Case report: Steroid responsive mesothelioma-related pleural effusion

Our plain-English summary of Case report: Steroid responsive mesothelioma-related pleural effusion, by M. Shehata, F. Zaid, P. Ottaviano, et al (Respiratory Medicine Case Reports, 2019).

The study

• Authors: M. Shehata, F. Zaid, P. Ottaviano, Y. Shweihat, N. Munn
• Journal: Respiratory Medicine Case Reports
• Published: 2019;26:131-135
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is an asbestos-related tumor arising in the pleural cavity. Symptoms reflect extension of disease and include shortness of breath and chest pain. Unexplained pleural effusion and pleural pain in patients exposed to asbestos should raise the suspicion of MPM. The most common radiologic presentation is ipsilateral pleural effusion with or without pleural thickening or a mass. Thoracoscopic biopsy remains the most appropriate procedure for definitive diagnosis of mesothelioma. Despite advancement in diagnostic procedures and biomolecular research, this tumor nevertheless has poor prognosis. Mesothelioma remains a diagnostic and therapeutic challenge and is likely to remain one in the years to come. Here we present the first reported case of steroid treatment responsive pleural effusion in a 72 year-old-male that initially was misdiagnosed as rheumatoid related effusion. However, Pleuroscopy with biopsy revealed mesothelioma.

In plain English

This case report described one patient, a 72-year-old man who was a retired plumber and former veteran and had quit smoking 38 years earlier. The article does not describe any asbestos exposure history for him. He had repeated visits for right-sided pleuritic chest pain with a recurring right pleural effusion (fluid around the lung). The effusion improved dramatically with steroids several times and returned when steroids were tapered. Positive rheumatoid factor and strongly positive anti-cyclic citrullinated peptide tests led doctors to suspect a rheumatoid-related effusion. The fluid was first sampled about four months after he first came to hospital, and cytology later showed atypical cells. Pleuroscopy biopsies showed a tumor consistent with epithelioid mesothelioma. A PET scan showed disease limited to the right pleura, and the disease was classified as stage 1. The authors described it as the first reported case of steroid-responsive pleural effusion due to mesothelioma. They said the repeated steroid response and the inability to sample fluid early made diagnosis challenging.

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 (single patient)
• Who was studied: One 72-year-old male patient, a retired plumber and former veteran, with no significant past medical history apart from hyperlipidemia, who had quit smoking 38 years earlier. The authors are affiliated with Marshall University and a Veterans Administration Medical Center in Huntington, WV, USA.
• Exposure: The article gives the patient's occupation as retired plumber. It does not report any asbestos exposure history, fiber type or dose for this patient.
• Main results:
  • The patient's right pleural effusion improved dramatically on steroids and his pleurisy symptoms returned when steroids were tapered, on more than one occasion.
  • Connective tissue disease testing showed positive rheumatoid factor and strongly positive anti-cyclic citrullinated peptide (level above 70), and the effusion was at first thought to be rheumatoid-related.
  • The first thoracentesis was done about 4 months after initial presentation, while the patient was still taking 30 mg prednisone, and its fluid studies were inconclusive.
  • Repeat thoracentesis showed exudative fluid with a fluid glucose of 137 mg/dl, which the authors said was atypical of rheumatoid pleural effusion. Cytology showed atypical cells on both thoracenteses.
  • Pleuroscopy biopsies of the parietal pleura showed a tumor consistent with epithelioid mesothelioma. The tumor cells were positive for calretinin, CK5/6, CK7 and WT-1 and negative for Napsin-A, CK20 and TTF-1.
  • The PET scan showed disease limited to the right pleura. The disease was classified as stage 1 under UICC and AJCC staging, and the patient was referred to a specialized cancer center.
• The authors' conclusion: The authors presented this as the first reported case of steroid-responsive pleural effusion due to mesothelioma, initially misdiagnosed as rheumatoid-related effusion. They said the repeated dramatic response to steroids and the inability to do thoracentesis early made the diagnosis challenging.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pleural Effusion, Pleural Mesothelioma, Pleural Cavity, Pleural Thickening, Thoracoscopic Biopsy, Prognosis, Biopsy.

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