral.

BAPE: How does it present?

50% or more may be asymptomatic. Most common symptom is chest pain. Fever Cough Dyspnea

BAPE, Characteristics:
Small to moderate sized effusion 10% bilateral Often recurrent Pleural plaques common Pleural calcifications uncommon

BAPE, Fluid Characteristics:

Exudative WBC usually <6000/mm3 but can be as high as 28,000 Neutrophil or mononuclear predominance Mesothelial cells Eosinophilia No asbestos bodies or fibers

BAPE, Sequelae:
Effusions last 1-10 months, median 3 mo. 28% recurrent, often contralateral. Pleural fibrosis Malignant mesothelioma (5% in one series of 61 patients occurring 6, 9, and 16 years after the initial effusion)

References
Epler, GR, McLoud, TC, Gaensler, EA. Prevalence and incidence of benign asbestos pleural effusion in a working population. JAMA 1982; 247:617. Hillerdal, G, Ozesmi, M. Benign asbestos pleural effusion 73 exudates in 60 patients. Eur J Respir Dis 1987; 71:113. Light, RW. Pleural Diseases, 3rd ed. 1995. UpToDate version 10.2, Pleural fluid eosinophilia. UpToDate version 10.2, Diagnostic evaluation of a pleural effusion. UpToDate version 10.2, Pulmonary pearls: A 47 year old man with left chest pain, dyspnea, and an eosinophilic pleural effusion.