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\begin{document}

\title{A Rapidly Progressing Pleural Effusion within 24 Hours: A Case Report}



\author[1]{Bassem  Alhariri}%
\author[1]{Ayisha  Ameen}%
\author[1]{Abdulqadir Nashwan}%
\affil[1]{Hamad Medical Corporation}%


\vspace{-1em}



  
  \date{June 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Patients with pleural effusion are mostly presenting with shortness of
breath and pleuritic chest pain. This report describes a case of PE who
presented with left shoulder pain and was found to have rapidly
accumulating massive effusion within 24 hours of presentation.
Thoracocentesis was performed a showed an exudative picture%
\end{abstract}%



\sloppy


Short title: A Rapidly Progressing Pleural Effusion

\textbf{Bassem N. Alhariri\textsuperscript{1}, Ayisha
Ameen\textsuperscript{1}, Abdulqadir J. Nashwan\textsuperscript{2}}

1. Department of Medicine, Hazm Mebaireek General Hospital (HMGH), Hamad
Medical Corporation (HMC), Doha, Qatar

2. Department of Nursing, Hazm Mebaireek General Hospital (HMGH), Hamad
Medical Corporation (HMC), Doha, Qatar

Corresponding author:

Mr. Abdulqadir J. Nashwan

anashwan@hamad.qa

Tel: (+974) 40240487

Mob: (+974) 66473549

P.O.Box 3050 Doha, Qatar

\textbf{Abstract}

Patients with pleural effusion are mostly presenting with shortness of
breath and pleuritic chest pain. This report describes a case of PE who
presented with left shoulder pain and was found to have rapidly
accumulating massive effusion within 24 hours of presentation.
Thoracocentesis was performed a showed an exudative picture.

\textbf{Keywords\emph{:}} massive pleural effusion; thoracocentesis;
exudative effusion; complicated parapneumonic effusion

\textbf{Key Clinical Message}

Patients can present with atypical symptoms on admission but may develop
massive parapneumonic pleural effusion within a short time that would
need definite management via urgent chest tube placement.

\textbf{BACKGROUND}

A pleural effusion (PE) occurs due to a disturbance in the balance
between pleural fluid (PF) formation and removal.\textsuperscript{1} It
does not arise as a disease by itself; instead is an outcome of
underlying pathology. Therefore, diagnosing PE requires a physician to
determine its cause to treat PE appropriately. Still, in nearly 20\% of
cases, the etiology of PE remains unclear. Therefore, a careful history
with good clinical examination should aid in diagnosing, especially in
patients with atypical presentations. Thoracocentesis is the crucial
step to determine the various etiologies. Considering the PF
biochemistry, cytology, and signs and symptoms; PE diagnosis can be
established in the vast majority of the cases.\textsuperscript{2} PF
analysis can be classified as exudative or transudative. Treating the
underlying cause is the typical management strategy for transudative
effusions.

Massive PE refers to an effusion that fills almost all the hemithorax. A
prospective study was conducted to establish the most common causes of
pleural effusions. Malignant effusion is the leading cause of massive
effusion, followed by PE secondary to~cirrhosis. On the other hand,
massive pleural effusions were far less likely to be caused by
congestive heart failure or infections.\textsuperscript{3} The study
added to the growing body of evidence that, whatever the source, a
substantial, refractory PE, whether transudate or exudate, symptomatic
relief could be established by drainage.

\textbf{CASE PRESENTATION}

A 44-year-old ex-smoker with no known co-morbidities arrived at our
emergency room with a one-week complaint of left-sided chest discomfort
and left shoulder pain. The pain was gradual in onset and continuous in
nature, radiating to the shoulder. The pain increased while deep
breathing and on movements. The pain was not relieved by any
medications. The patient complained of fever at night and dry cough, and
some loss of appetite but no history of shortness of breath, productive
cough, no night sweats, no history of significant weight loss. He denied
known TB contact and any history of TB. No other history of any
traumatic event (Table 1). The patient was afebrile on examination, with
a heart rate (HR) of 90 beats per minute and blood pressure (BP) of
130/73 mmHg, respiratory rate (RR) of 19 breaths per minute, and an
oxygen saturation (O\textsubscript{2} sat) of 100 percent on room air.
No clubbing or supraclavicular lymphadenopathy On examination of the
respiratory system, there was no visible deformity, no tenderness on
palpation, the percussion note was dull on the lower left side of the
chest, and the percussion note was dull on the on auscultation decreased
air entry on the left side with left basal crackles.

