Monday, January 21, 2008

Double Trouble

A 70 year old man with a 40 pack-year history of smoking and a previous occupation as a shipyard worker presents to the ER with chest pain, shortness of breath, and cough. On exam, you find diminished breath sounds on the right and decreased fremitus. While listening to the patient with a stethoscope, whenever he says "E" you hear "A." A lateral decubitus chest X-ray is shown above. Your attending makes the marks "A" and "B." After further evaluation, you do a biopsy of the pleura of the lungs.

Here's the biopsy:

The left is lower magnification while the right is a higher magnification image.

Challenge: What is the pathology shown in the biopsy?

Related Questions:
1. What is the "E to A" change called?
2. What is shown on the CXR?

First image is in the public domain. Second image shown under fair use.


Craig said...

Double Trouble

The patient initially presented with a pleural effusion. The arrow A on the CXR shows fluid layering in the right pleural cavity. Signs on exam would include decreased chest movement on the affected side, dullness to percussion, diminished breath sounds, decreased fremitus, pleural friction rub, and egophony (E->A changes). The history of smoking and shipyard occupation increase suspicion for asbestos-related diseases. The biopsy confirms this. Pleural mesothelioma is strongly associated with asbestos exposure. The image shows epithelial cells forming papillary projections and stromal cells.

Sources: Wikipedia; Brown University Website

Alex said...

Hey, I found that bates contradicts wikipedia: egophony. I heard in a lecture that it's tough to distinguish consolidation and pleural effusion because both feature decreased breath sound and dullness to percussion. This is why tactile fremitus is essential in differentiating between the two.

Only consolidation has the following increased: egophony / whispered pec / tactile fremitus. In a pleural effusion, all of those are decreased to absent. There's a note that TF / transmitted sounds "may be increased toward the top of a large effusion" but that's the exception.