Malignant Pleural Effusion And White-Out!

Today we discussed a case of malignant pleural effusion causing complete opacification of a hemithorax. We learned the framework for subacute-chronic dyspnea, discussed the physical exam finding of clubbing, reviewed Light’s Criteria and discussed transudates and exudates. Here is a recap:

Subacute-Chronic Dyspnea DDx:

  • Pulmonary (malignancy falls into all of these categories)
    • Airway
      • bronchitis
      • COPD
      • Asthma
      • Bronchiectasis
      • Foreign body
    • Parenchyma
      • PNA
      • edema
      • atelectasis
      • ILD
    • Vasculature
      • PE
      • pHTN
      • AVMs (HPS can cause these)
    • Pleura
      • Pleural effusion
      • PTX
  • Cardiac
    • Arrhythmia
    • Ischemia
    • Valvular disease
    • Tamponade
    • Constrictive pericarditis
    • Myocarditis
  • Other
    • Anxiety
    • Anemia
    • Reduced PiO2
    • Hypoventilation
    • compensation for metabolic acidosis
    • pregnancy
    • Thyrotoxicosis

DDx for Clubbing:

  • 80% with underlying respiratory disorders
  • 10-15% with miscellaneous disorders
  • Congenital cyanotic heart disease, liver cirrhosis, chronic diarrhea, subacute endocarditis
  • 5-10% hereditary or idiopathic clubbing

Lights Criteria and Pleural Effusions (see this previous blog post for an excellent review)

https://scvmcmed.com/2017/04/17/am-report-32217-pleural-effusion/

DDx For Complete Opacification of a Hemithorax

  • Trachea pulled toward opacified side
    • Pneumonectomy
    • Total lung collapse
    • Pulmonary agenesis
    • Pulmonary hypoplasia
  • Trachea pushed away from the opacified side
    • Pleural effusion
    • Diaphragmatic hernia
    • Large pulmonary mass
  • Trachea remains central in position
  • Consolidation
  • ARDS/pulmonary edema
  • Pleural mass
  • Chest wall mass

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