Examination of the left shoulder joint showed no tenderness and a normal
range of movements. The remaining systemic examination, including
cardiovascular, neurological, and gastrointestinal exam, was
unremarkable. A chest x-ray (CXR) (Figure 1) was performed, which showed
a mild/moderate amount of left-sided PE with underlying atelectasis. The
diagnosis of left-sided PE was made, and the patient was started on
antibiotics empirically as a case of parapneumonic effusion. Diagnostic
PF aspiration was done under septic conditions, and workup was sent for
PF analysis to determine the cause of the effusion without typical
respiratory symptoms. The patient was kept on isolation is suspicion of
TB. Within the next 24 hours; the patient developed worsening chest pain
on the left side, shortness of breath, and desaturation. A repeated CXR
(Figure 2) was performed and compared with the previous CXR; there is a
considerable interval increasing amount of PE with
collapse/consolidation left lung. In the account of thoracocentesis done
the previous day, traumatic hemothorax was suspected but was ruled out
as there was no drop in hemoglobin. The diagnosis of massive PE on the
left side that had rapidly progressed over 24 hours, with worsening
chest symptoms, was made. An urgent chest drain was inserted under
ultrasound guidance, and drainage was done. Following this, a CT chest
was done (Figure 3), and it showed improvement in the PE and no evidence
of empyema or abscess formation. The patient started feeling better with
the chest drain in place, and he drained. He improved clinically, and
the inflammatory markers improved from admission. The PF analysis showed
an exudative picture with a neutrophilic predominance (Table 2). PF
cultures were negative. Work up for TB and malignancy were negative.

On Day 9, after the chest tube was inserted, the drainage of fluid was
nil. A repeat CXR was done, and it showed resolution of PE, the chest
tube was removed, and the patient was discharged on antibiotics for a
total of 21 days, and an outpatient follow-up appointment with the
pulmonologist was given.

\textbf{DISCUSSION}

The pleural sac is a compartment typically filled with a thin layer of
fluid known as pleural fluid, which acts as a lubricant and helps reduce
friction between the parietal and visceral pleural lining surfaces
during respiration.\textsuperscript{4} An accumulation of fluid occurs
because of an imbalance in the rate of production and drainage of fluid
due to changes in many local factors.\textsuperscript{4}

The typical presentation of a case of PE may include the pleuritic type
of chest pain, which indicates inflammation of the pleura, with the pain
increasing on movement and respiration with some associated shortness of
breath and dry cough. In contrast, the patient presented with only
left-sided shoulder pain with no respiratory symptoms in this case. As a
clinician, the underlying PE may present with these atypical symptoms
and should not be simply mistaken for musculoskeletal pain. PE should be
on the top of the list of differentials. An underlying undiagnosed
rapidly accumulating PE can, in turn, lead to rapid deterioration of the
patient.

The first step in determining the cause of a PE in cases where clinical
history does not correlate, but PE is evident on clinical imaging is to
perform a diagnostic thoracocentesis; this will help a clinician to
differentiate if the PE is transudative or exudative. However,
diagnostic thoracentesis is not required in patients with a small
quantity of PF (\textless{}500 cc) and a definite diagnosis (e.g., viral
pleurisy) or in patients with heart failure (HF), obvious on clinical
examination but no unusual findings.\textsuperscript{5}

In patients with an exudative PE, like the case we are discussing here,
Further evaluation is needed to determine the underlying pathology
affecting the pleura leading to the PE. Lactic Acid Dehydrogenase (LDH)
and serum protein levels in the PF and serum are used to confirm an
exudative effusion diagnosis. The Light's criteria are the most widely
used criterion for distinguishing between exudative and transudative
effusions.\textsuperscript{6,7}

According to the lights criteria; the following can be calculated:

\begin{itemize}
\tightlist
\item
  Ratio between PF protein and serum protein \textgreater{} 0.5;
\item
  Ratio between PF LDH and serum LDH \textgreater{} 0.6;
\item
  LDH in PF is more than two-third of the upper limit of serum LDH.
\end{itemize}

When one of the three conditions is satisfied, the effusion is
exudative, as in this example. A variety of conditions can cause
exudative effusions, and their care can be difficult since they
frequently necessitate surgical interventions in addition to the medical
management.\textsuperscript{8}

What strikes the most, in this case, is that how the patient initially
on presentation had mild PE and needed only medical treatment for his
underlying asymptomatic pneumonia. However, within the next 24 hours,
the patient started to reaccumulate fluid in his pleural space, which
leads to his sudden clinical deterioration, which required the urgent
need for chest tube placement and drainage under interventional
radiology guidance.

