Gelatinous Pleural Effusion: A Diagnostic Challenge for Pleural Mesothelioma in an 80-Year-Old Man

Our plain-English summary of Gelatinous Pleural Effusion: A Diagnostic Challenge for Pleural Mesothelioma in an 80-Year-Old Man, by A.M. Ibnian, O.U. Khan, R. Chan, et al (The American Journal of Case Reports, 2023).

The study

• Authors: A.M. Ibnian, O.U. Khan, R. Chan, U. Bangalore Lakshminarayana, F. Kiran, S. Abed, R. Abbas, A. Amir, N.K. Al-Kofahi
• Journal: The American Journal of Case Reports
• Published: 2023;24:e941263
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND Gelatinous pleural effusion, due to raised hyaluronic acid, can be associated with pleural infection and malignancies, such as tuberculosis, metastatic pleural disease, and mesothelioma. This report is of an 80-year-old man presenting with a gelatinous pleural effusion and diagnosis of pleural mesothelioma. CASE REPORT An 80-year-old man with diabetes mellitus, ischemic heart disease, metastatic prostate cancer, 30-pack-year smoking history, and 5-year history of asbestos exposure (during his 30s), presented with a 4-week history of breathlessness and was found to have right-sided pleural effusion. Thoracic computed tomography (CT) showed mild right-sided pleural thickening. Pleural tap revealed exudative fluid, with a pH of 7.4, and unremarkable cytology and microbiology analyses. The patient was treated for pneumonia and para-pneumonic effusion and discharged home. He came back 5 weeks later with worsening of symptoms and re-accumulation of pleural fluid. Repeated thorax CT showed extensive right-sided pleural lobular thickening. Pleural tap again yielded an exudative fluid, with a pH of 7.37. Cytology and microbiology did not reveal any positive signs for malignancy or infection. This time the pleural fluid appeared gelatinous in consistency. Pleural biopsy showed atypical epithelioid mesothelial cells arranged in trabeculae, with a tubulo-papillary configuration. Also, immunohistochemistry panel showed tumor cells expressed calretinin, EMA, WT1, and D2-40, with negative TTF1, CEA, and BerEp4. Final diagnosis was epithelioid mesothelioma. CONCLUSIONS This report has shown that a gelatinous pleural effusion can be associated with malignant and inflammatory pleural diseases. In this case, imaging and pleural biopsy with histopathology confirmed a diagnosis of pleural mesothelioma.

In plain English

This case report described an 80-year-old man in Grimsby, United Kingdom, diagnosed with pleural mesothelioma, a cancer of the lining around the lung. He had heart disease, diabetes, and prostate cancer that had spread to the spine. He had smoked (30 pack-years), and the authors noted a brief history of asbestos exposure from working in the docks for 5 years in his 30s. He first came in breathless, with fluid around the right lung. Tests on the fluid showed no cancer cells and grew no germs, and he was treated as having fluid linked to pneumonia. Five weeks later the fluid had returned, and when drawn out it immediately turned jelly-like. Repeat fluid tests gave similar results, and antibiotics for suspected infection did not help. A new CT scan showed the right lung lining had thickened considerably. A biopsy with special staining confirmed epithelioid mesothelioma. Because of his poor condition he was not offered chemotherapy, and he died a couple of weeks after discharge. The authors concluded that gelatinous fluid can be associated with pleural disease, including mesothelioma.

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 (a single patient)
• Who was studied: One 80-year-old man with ischemic heart disease, diabetes mellitus, and prostate carcinoma with spread to the spine, seen at the Respiratory Medicine Department, Diana Princess of Wales Hospital, Grimsby, United Kingdom
• Exposure: A brief history of asbestos exposure from working in the docks for 5 years in his 30s (fiber type not stated). He was also a smoker (30 pack-years).
• Main results:
  • At first presentation, the fluid drained from the right side of the chest was exudative with a pH of 7.4. Cytology showed inflammatory and reactive mesothelial cells and no malignant cells. The fluid grew no microbes, including tuberculosis. He was treated as a case of para-pneumonic effusion.
  • When he returned five weeks later with re-accumulated fluid, the fluid became jelly-like immediately after it was drawn out. The drain filled no more than 50 mL despite a large effusion on ultrasound. Repeat biochemistry, cytology and microbiology gave results similar to the first time.
  • After antibiotics for suspected partially treated empyema did not improve inflammatory markers, a repeat CT showed lobular thickening of the right pleura with rapid progression over a period of 8 weeks.
  • A CT-guided biopsy showed an epithelioid cell lesion. Immunohistochemistry was positive for the mesothelial markers calretinin, EMA, Wilms Tumor 1 and D-240, and negative for the adenocarcinoma markers TTF1, CEA and BerEp4. This confirmed primary epithelioid malignant pleural mesothelioma.
  • With a performance status of 3 and his other illnesses, he was judged not fit for first-line chemotherapy, and further pleural procedures were judged likely to cause more harm than benefit. He died a couple of weeks after discharge.
• The authors' conclusion: The authors concluded that a gelatinous pleural effusion can be associated with pleural disease, including malignant pleural mesothelioma, and that in this case imaging and pleural biopsy with histopathology confirmed the diagnosis.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Pleural Mesothelioma, Hyaluronic Acid, Mesothelioma, Asbestos Exposure, Pleural Thickening, Cytology, Thorax.

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• Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions in Denmark — F. Willendrup, U. Bodtger, et al. (2014)
• Retrospective investigation on diagnostic process for benign asbestos pleural effusion (BAPE) using checklist — T. Kishimoto, N. Fujimoto, et al. (2020)
• Diagnostic utility of pleural fluid eosinophilia — M. Adelman, S.M. Albelda, et al. (1984)
• A retrospective study on radiological findings of diffuse pleural thickening with benign asbestos pleural effusion in Japanese cases — T. Kishimoto, K. Kato, et al. (2022)

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