Case Report

24 years youngman with Loculated Malignancy Pleural Effusion, Anterior Mediastinal

Mass, New Case of Pulmonary Tuberculosis on Treatment Intensive Phase, Vena Cava
Superior Syndrom Grade II, Cancer Pain

Irma Fitriani
Pulmonology and Respiratory Medicine Department
Medical Faculty of Hasanuddin University
(July, 26th 2022)
 CASE REPORT

Identity :
Name : Mr. IRD
Age : 20 yo
Admission : July, 17th 2022
Room : 3rd floor of IC
Pulmonologist : dr. Nurjannah Lihawa Sp. P (K)

Admission Diagnosis:
1. Massive left pleural effusion
2. Suspect Mediastinal Mass
3. New Case of Pulmonary Tuberculosis on treatment
 History Taking

Chief complain : Shortness of breath

Auto-anamnesis:
Referral patient from Sulbar Hospital with Mediastinum Tumor and
Hemorrhagic pleural Effusion. The patient complain occasional shortness of
breath since 4 month ago and worsening in a month. The patient cannot
sleep in supine position. He also has cough since 4 month ago with white
phlegm. No coughing up blood, history of coughing up blood streak a year
ago. He has occasional left chest pain since a year ago. No fever or or history
of fever. No sweating at night without activity. He has no nausea or vomiting.
No hoarseness. He has a good appetite, but he has weight lose about 10 kg
in 4 month. No complain in urination or defecation.
 History Taking

₋ History of ATT since 6th June 2022 based on positive AFB on May 2022 from Mamuju Hospital
₋ History of close contact to Pulmonary Tuberculosis Patient (his father)
₋ No history of hereditary disease.
₋ History of malignancy in family.
₋ History of passive smoker.
₋ History of covid 19 vaccination twice, no history of being confirmed of covid 19
₋ Working as an employee at private firm in Center Mamuju.
₋ History of hospitalization in May 2022 with shortness of breath ecausa pleural effusion. Thoracocentesis had been
perform 3 times and 3000cc serohemorhagic pleural fluid had been drained, medicated with Furosemide,
Erdostein.
₋ Thoracocentesis 4 times in Mamuju Hospital Poliklinik
 History of Illness

July 25th 2022

Pleural fluid cytology result: Malignant tumor dd/ lymphoma
malignant, poor differentiated of carcinoma
Chest tube repair was performed due to there was no drained

July 26th 2022

Chest Xray control
July 22nd 2022 800 cc serohemorrhagic pleural fluid
July 17th 2022
TTNA Prodiagnostic drainedby thoracocentesis
Admitted to WS Hospital and chest tube were inserted

16 July th 2022
Admitted to Mamuju Hospital and referred to WS Hospital

June, 6th 2022

Control to Policlinic and start ATT intensive phase

May 14th 2022

Being an inpatient at Mamuju Hospital due to worsening of shortness of breath and 3000 cc pleural fluid drained, positive Sputum
AFB
 Physical Examination (July, 24th 2022)
General Condition : Moderate Illness/Underweight
(Wight: 50, Height: 168, BMI: 17.7)/E4V5M6 • Thorax (erect) :
• Inspection: asymmetric, left hemithorax
SpO2 94% room air, 98% with 5 lpm nasal cannula decrease on static and dynamic.
BP : 120/82 mmHg • Palpation: decrease tactile fremitus at right
hemithorax, Ictus cordis moved to ICS V right
HR : 116 times/minute
mid clavicula anterior
RR : 24 times/minute • Percussion: dullness on ICS IV-basal right
BT : 36.7oC hemithorax and apex-basal left hemithorax
• Auscultation: decrease breath sound at medio-
basal right hemithorax and at apex to basal left
Head and eye : Normocephal, no pale conjunctiva, hemithorax
no yellowish sclera • Cardi: heart sound normal, no mur-mur
Neck : trachea shift to the right, no enlargement • Abdomen: soepel, enlargement liver 3 finger below
of lymphnode arcus costae, tenderness at upper left abdomen.
• Extremity: no pretibial oedem, warm acral
 Laboratory Finding
LAB 16-7-2022 17-7-2022 25-7-2022 Normal Range
(Mamuju
Hospital)

WBC 10.9 11.9 13.8 4.0-10.0

HB 12.4 11.5 12.5 12-16
PLT 271 244 460 150-400
Neut 68.6 72.6 87.6 52-75
Lymph 19.4 13.8 5.4 20-40
Na/K/Cl - 130/3.7/101 134/4.4/94 135-145/3.5-5.1/97-111
PT/INR/APTT - 11.1/1.03/24.1 10.8/1/21.9 -
RBG/Hba1c 85 117 112 140/<6.5
Ur/Cr - 15/0.52 33/0.67 10-50/<1.1
SGOT/PT - 49/9 40/10 <38/<41
Albumin - 3.7 3.8 3.5-5.0
HbsAg/Anti HCV - nonreactive - Nonreactive
Procalcitonin - - 3.6 <0.05
Bilirubin direct/total - - 1.07/0.67 <1.1/<0.3
LDH - 1813 1189 210-425
Protein - 6.7 - 6.6-8.7
 BGA

BGA 17-7-2022 18-7-2022 19-7-2022 20-7-2022 Normal

Lactate artery 3.9 6.2 7.8 6.5
pH 7.598 7.503 7.566 7.614 7.35-7.45
So2 99.1 98.7 97.6 99.1 95-98
PO2 186.3 153.1 90.1 164.5 80-100
PCO2 21.3 28.2 27 27 35-45
HCO3 21.0 22.3 26 27.6 22-26
BE -0.8 -1.0 4.0 6.1 -2-2
Previous fiO2 0.36 0.8 0.8 1
Recent fiO2 0.21 0.52 0.86 0.61
Conclusion Partially Respiratory Respiratory Mixed alkalosis
compensated alkalosis alkalosis
metabolic
alkalosis
 Laboratory Finding

Other laboratory Date

finding Result

Sarcov-2 PCR 17-7-2022

negative

Sputum Gram 18-7-2022

Gram positive, gram negative

Quantity 18-7-2022
Positive 3+ and Positive 3+

BTA 18-7-2022
Negative

Pleural Fluid Cytology 20-7-2022

Hemorrhagic Pleural Effusion

Pleural Fluid Cytology 22-7-2022 Malignant Tumor dd/Lymphoma

maligna-Poor differensiated Carcinoma
Pleural Fluid Analysis (July 17th 2022)
Item July, 17th 2022

Color Redish brown

pH 8.0

Light Criteria
Clotting Founded
July, 17th 2022
Rivalta test Positive PF protein/serum protein 5200/6.7 776>0.5
PF LDH/serum LDH 18403/1813 10.15>0.6
Leukocyte 85, MN 16%, PMN PF LDH > 2/3 upper limit Serum LDH 18403>280

exudate
84%
LDH 18403

Glucose 36

Total protein 5200

 Radiology Finding
(Chest Xray)

15-7-2022 (RSWS) 17-7-2022 (RSWS) before chest tube

 Radiology Finding
(Chest Xray)

17-7-2022 (RSWS) after chest tube 26-7-2022 (RSWS) after chest tube
Radiology Finding
(Chest Xray)
Radiology Finding
(Chest Xray)
 Diagnosis and Treatment
Assessment :
1. Loculated malignancy left pleural effusion
2. Anterior Mediastinal Mass suspect Thymoma dd/
Lymphoma
3. Vena Cava Superior Syndrome grade II
4. Cancer pain VAS score 5/10
5. New Case of bacteriologically confirmed
Pulmonary Tuberculosis on treatment intensive
phase d52
Problems :
6. Serohemorrhagic pleural fluid drained by
thoracocentesis, but no output from chest tube
drained
7. No improvement of dyspnea
8. Less general condition improvement
9. No treatment for tumor yet
Planning :
1. Waiting for biopsy result
2. AFB control, start continuous phase Tb
treatment
3. BGA control
4. Antibiotic therapy (Ceftazidime 1
gram/8hours/IV)
Therapy:
5. O2 nasal cannula 5 lpm
6. Furosemide 40 mg/12hour/IV
7. Methylprednisolone 125mg/12hour/IV
8. Acetaminophen 500mg/8hour/oral
9. Gabapentin 300 mg/12 hour/oral
10. Codeine 10mg/6hour/oral
11. 4 FDC 3 Tab/24 hour /oral (H52)
 Treatment from Other Divisions

