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Case based discussions
Pleural effusion as a late complication of intravesical BCG treatment
  1. Ailish Nimmo1,
  2. Amy Gray1,
  3. Aarti Patel2,
  4. Joseph MacKenzie1,
  5. Ian Fairbairn1
  1. 1Respiratory Department, Victoria Hospital, Kirkcaldy, UK
  2. 2Histopathology Department, Victoria Hospital, Kirkcaldy, UK
  1. Correspondence to Dr Ailish Nimmo, Victoria Hospital, Hayfield Road, Kirkcaldy KY2 5AH, UK; ailish.nimmo{at}googlemail.com

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Amy Gray (Junior Doctor): An 88-year-old man with a background of transitional cell bladder cancer diagnosed in 2012 was referred to the ambulatory care clinic with a 1-month history of increasing breathlessness. He had constitutional symptoms of fatigue, reduced appetite and weight loss for the past 4 months. There was no history of cough, fever or night sweats. His bladder cancer had been resected in 2013 with pathology confirming this as a G3 pT1 transitional cell cancer (TCC), and there was no evidence of recurrence on surveillance flexible cystoscopies. He had been on maintenance intravesical BCG therapy since this time, last given 8 months previously. Of note, his last BCG instillation had been traumatic with haematuria postprocedure. He was an ex-smoker of 25 years and had worked within manufacturing and sales in the wallpaper industry. He had no known exposure to asbestos or TB and no animal exposure.

He had a chest X-ray, which showed a left-sided pleural effusion taking up 50% of the hemithorax (figure 1). A CT chest was then performed, which confirmed a moderate left-sided pleural effusion and also showed a spiculated 16 mm nodule in the left upper lobe and a spiculated 23 mm nodule in the right upper lobe. These were not present on a previous CT in 2014.

Figure 1

Initial chest X-ray showing large left-sided pleural effusion.

Ian Fairbairn (Respiratory Consultant): In summary, this elderly man with a background of bladder TCC presents with a large left-sided pleural effusion and pulmonary nodules. A unilateral effusion in the presence of pulmonary nodules is more likely to be exudative than transudative in nature, …

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