• pleural disease
• respiratory infection

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.

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, …