• Clinical nutritionist
1. Zink 20mg/24 hour/oral
2. Vitamin b comp 2tab/8 hour
3. Curcuma 400mg/8hour/oral
 Follow Up Daily List
25-7-2022 14-7-2022
S: S:
Shortness of breath, chest pain, no cough Shortness of breath, chest pain, no cough
O: O:
Moderate illness/composmentis Moderate illness/composmentis
BP: 110/80 mmhg HR: 116 times/minute BP: 110/80 mmhg HR: 116 times/minute
RR: 24 times/minute BT: 36.4oC RR: 24 times/minute BT: 36.4oC
SpO2: 93% room air, 97% Nasal canula 5 lpm SpO2: 93% room air, 97% Nasal canula 5 lpm
Thorax: Thorax:
Inspection: asymmetric, left hemithorax decrease on static and dynamic. Ictus cordis moved t Inspection: asymmetric, left hemithorax decrease on static and dynamic. Ictus cordis moved t ICS V right
ICS V right mid clavicula mid clavicula
Palpation: decrease tactile fremitus at right hemithorax Palpation: decrease tactile fremitus at right hemithorax
Percussion: dullness on ICS IV-basal right hemithorax and apex-basal left hemithorax Percussion: dullness on ICS IV-basal right hemithorax and apex-basal left hemithorax
Auscultation: Absent breath sound at CS IV-basal right hemithorax and at apex to basal Auscultation: Absent breath sound at CS IV-basal right hemithorax and at apex to basal
A: A:
1. Loculated malignancy left pleural effusion 1. Loculated malignancy left pleural effusion
2. Anterior Mediastinal Mass suspect Thymoma dd/ Lymphoma 2. Anterior Mediastinal Mass suspect Thymoma dd/ Lymphoma
3. Vena Cava Superior Syndrome grade II 3. Vena Cava Superior Syndrome grade II
4. Cancer pain VAS score 5/10 4. Cancer pain VAS score 5/10
5. New Case of bacteriologically confirmed Pulmonary Tuberculosis on treatment 5. New Case of bacteriologically confirmed Pulmonary Tuberculosis on treatment intensive phase
intensive phase d52 d52
Chest tube d8 Chest tube d8
Volume:- Volume:100
Color: deep red (serohemporragic) Color: deep red (serohemporragic)
Undulation – Undulation –
Bulble - Bulble -
R/ R/
6. O2 nasal cannula 5 lpm 6. O2 nasal cannula 5 lpm
7. Furosemide 40 mg/12hour/IV 7. Furosemide 40 mg/12hour/IV
8. Methylprednisolon 125mg/12hour/IV 8. Methylprednisolon 125mg/12hour/IV
9. Acetaminophen 500mg/8hour/oral 9. Acetaminophen 500mg/8hour/oral
10. Gabapentin 300 mg/12 hour/oral 10. Gabapentin 300 mg/12 hour/oral
11. Codein 10mg/6hour/oral 11. Codein 10mg/6hour/oral
12. 4 FDC 3 Tab/24 hour /oral (H51) 12. 4 FDC 3 Tab/24 hour /oral (H51)
P: P:
Repair Chest Tube Thoracocentesis800cc serohemorrhagic PF drained
 Chest tube Volume
250

200

150

100

50

0
D1 D2 D3 D4 D5 D6 D7 D8 D9

Drained
THANK YOU