Pleural effusion: An unusual cause and association
A 70-year-old man presented with cough with expectoration and shortness of breath since 6 months. He also had recurrent episodes of hemoptysis since the past 1 month. On further enquiry, he had repeated hospital admissions for cough with expectoration since the past 6 months. The patient had no past history of Filarial infestation or eosinophilia or pulmonary tuberculosis. He had undergone coronary artery bypass graft (CABG) surgery 5 years back.\nOn examination (O/E) the patient was moderately built and nourished. He was tachypnoeic at rest with tachycardia and blood pressure of 110/70 mmHg. Respiratory system examination revealed features suggestive of right-sided pleural effusion. Other system examinations were not contributory.\nBlood investigations revealed hemoglobin of 9.7 gm% and leukocytosis with neutrophilia. However, there was no eosinophilia. His absolute eosinophil count was within normal limits. Erythrocyte sedimentation rate was elevated at 60 mm at the end of the 1st h. His blood chemistry was within normal limits. Chest X-ray showed a right-sided pleural effusion []. Sputum for acid fast bacilli (AFB) and pyogenic organism culture/sensitivity was negative. Pleural fluid analysis was grossly hemorrhagic. Biochemically, it was an exudative effusion with lymphocyte pre-dominance (75%). Pleural fluid lactic dehydrogenase (LDH) was 150 U/L. Pleural fluids adenosine deaminase (ADA) and carcino embryonic antigen (CEA) levels were within normal limits. Pleural fluid Gram staining showed only few polymorphs but no organisms were isolated in culture. Zeihl-Neelsen staining of Pleural fluid did not reveal any acid fast bacilli. Pleural fluid cytology showed only RBCs admixed with few inflammatory cells and mesothelial cells but no definite malignant cells. Pleural fluid cytology also showed a focus of Filarial parasites [].\nMultidetector computed tomography (CT) of the chest revealed right upper lobe cavitatory mass with thick irregular walls with heterogeneous enhancement and posterior pleural thickening. Small sub-pleural cystic foci were seen in the rest of the lung fields. Ultrasonography (USG) abdomen done was a normal study. Echocardiography showed mild mitral regurgitation (MR) with mild left Venticular (LV) systolic dysfunction, consistent with old myocardial infarction. Bronchoscopy was done that revealed purulent secretions in the basal segment of the right lower lobe. No endobronchial lesions were seen. Lavage fluid analysis revealed polymorphonuclear leucocytes (PMNs), but was negative for any growth or malignant cells. A CT-guided fine needle aspiration cytology (FNAC) done from the wall of the cavitatory mass revealed adenocarcinoma of lung.\nHe was put on diethyl carbamazine for 3 weeks and he promptly responded for the same. His repeat chest radiograph done showed resolution of pleural effusion. Patient was offered further evaluation and treatment for lung malignancy, which he declined.