A 42-year-old man comes to the physician with 4-6 weeks of occasional subjective fever, mild shortness of breath on exertion, intermittent cough, and right-sided chest pain. The patient was started on chlorthalidone for hypertension 4 months ago. He has smoked 2 packs of cigarettes daily for 15 years. The patient emigrated 14 years ago from Russia, where he used to work in construction and building demolition and did not wear a respirator mask at work. He has lived in Chicago since his arrival to the United States.
The patient's temperature is 37.3 C (99.1 F). Lung examination is significant for decreased breath sounds at the right base.
Chest x-ray reveals a small right-sided effusion with mild pleural thickening. A thoracentesis is performed.

What is the most likely cause of the effusion?

Question

A 42-year-old man comes to the physician with 4-6 weeks of occasional subjective fever, mild shortness of breath on exertion, intermittent cough, and right-sided chest pain.  The patient was started on chlorthalidone for hypertension 4 months ago.  He has smoked 2 packs of cigarettes daily for 15 years.  The patient emigrated 14 years ago from Russia, where he used to work in construction and building demolition and did not wear a respirator mask at work.  He has lived in Chicago since his arrival to the United States.
The patient's temperature is 37.3 C (99.1 F).  Lung examination is significant for decreased breath sounds at the right base.
Chest x-ray reveals a small right-sided effusion with mild pleural thickening.  A thoracentesis is performed.

What is the most likely cause of the effusion?

Quizplus · Accepted Answer

Building demolition carries a significant risk of asbestos exposure. Benign asbestos-related pleural effusions (BAPE) are an early pleural manifestation of asbestos-related lung disease, usually occurring between 10-15 years postexposure. They are usually small (<500 mL), often bloody, and exudative, with eosinophilic predominance (>10% of nucleated cells, frequently >50%). BAPE may be asymptomatic or present with dyspnea, low-grade fever, and pleuritic chest pain. Spontaneous resolution over weeks to months is the norm. BAPE usually predates asbestos-related pleural plaques and may be a marker for future development of diffuse pleural thickening. exudative (Choice B) Coccidioidomycosis can cause an eosinophilic effusion and presents with subacute onset of respiratory and systemic symptoms (valley fever). Risk of infection is geographically limited (US southwest desert, parts of Mexico, and Central America). (Choice C) Drugs associated with an eosinophilic effusion include dantrolene, bromocriptine, nitrofurantoin, and valproic acid. (Choice D) Malignant effusions may be eosinophilic. Although this patient is at risk for malignancy, malignant effusions frequently have lower glucose values. This patient's history of asbestos exposure and presence of pleural thickening make BAPE more likely. (Choice E) Although this patient lived in an area where tuberculosis may be a concern, tuberculous effusions tend to be predominantly lymphocytic. Educational objective: Benign asbestos-related pleural effusions are often exudative and bloody, with pleural fluid eosinophilia (>10% nucleated cells, frequently >50%). They may be asymptomatic or cause pleuritic pain and dyspnea and are considered a marker for future development of asbestos-related pleural disease. __________ References: Benign asbestos pleural diseases. (http://www.ncbi.nlm.nih.gov/pubmed/12806238) Asbestos-related lung disease. (http://www.ncbi.nlm.nih.gov/pubmed/17375514)

A 42-Year-Old Man Comes to the Physician with 4-6 Weeks