Pleural Effusion Caused by Trapped Lung

Jay T. Heidecker, MD, Marc A. Judson, MD

Disclosures

South Med J. 2003;96(5) 

In This Article

Case Report

A 65-year-old woman with a remote history of tobacco use presented with cough, shortness of breath, and wheezing for one month. Physical examination revealed decreased breath sounds over the right chest. Initial chest x-ray revealed a right upper lobe infiltrate, right pleural effusion, a small left upper lobe infiltrate, and a widened mediastinum (Fig. 1). Transbronchial lung biopsy revealed noncaseating granulomas. Acid-fast bacilli and fungal stains of the biopsy were negative. A thoracentesis revealed serosanguinous fluid with a red blood cell count of 218/mm3; a white blood cell count of 2,420/mm3, 69%, lymphocytes, 31% neutrophils; total protein 4.3 g/dl; glucose 104 mg/dl; amylase 36 IU/L; cholesterol 82 mg/dl; triglycerides 29 mg/dl. Gram's stain, acid-fast bacilli, fungal stains, and cytology of the pleural fluid were negative. A chest computed tomographic scan revealed a loculated right pleural effusion and right lung consolidation (Fig. 2).

Chest x-ray obtained at initial presentation showing right upper lobe infiltrates and right pleural effusion.

Chest CT scan showing loculated pleural effusion and right lung consolidation.

The patient had transient relief of dyspnea after the thoracentesis; however, pleural fluid reaccumulated within one month. A therapeutic thoracentesis was therefore repeated. The patient was started on 10 mg prednisone daily and increased to 30 mg/d over 4 months without relief of her dyspnea or pleural effusion. Methotrexate 12.5 mg/wk was subsequently added without symptomatic or radiographic improvement. The persistence of the pleural effusion and lack of response to steroids and methotrexate raised concern that a process other than sarcoidosis was responsible. Thoracoscopy was therefore performed for definitive diagnosis and possible pleurodesis. Thoracoscopy revealed dense fibrous bands throughout the right lung. This fibrosis prevented the middle and lower lobes from expanding completely and limited expansion of the right upper lobe. The parietal pleura was stripped and decortication was attempted; however, the lung did not completely reexpand because of extensive residual fibrous adhesions. Multiple biopsies of right lung and parietal pleura all showed noncaseating granulomas. After the surgical procedure, the pleural effusion resolved. The patient had a residual small loculated right pneumothorax and her right middle and lower lung lobes remained consolidated. Clinically, the patient noted marked improvement in her dyspnea.

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