A 50-year-old man with no prior medical history sought medical attention for flu

Question

A 50-year-old man with no prior medical history sought medical attention for flu-like symptoms. The patient has a current history significant for a persistent cough and fever of 2 weeks duration. Antibiotic therapy was prescribed by the physician and the patient was sent home with the directive to increase fluid intake and bed rest.

                                    

After 3 days, severe left-sided chest pain and shortness of breath developed. The patient was brought to the emergency room. A radiologic test revealed a collection of fluid in the left chest cavity. The fluid was withdrawn for analysis and a simultaneous peripheral blood specimen was collected. The laboratory values obtained on the chest fluid and peripheral blood are listed in the table below:

Serum Total Protein

6.0 g/dL

Serum LDH

50 U/L

Chest Fluid Appearance

Thick, turbid, yellow

Chest Fluid Total Protein

4.5 g/dL

Chest Fluid LDH

40 U/L

LDH Ratio

0.8

Chest Fluid WBC count

20,000/L

Chest Fluid Differential

Neutrophils 90%

Macrophages 10%

Many degenerating cells present

What is the name of the fluid collected from the chest cavity?

What is the name of the procedure used to collect the fluid from the chest cavity?

Is the fluid considered a transudate or an exudate?

Why did you classify the fluid as a transudate or an exudate?

Is the fluid chylous? Why or why not?

What additional testing should be performed on this specimen to diagnose the cause of the patient’s illness? (More than one answer is correct; just make sure your response is logical!)

Serum Total Protein

6.0 g/dL

Serum LDH

50 U/L

Chest Fluid Appearance

Thick, turbid, yellow

Chest Fluid Total Protein

4.5 g/dL

Chest Fluid LDH

40 U/L

LDH Ratio

0.8

Chest Fluid WBC count

20,000/L

Chest Fluid Differential

Neutrophils 90%

Macrophages 10%

Many degenerating cells present

Explanation / Answer

1. What is the name of the fluid collected from the chest cavity? Ans. Pleural fluid

Explanation: Lungs are covered by serous pleural membranes which contains pleural fluid that act as a lubricant(surfactant) for lungs to ease respiration. The effusion(accumulation) of fluid commonly called as water on the lung is an excessive buildup of fluid in the space between lungs and chest cavity causing flu like symptoms, fever, shortness of breath, difficulty in breathing, pain in chest. Causes of pleural effusions include cancers like lung and breast cancer, congestive heart failure, cirrhosis, pulmonary embolism, open heart surgery complications, pneumonia, severe kidney diseases etc

2. What is the name of the procedure used to collect the fluid from the chest cavity? Ans. Thoracentesis

Explanation: Thoracentesis also known as pleural tap is a procedure which involves where too much of pleural fluid is drained by using a catheter and ultrasound guiding machine to place the needle correctly

3. Is the fluid considered a transudate or an exudate? Exudate

Exudate represent a increased capillary permeability, decrease lymphatic resorption, infections like bacterial, tuberculosis, viral, Neoplasms, Rheumatoid disease, lupus erythematosus, trauma, pancreatitis, bile peritonitis

4. Why did you classify the fluid as a transudate or an exudate? Basing on Light's criteria

Explanation: Lights criteria states that a fluid is considered as exudate if:

i. Effusion protein/ serum protein ratio is greater than 0.5 (here the value is 4.5/6.5= 0.692. Hence exudate)

ii. Effusion lactate dehydrogenase(LDH)/ serum LDH ratio is greater than 0.6(here the value is 0.8. Hence exudate)

5. Is the fluid chylous? Why or why not? Chylous

The color of the fluid is thick, turbid and yellow, presence of neutrophils, macrophages, high leucocyte count(>1000mu/L) and more importantly 90% of all exudates are chylous in nature. Hence it is classified as chylous

6. What additional testing should be performed on this specimen to diagnose the cause of the patient’s illness?

1. Gram staining to detect the presence of bacteria to ascertain whether it is pneumonia or not

2. Cytology - A cytocentrifuged sample would reveal the presence of tumor cells

3. Fungal tests- To determine fungal infection

4. Adenosine deaminase- To determine Mycobacterium tuberculosis infection

5. Triglyceride levels- To determine leakage from the lymphatic system

6. Tumor markers-Carcinoebryonic antigen(CEA) to determine cancer

7. Amylase levels- To determine pancreatitis, esophageal injury or malignancy

8. Glucose levels-Rheumatoid arthritis

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