HPI: 47 y/o F, no PMHx, sent in from UC for R sided pleural effusion

3 weeks gradually worsening SOB associated w/ dry cough

Worse with exertion and laying flat

No recent fevers, URIx, weight loss, changes in appetite 

Physical Exam

BP 143/67  | Pulse 96 | Temp 97.2 °F (36.2 °C) (Oral)  | Resp (!) 32 | SpO2 96%

Cardio: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.

Pulm: Moderate respiratory distress w/ increased work of breathing and tachypnea. Decreased breath sounds throughout the entire R lung field. No wheezing or rhonchi 

Abd: Soft, non-tender

Portable CXR: Large right pleural effusion with mediastinal shift to the left. Complete opacification of the right hemithorax.

POCUS cardiac / lungs: Large amount of fluid R pleural space

DDx:

Malignancy

Parapneumonic effusion

Low risk for PE - PERC negative - and would be unlikely to cause such a large effusion. 

No history of CHF or cirrhosis to cause transudate effusion. 

No hx trauma to suspect hemorrhage

Work up / Plan: 

CBC, BMP, coags, urine preg, EKG

Pigtail catheter for diagnostic and therapeutic pleurocentesis  

Procedure: Pigtail catheter placed with immediate drainage of 2L of straw colored fluid

Follow up CXR: Interval placement of a right basilar pigtail catheter. Interval minimal improvement in aeration of the right lung compared to prior study

 Further Steps → CT chest w/ contrast

Heterogeneous, predominantly cystic anterior mediastinal lesion containing fluid, fat, soft tissue, and calcium. Findings are compatible with a mature teratoma. Moderate right pleural effusion, which may be seen with ruptured mature teratoma. 

Outcome

CTAP w/ contrast: no evidence of intra-abdominal or ovarian/GYN masses

bHCG and AFP negative. Normal LDH, TSH. 

Thoracic surgery - resection of anterior mediastinal mass

Cytology - Mature teratoma

Pearls 

Light’s Criteria - Exudate vs Transudate → 1+ of the below = exudate

Pleural fluid: serum protein > 0.5

Pleural fluid: serum LDH > 0.6

Pleural fluid LDH > ⅔ upper limit normal serum

Exudates: inflammation and increased capillary permeability (ie: PNA, cancer, TB, viral infection, PE, autoimmune)

Transudates: increased hydrostatic pressure OR low oncotic pressure (ie: CHF, cirrhosis, nephrotic syndrome, PE, hypoalbuminemia)