1. Unusual Cause of Pleural Effusion Dr. Mazen Badawi Dr. Abdulrahman Al-Demerdash Prof. Omer Al-Amoudi

2. Week 1 63 yrs old Saudi gentleman, Presented to ENT clinic with 1 wk history of:  Sore throat, low grade fever, generalized fatigue  Diagnosed as URTI, received antibiotics

3. Week 2 Partial improvement Having heaviness in Rt side of chest Received 2 nd course of antibiotics for suspected pneumonia

4. Week 3 Patient developed shortness of breath Seen in our OPD Admitted

5. Week 3 : History Cough, pleuritic chest pain Smoker for 35 years, DM and HTN on oral medications Other systemic review was unremarkable

6. Week 3 : Examination Signs of Rt. Sided moderate pleural effusion

7. Week 3 : Examination Incidental findings  Left small breast mass  Goiter Otherwise, normal

8. Week 3 : Investigations CBC, U&E, LFT  normal CXR= moderate Rt sided pleural effusion

12. Diagnosis so far ?…

13. Week 3 : Management Initial DX  Parapneumonic effusion Pleural tapping done  light yellowish fluid  sent for diagnostics  IV antibiotics were started  Chest tube inserted

15. Analysis RatioSerumPleural fluid 60%7042Protein 80%148121LDH 60%14.88.8Glucose Cell count 5333 cells/cc 81% Lymph 3% Mono/Macro WBC 833RBC -veAFB + PCR -veBacterial stain + cult. Abundant lymphocytesCytology

16. Week 3 : Work up CT chest =  LN Mediastinal Rt hilar Para aortic  Multiloculated, nodular soft tissue mass at left breast,  Goiter  No parynchymal lung lesion

21. Week 4 Chest tube drainage turned to be more whitish Daily drainage = 300cc for more than 2 weeks

22. ?

23. Analysis RatioSerumPleural fluid 60%7042Protein 80%148121LDH 60%14.88.8Glucose Cell count 5333 cells/cc 81% Lymph 3% Mono/Macro WBC 833RBC -veAFB + PCR -veBacterial stain + cult. Abundant lymphocytesCytology

24. Week 4 : The lab story pleural TG sample

25. Surprisingly … TG =450 mg/dl

26. Diagnosis : TG > 110 mg/dl  chylothorax Possibly ruptured thoracic duct, due to :  Lymphoma : HD, NHL  Lung CA  Mets.

27. Week 5 Surgeons were hesitant for immediate mediastinoscopy Breast and thyroid lesion were biopsied

28. Week 6 Thyroid FNA  Follicular growth, no malignant cells Breast biopsy  hemangioma

29. Week 7 Patient admitted under surgical care, underwent mediastinoscopy. LN histopathology : Invasive keratinizing squamous carcinoma, well differentiated 1ry is ? : Lungs, larynx, nasopharynx, esophagus

30. Plan Localizing primary site, staging Treating

31. Thank You…