A 45 year old male of Indian/Aryan ethnicity who was apparently normal 7 months back was referred to our hospital with complaints of cough for 7 months which was dry in nature and associated with breathlessness and fever. He had a past history of pulmonary tuberculosis, 20 years ago for which he received anti-tuberculosis therapy for a period of 12 months. Three years ago he also developed cholelithiasis for which he underwent cholecystectomy.
He was evaluated elsewhere and on basis of chest X-ray findings of consolidation and pleural effusion, anti-tuberculosis therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) was started. Inspite of 3 months therapy his symptoms did not subside and he started noticing gradual abdominal distension. He was shifted to a tertiary care centre in Dehradun where he was found to have bilateral pleural effusion with ascites. Thoracocentesis was done which showed cell count—30 (polymorph 10 % and lymphocytes 90 %), glucose—92 mg/dl, protein—2800 mg/dl, adenosine deaminase—0.93. Cartridge-based nucleic acid amplification test for tuberculosis was negative. Contrast enhanced computed tomography (CT) revealed gross ascites, bilateral pleural effusion, mild pericardial effusion and inferior vena cava thrombosis. He was then referred to another tertiary care centre at Delhi and he was re-evaluated. Intercostal drainage (ICD) tube was inserted and pus drained from the pleural cavity which was positive for acid fast bacilli (AFB) on Ziehl–Neelsen stain. Fine needle aspiration and cytology of right axillary lymphnode showed reactive lymphadenitis. Repeat CT of chest and abdomen revealed similar finding as before with additional thrombosis in superior and inferior vena cava, right internal jugular vein and bilateral brachiocephalic veins.
Patient was then brought to our hospital. On examination he was conscious and oriented. Pallor and anasarca were present. Bilateral crepitations with decreased air entry at base and right sided ICD tube were noted. His abdomen was distended and shifting dullness was present.
Hematological profile revealed microcytic hypochromic anemia with mild leukocytosis. Urine routine microscopy revealed proteinuria. Renal function tests were normal, liver function tests revealed hypoalbuminemia. Blood culture and urine culture were sterile and procalcitonin was 0.07. Anti nuclear antibody and lupus anticoagulant were negative.
Chest x-ray revealed ill defined radio opacity in left lower zone, fibrotic opacities with subsegmental atelectasis seen in bilateral upper zones and bilateral pleural effusion with ICD tube in situ on the right side (Fig. 1).
Thoracocentesis was done and chylous fluid was aspirated. Laboratory evaluation of the fluid revealed cell count—38 polymorphs 10 % and lymphocytes 90 %, protein—1.1 gm/dl, albumin—0.7, glucose—116, ADA 4.0, triglycerides −360 mg/dl, cholesterol—36 mg/dl, culture-sterile, KOH stain-negative, gram stain-negative. Cytology was negative for cancer and consistent with chylothorax.
CT venography chest and abdomen was done which showed hypodense filling defect in the bilateral brachiocephalic veins, right internal jugular vein, superior vena cava and infra renal inferior vena cava suggestive of thrombosis. Pulmonary thromboembolism was also noted. (Figs. 2, 3) mild ascites with omental thickening with diffuse wall thickening of small bowel was noted.
In view of these findings, omental biopsies along with subdiaphragmatic lymph node biopsy were done. Histopathology showed malignant mesothelioma with nodal metastasis. Under oncology care low dose chemotherapy including carboplatin and pemetrexed were given.
He withstood the first cycle of chemotherapy well and gradually his anasarca reduced. Daily regimen of four drugs ATT (rifampicin, isoniazid, ethambutol and pyrazinamide) was also continued and he was discharged in a clinically stable condition with advice to follow-up for chemotherapy. He is now on regular follow-up with medical oncologist.