Massive pleural effusions are a common manifestation of pulmonary
tuberculosis, \textsuperscript{9} or an underlying malignancy. It has
been reported in malignancies of different origins, the most frequent
being ovarian carcinoma, sarcomas, mesotheliomas, and pancreatic
adenocarcinomas. Some cases of massive PE, although rare are reported
even in patients with pancreatic pleural fistulas, alcohol-induced
pancreatitis and sarcoidosis.\textsuperscript{10}

In our patient, the rapidly developing and reaccumulating PF raised the
suspicion for any underlying malignancy or TB as statistics prove it to
be the most common pathological cause, but the diagnostic pleural
tapping in this patient ruled out these causes and the workup for any
other potential cause was not supported by further investigations that
were done.

Therefore, the diagnosis of massive parapneumonic effusion was made do
the neutrophilic predominant picture of the thoracocentesis, which was
complicated with drainage via a chest tube, although this is rare in
literature to accumulate within a short period of time rapidly.

\textbf{CONCLUSION}

Clinicians and pulmonologists must be aware of the potential atypical
presentations of PE for timely patient management. A high index of
suspicion must be maintained for patients with left shoulder pain who
can have an underlying collection of fluid in their pleural space,
leading to rapid deterioration due to desaturation.

\textbf{Abbreviations}

PE: Pleural Effusion

PF: Pleural Fluid

LDH: Lactic Acid Dehydrogenase

\textbf{Declarations}

\textbf{Ethics approval and consent to participate}

The article describes a case report. Therefore, no additional permission
from our Ethics Committee was required.

\textbf{Consent for publication}

The consent for publication was obtained.

\textbf{Availability of data and material}

All data generated or analyzed during this study are included in this
published article.

\textbf{Competing interests}

The authors declare that they have no competing interests.

\textbf{Funding}

This study was not funded.

\textbf{Authors' contributions}

BNA, AYA, AJN: Data Collection, Literature Search, Manuscript
Preparation

All authors read and approved the final manuscript

\textbf{Acknowledgments}

We thank the patient for allowing us to share his case. Open Access
funding provided by the Qatar National Library

\textbf{References}

1. Karkhanis VS, Joshi JM. Pleural effusion: diagnosis, treatment, and
management. \emph{Open access emergency medicine: OAEM.} 2012;4:31.

2. Collins TR, Sahn SA. Thoracocentesis: clinical value, complications,
technical problems, and patient experience.
\emph{Chest.}1987;91(6):817-822.

3. Jim\selectlanguage{ngerman}énez D, Díaz G, Gil D, et al. Etiology and prognostic significance
of massive pleural effusions. \emph{Respiratory
medicine.}2005;99(9):1183-1187.

4. Koppurapu V, Meena N. A review of the management of complex
para-pneumonic effusion in adults. \emph{Journal of thoracic
disease.}2017;9(7):2135.

5. Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo
J.\emph{Harrison's principles of internal medicine, 19e.} Vol 1:
Mcgraw-hill New York, NY, USA:; 2015.

6. Light RW, Macgregor MI, Luchsinger PC, BALL JR WC. Pleural effusions:
the diagnostic separation of transudates and exudates. \emph{Annals of
internal medicine.} 1972;77(4):507-513.

7. Light RW. The Light criteria: the beginning and why they are useful
40 years later. \emph{Clinics in chest medicine.} 2013;34(1):21-26.

8. Jany B, Welte T. Pleural effusion in adults---etiology, diagnosis,
and treatment. \emph{Deutsches Ärzteblatt
International.}2019;116(21):377.

9. Soe Z, Shwe WH, Moe S. A study on tuberculous pleural
effusion.\emph{International Journal of Collaborative Research on
Internal Medicine \& Public Health.} 2010;2(3):0-0.

10. Sherani K, Alnuaimi A, Vakil A, Cervellione K, Kulsum U, Shalonov A.
Massive Pleural Effusion as an Initial Manifestation of
Sarcoidosis.\emph{Chest.} 2016;149(4):A225.

\textbf{Tables and Figures}

Table 1. Laboratory investigations upon admission

Table 2. Pleural fluid analysis

Figure 1. left-sided pleural effusion with underlying atelectasis.

Figure 2. a large amount of pleural effusion on the left side with the
collapse of lung parenchyma

Figure 3. mild pleural effusion on the left side no evidence of
collection

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