SG IM FO RUM 2016; 39 (12 ) SHARE MORNING REPORT A SICK Veteran David Bittleman, MD (presenter), and Rebecca Sell, MD, (discussant, in italic)

Dr. Bittleman is a clinical associate professor in the department of general internal medicine at the VA and UCSD ([email protected]); Dr. Sell is a clinical assistant professor in the division of pulmonary and critical care medicine and an associate program director for the internal medicine residency program at UCSD ([email protected]).

he patient, a 66-year-old African- An elevated ESR should prompt a or more of the following: pleural TAmerican Vietnam War veteran, search for a serious underlying cause. fluid total protein/serum total pro - presented to the outpatient clinic In one large retrospective review, an tein>0.5, in this case 0.6, pleural with loss of appetite and an uninten - ESR of more than 100 mm/hr was fluid LDH/serum LDH>2/3, the tional weight loss of three pounds. not sensitive but was highly specific upper limit of normal for serum He has a history of hypertension, hy - for systemic illnesses: 96% for malig - LDH. The pleural fluid LDH of 410 perlipidemia, alcoholism, tobacco nancies, 97% for infection, and more IU/L is well above 2/3 of the upper use, and old, treated pulmonary tu - than 99% as a “sickness” index. The of normal of the serum LDH. An al - berculosis. While in the army he was term sickness index suggests a sim - ternative way to determine exudate treated for pulmonary tuberculosis ple mnemonic. When the sedimenta - includes pleural fluid total protein, with Isoniazid. To our knowledge, tion rate (S) is more than 100 mm/hr, LDH, and cholesterol (the three-test this was his only prescribed medica - consider infection and inflammatory rule). A pleural fluid cholesterol>45 tion while in the army. His daily med - conditions (I), cancer (C), kidney dis - mg/dl suggests an exudate. ications include atorvastatin (10 mg), ease (K). 1 With an elevated ESR, Despite the relatively low cell Lisinopril (40 mg), and fluticasone weight loss, and a history of smoking count, the neutrophilic predominance nasal spray. The patient’s family his - and of tuberculosis, I would order a suggests an acute response, such as tory is notable only for diabetes. He chest X-ray . acute pneumonia or complicated effu - is single and has no children. A chest X-ray that was completed sion. A predominance of mononuclear On review of systems, he re - a few weeks after the clinic visit re - cells, especially small lymphocytes, ported post-nasal drainage, but denied vealed a large, left pleural effusion, would favor cancer or tuberculosis. fevers, chills, cough, or abdominal obscuring the left lower- and mid- The presence of the low pleural fluid pain. He felt his appetite was improv - lung zones. The right lung was clear. glucose concentration of less than 60 ing since he had cut back on alcohol. There was a curvilinear opacity with mg/dL suggests a complicated parap - The patient was a thin appealing central lucency in the left lung apex. neumonic effusion, tuberculosis, or 1 man in no acute distress. He was A unilateral pleural effusion along malignancy. 2 afebrile, BP 125/84, pulse 106 and with parenchymal opacities raise the This patient’s pleural fluid is regular, respiratory rate 16, BMI 22. possibility of empyema/complicated consistent with an exudate, and has There was exudate and cobble-ston - parapneumonic effusion, lung can - features that are suggestive of malig - ing in his posterior pharynx. Lungs cer, tuberculosis, or even congestive nancy, tuberculosis, or parapneu - were clear without wheezing. Heart heart failure. The next step is to per - monic infection. Additional work-up exam was regular without a mur - form thoracentesis and pleural fluid s indicated. Fewer than 40% of pa - mur. Abdomen was soft and non- analysis . tients with pleural tuberculosis have tender without hepatosplenomegaly. Thoracentesis was performed positive cultures, and therefore other There was no peripheral edema or yielding pleural fluid that was slightly clues, such as adenosine deaminase lymphadenopathy. turbid; cell count 84 cells/uL with 60% levels, could be sent. A pleural fluid Basic labs were ordered, including neutrophils and 39% lymphocytes and adenosine deaminase level above 40 a complete blood count, comprehen - no red blood cells. The pleural fluid U/L is highly suggestive of tuberculo - sive metabolic panel, urinalysis, and glucose was 38mg/dL, cholesterol 46 sis pleural effusion .2 sedimentation rate. The white blood mg/dl, total protein 4.9 g/dL, and LDH Our patient’s pleural fluid adeno - cell count (WBC) was 6,800 cells/mL 410 IU/L. Serum total protein was 7.6 sine deaminase level was only 4.8 with a normal differential and the he - g/dL and LDH was 176 IU/L (range: U/L, well below the level suggestive moglobin was slightly low at 11.9 serum LDH<190 IU/L). of tuberculosis pleuritis. Pleural fluid g/dL. The basic metabolic panel and Light’s Criteria is used to catego - cultures, microscopic stains for the tu - liver function tests were within nor - rize pleural fluid as exudative or tran - berculosis bacteria, and cytology were mal limits. The sedimentation rate sudative, an important distinction for all performed and all tested negative. (ESR) was markedly elevated at 110 diagnosis and management. An ex - A second thoracentesis yielded simi - mm/hr (normal 0–10 mm/hr). udative pleural effusion requires one continued on page 2 SHARE

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lar results; however, the second cell usually unilateral, lymphocytic pre - • determine whether the fluid count was 90% lymphocyte predomi - dominant exudative effusions, seen is an exudate or transudate. If nant. Because of ongoing concern for in concert with lung opacities. Com - exudative, check cell count, underlying malignancy, the patient un - mon presenting symptoms are fever glucose levels, cytology, and derwent a PET/CT scan that identified and malaise. Diagnosis begins with cultures; consider markers for a PET avid left upper lobe nodule. A a thoracentesis and may require a tuberculosis; and CT-guided transthoracic fine needle pleural biopsy or a bronchoscopy, • realize that tuberculosis can be aspiration revealed granulomas. Given as AFB cultures are rarely positive. difficult to diagnose and that the concern for underlying tuberculo - Treatment is the same as for active more advanced techniques sis, the county health department be - pulmonary tuberculosis. including bronchoscopy, came involved, and the patient was Important points to remember bronchoalveolar lavage, or pleural directly admitted to the hospital for include the following: biopsy may be required . bronchoscopy with bronchoalvelolar lavage (BAL). Acid fast stain and MTB • think of ordering a sedimentation References complex probe of the BAL sample rate if concerned about a serious 1. Fincher RM, Page MI. Clinical were positive for tuberculosis. He infection or malignancy. If the significance of extreme elevation was started on a four (4) drug regi - ESR is more than 100 mm/hr, of the erythrocyte sedimentation men with Isoniazid 300mg, Rifampin you will very likely find a serious rate. Arch Intern Med 1986; 600mg, Pyrazinamide 1500mg, etiology; 146(8):1581-3. Ethambutol 1200mg, and pyridoxine. • a unilateral pleural effusion 2. Light RW. Clinical practice. Tuberculous pleural effusions can should always prompt further Pleural effusion. N Engl J Med occur in the setting of primary or re - evaluation, usually with 2002; 346(25):1971-77. activation tuberculosis. These are thoracentesis; SGIM

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SG IM FO RUM 2016; 39 (12 )