A 75 year old male with recurrent unilateral pleural effusion and positive ANA

Our plain-English summary of A 75 year old male with recurrent unilateral pleural effusion and positive ANA, by T. Wallen, N. Jagan, M. Krishnan, et al (Respiratory Medicine Case Reports, 2019).

The study

• Authors: T. Wallen, N. Jagan, M. Krishnan, Z. Depew
• Journal: Respiratory Medicine Case Reports
• Published: 2019;26:301-303
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

This case report describes the clinical course and diagnostic challenges arising in a 75 year old man who initially presented with progressive shortness of breath. Imaging revealed a pleural effusion, which was recurrent following thoracentesis. While his initial workup suggested an autoimmune etiology, further diagnostic testing revealed a diagnosis of malignant pleural mesothelioma. Curiously, the patient had no known asbestos exposure, which is classically associated with acquired mesothelioma. There are a small number of similar cases with a possible overlap between positive autoimmune serologies and mesothelioma; however, the underlying pathophysiology remains elusive. It is the authors' goal to contribute this case to the few cases describing such overlap syndromes.

In plain English

This case report described a 75-year-old lifelong non-smoking contractor with no known asbestos, silica or other environmental exposures who had months of worsening shortness of breath. He had a large right-sided pleural effusion. Doctors drained 3 L of fluid, and cytology was negative. Blood tests were positive for ANA, double-stranded DNA and rheumatoid factor, but he had no other signs or symptoms of lupus, such as rash or joint pain. The effusion was therefore thought to be due to connective tissue disease, and he was given prednisone. The fluid returned within a week, and repeat cytology was again negative for malignant cells. A CT scan showed multiple right-sided pleural masses, and biopsies of the pleura showed the epithelioid subtype of mesothelioma. He refused a pneumonectomy and began carboplatin and pemetrexed chemotherapy. He died while the report was being published. The authors concluded that falsely positive autoimmune blood tests can stand in the way of the diagnosis and that invasive testing should be pursued when suspicion is high. They added that the small number of such cases makes generalizations difficult.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report (one patient)
• Who was studied: One 75-year-old lifelong non-smoking Caucasian man seen at a pulmonology clinic (Creighton University, Omaha, Nebraska, United States); dates of care not given
• Exposure: No known asbestos exposure. The patient worked as a contractor with no known asbestos, silica, or other environmental exposures.
• Main results:
  • At first presentation the patient had a large right-sided pleural effusion. Thoracentesis removed 3 L of fluid, which was exudative and macrophage predominant. Gram stain, culture and cytology were negative.
  • The patient's blood tests showed elevated ESR (52 mm/hr) and CRP (32.7 mg/L), a positive ANA (no titer obtained), double-stranded DNA 15 IU/ml and rheumatoid factor 16 IU/ml. He denied symptoms such as rash, oral ulcers or joint pain, and the authors said he had no other signs or symptoms consistent with SLE.
  • The effusion was thought to be related to connective tissue disease, and the patient was started on empiric prednisone.
  • Within a week the pleural fluid had reaccumulated. On repeat analysis, cultures were sterile and cytology was negative for malignant cells.
  • A chest CT showed multiple pleural masses and nodules in the right hemithorax.
  • Parietal pleural biopsies taken at thoracoscopy showed the epithelioid subtype of mesothelioma (malignant pleural mesothelioma).
  • Needle aspirates of the lymph nodes found reactive cells but no malignant cells at any lymph node station.
  • The patient was judged not a candidate for pleurectomy and was offered pneumonectomy instead. He refused, and chemotherapy with carboplatin and pemetrexed was started.
  • The patient died during the publication process of the report.
• The authors' conclusion: The authors concluded that the diagnosis of malignant pleural mesothelioma is not straightforward, because falsely positive serology can act as a deterrent and pathologists find it hard to tell mesothelioma from benign reactive cells. They said invasive diagnostic tests should be pursued when suspicion is high. They also said non-asbestos mesothelioma has shown clinical and serological overlap with autoimmune disease, but with no consistent unifying pattern so far.
• Limitations the authors state:
  • The authors said that the small number of such cases makes generalizations difficult.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Thoracentesis, Etiology, Pleural Mesothelioma, Asbestos Exposure, Mesothelioma.

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• A Man in His 20s With Cough, Unilateral Pleural Effusion, and Nodular Pleural Thickening — M.A. Sonnick, S. Weisman, et al. (2019)
• Positive FDG-PET/CT of the pleura twenty years after talc pleurodesis: three cases of benign talcoma — T. Vandemoortele, S. Laroumagne, et al. (2014)
• Positive pleural cytology is an indicator for visceral pleural invasion in metastatic pleural effusions — M.E. Froudarakis, J. Plojoux, et al. (2018)
• Multicystic peritoneal mesothelioma in a 29 year old male — P. Cregan, S. Wiley, et al. (1987)

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