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Case based discussions
Going with the flow: diagnosing a lymphocyte-rich pleural effusion
  1. Catherine Hyams1,
  2. Megan H Jenkins2,
  3. Richard Daly3,
  4. Izak C Heys2,
  5. Nicholas A Maskell1,4
  1. 1 Academic Respiratory Unit, Department of Clinical Sciences, University of Bristol, Bristol, UK
  2. 2 Department of Infectious Diseases, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  3. 3 Department of Histopathology, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  4. 4 North Bristol Lung Centre, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  1. Correspondence to Dr Catherine Hyams, Academic Respiratory Unit, University of Bristol, Bristol BS8 1TH, UK; catherine.hyams{at}bristol.ac.uk

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Dr Catherine Hyams (CH), Respiratory Registrar

Presentation to pleural clinic

A 52-year-old Medical Secretary was seen in Pleural Outpatient Clinic as follow-up after hospital discharge from the Surgical team 3 weeks previously. Since discharge, the patient had progressive breathlessness with an exercise tolerance of 10 m (previously unlimited) and noted a mild dry cough. She was a lifelong non-smoker. Fevers, sweats or weight loss were not reported. She had no relevant medical or travel history, with no known exposure to asbestos or other chemical agents. Clinical examination was consistent with a large left-sided pleural effusion, which was confirmed on chest radiograph (figure 1A) and thoracic ultrasound. The chest radiograph also demonstrated infiltrates in the left upper zone.

Figure 1

(A) Chest radiograph on presentation to Respiratory Outpatient Clinic showing moderate left-sided pleural effusion and left upper zone infiltrate. (B) CT showing SL and HP. (C) H&E stained section (×25 magnification) from the splenectomy specimen, demonstrating large geographic areas of non-caseating suppurative granulomata bordered by a palisaded arrangement of histiocytes (highlighted by arrows) and the notable absence of multinucleated giant cells, with background normal splenic parenchyma occupying the rest of the image. (D) Slice of CT scan demonstrating left-sided pleural effusion. (E) Chest radiograph after treatment, with complete resolution of the pleural effusion and lung infiltrate. HP, haemoperitoneum; SL, splenic laceration.

Previous surgical history

The patient originally presented with abdominal pain and non-bloody diarrhoea 4 months prior to her clinic appointment. Routine blood tests were unremarkable, and she was diagnosed with probable infective colitis. She was discharged home with a plan for outpatient colonoscopy if her symptoms continued. Two months following this, the patient re-presented to the surgical team; however, her pain was now epigastric. An abdominal ultrasound was unremarkable, and she was discharged home and her colonoscopy expedited.

The patient was readmitted 48 hours following this second discharge and was haemodynamically unstable with an acute abdomen. …

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Footnotes

  • Twitter @cathyams

  • Contributors All authors (CH, MHJ, RD, ICH and NAM) contributed to the preparation of this manuscript for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval This publication did not require Ethics Approval. Patient consent was sought for publication, and the BMJ Patient Consent Form completed by the patient.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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