Post Orchiectomy with right sided Pleural Effusion, what could it be?

CME INDIA Case Presentation By Dr Nishith Kumar, Pulmonologist, Orchid Hospital, Ranchi.

CME INDIA Case Study

Clinical Insights

K/C/O Seminoma Post Orchiectomy (2017) presented with c/o mild breathlessness on exertion & minimal weight loss since last 6 months.
Chest Radiology S/o right sided Pleural Effusion.
Diagnostic Pleural Tap s/o Exudative Effusion (Protein 5.0gm/dl) with Low Glucose (30mg/dl) with predominant lymphocytes (90%) with Low ADA (18U/L) with negative malignant cytology.

CT Thorax

Right sided pleural effusion with underlying lung collapse…No f/S/O Mass/growth lesion
Pleural fluid MTB GeneXpert- MTB Not detected

What is your Diagnosis?

Thoracoscopic Pleural Biopsy done, see video:

Pleural Biopsy MTB Gene Xpert – MTB detected
Luckily turned out to be a case of Tubercular Pleural Effusion despite having low ADA & background H/O Seminoma

CME INDIA Discussion

Dr Sudhir Kumar, DM, (Pulmonology), Patna:

When was his first X-ray done, i.e., after how many weeks / months of onset of symptoms?
What was the opinion of radiologist in his report of CECT thorax especially on pleura and parenchymal shadow?
ADA is normal in minority of tubercular pleural effusion
But has a normal glucose level (2/3 of plasma glucose level) almost invariably
So definitely some other cause of low glucose should be thought of.
CT shows right sided pleural effusion
There is a general rule that if pleural fluid is unexplained than bronchial tree examination should be Done to assess for the bronchial lesion as a cause of pleural effusion
What was the colour of pleural fluid?
Why on thoracoscopy / pleuroscopy the colour of pleural cavity is homogeneously bloody coloured
Pleural bx shows very scanty granuloma (occasional).
Similarly, Gene expert detection of m tb is very low (false positivity increases for Both detection and active tb
What’s the written report of pleuroscopy i.e., visual description and impression?
However, having pleural effusion without mediastinal lymph nodes metastasis in seminoma is unusual as it’s found in less than ten percent of total pleural effusion cases
Mediastinal lymph nodes enlargement is commonest (75-80%) and pulmonary metastasis in 40 % even intra bronchial metastasis can be found. Pleural effusion is in less than 20%
I feel a bronchoscopy should be done in this patient too

Dr Nishith Kumar:

As a general rule Bronchoscopic evaluation is done in most of the cases of non-resolving pleural effusion prior to Thoracoscopic intervention as screening of Endobronchial tree permits identification of an underlying obstructing bronchial carcinoma or central airway tumor which may lead to non-expansion of lung post Thoracoscopy.
In this particular case I had the privilege of going through his prior chest x ray films. The patient had underwent diagnostic + therapeutic pleural taps two times before finally being referred to me. Immediate post therapeutic thoracocentesis CXR has shown almost complete expansion of Right lung without any significant parenchymal abnormality.
Even at the time of admission for Thoracoscopic evaluation there was hardly 200ml pleural fluid in right pleural cavity with lots of septations (USG Finding) We had to create an artificial pneumothorax few hours prior to Thoracoscopic intervention to create space.
I will post the CT Report in a while.
The color of the fluid was slightly reddish.
The pleural cavity is homogeneously reddish/bloody as lots of instrumentation (mechanical Adhenolysis + multiple biopsies) was done prior to this video.
Adhesions, fibrous strands, thickening of parietal pleura, hyperaemia along with presence of few scattered nodules over parietal pleura was noted during Thoracoscopic visualisation of pleural cavity.
Microbiological + Histopathological evidence from two different doctors’ points towards the same aetiology i.e., Tuberculosis so chances of it being false positive is minuscule.
As an afterthought I will definitely proceed for Bronchoscopic evaluation if patient does show adequate response to ATT after 1 month.
Thanks for value addition & inputs sir🙏🏽🙂

Dr Sudhir Kumar:

Thanks, Nishith for your elaborate inputs on the case
Part 1
“As a general rule Bronchoscopic evaluation is done in most of the cases of non-resolving pleural effusion prior to Thoracoscopic intervention as screening of Endobronchial tree permits identification of an underlying obstructing bronchial carcinoma or central airway tumor which may lead to non-expansion of lung post Thoracoscopy. “👆🏻
This rule for assessing non-expansion is mostly but not invariably for malignant pleural effusion where you want to do pleurodesis to assess for expansiveness by ruling out malignant airway obstruction and similar causes.
Whereas in unexplained persistent or recurring exudative effusion it is done to rule out or pick cause of pleural effusion as some bronchial abnormalities like bronchial stenosis, amyloid foreign body bronchial tb bronchial CA may be missed on ct. in this case recurrent bloody pleural effusion with low Ada with history of seminoma warranted a bronchoscopy even though the chances of picking the abnormalities may not be very high.
With all the relevant history and fluid characteristics in considers If the usg is showing lot of adhesions with only 200 ml fluid then the prime objective of thoracoscopy is diagnostic to rule out malignancy and try to establish the possible aetiology though in this particular case one had to do therapeutic procedures before getting to see the pleural spaces.

Dr Nishith Kumar shares CT:

CT of the same patient immediately after creating artificial pneumothorax

Dr Sudhir Kumar Pulmonology, Patna:

Part 2

“In this particular case I had the privilege of going through his prior chest x ray films. The patient had underwent diagnostic + therapeutic pleural taps two times before finally being referred to me. Immediate post therapeutic thoracocentesis CXR has shown almost complete expansion of Right lung without any significant parenchymal abnormality.
Even at the time of admission for Thoracoscopic evaluation there was hardly 200ml pleural fluid in right pleural cavity with lots of septations (USG Finding) We had to create an artificial pneumothorax few hours prior to Thoracoscopic intervention to create space.
I will post the CT Report in a while.
The color of the fluid was slightly reddish. “When was the first cxr done and the dates of subsequent (I suppose) another three x-rays
The very fact that it showed two times good expansion post aspirations suggests that septations adhesions pleural fibrosis was not there until probably the last X-ray prior to thoracoscopy.
This may suggest that adhesions and septations was probably due to repeated thoracocentesis rather than the primary underlying disease. The course is long six-month history which is sufficient for spontaneous recovery of primary pleural tb even without ATT in one third of patients (this may explain scanty granuloma and very low detection of MTB)
The reason of low pleural fluid glucose is to pondered upon
My understanding for gene expert test goes like this
- High detection and medium detection
- Chances of active disease as well as credibility of rifampicin resistance status is high
- For low detection, the credibility is medium and for very low detection the credibility is low and should be accepted with a pinch of salt. Even rifampicin resistance results are more erroneous. Gene expert can be detected in treated pulmonary tb even up to three to five years in sputum and especially in bronchoscopic lavage fluid samples
- Same can apply for granuloma where scanty granuloma may not depicting active cases. We all know that loose granulomas can be found in many non-tubercular diseases including malignancy
- We must subject the biopsy specimens to culture where positivity will confirm active case as well as definitive resistance pattern can be accessed especially in patients with very low m tb detection.
Points in favour of active TB
- Weak: scanty granuloma
- Very low detection of m tb on cbnaat
- No AFB positivity
- Medium strong: few scattered nodules over parietal pleura
- Points not favouring pleural tb
- Bloody fluid
- Low Ada
- Low glucose
- History of seminoma
- Lack of AFB detection
- Lack of culture growth
My take – It’s likely to be TB but not proved beyond reasonable doubt with a lack of normal bronchoscopy

Dr Nishith Kumar:

Patient Will follow up in March. Will revert back with latest CXR & see to it whether there is clinical improvement or now. If required then I will definitely do a Bronchoscopic evaluation 👍🏻😊

Dr Sudhir Kumar:

Post procedure or Before doing intervention

Dr Nishith Kumar:

Before, after creating pneumothorax but before Thoracoscopic intervention

Dr Sudhir Kumar:

Lot of pleural debris adhesions septations with diseased lungs adherent to the pleura at places.
Sub visceral pleura lung is densely consolidated.
You did a great job in this complicated patient.
Early the pleuroscopy safer the interventionist as well as the patient 😀 Posting VIDEO: