01-13-2009, 08:57 AM
A 25-year-old man is evaluated for a 2-month history of low-grade-fevers, cough, night sweats, fatigue, pleuritic chest pain, and weight loss. The patient emigrated from Mexico almost 2 years ago and now lives in Central California.
On physical examination, his temperature is 38 °C (100.4 °F), pulse rate is 96/min and regular, respiration rate is 22/min at rest, and oxygen saturation is 94% on room air. There is diminished breath sound and vocal fremitus over the right hemithorax. The left lung is clear.
Peripheral blood leukocyte count is 9000/μL (9 × 109/L), with 60% neutrophils and 35% lymphocytes. Liver function test results are normal. Chest radiograph shows a moderate right-sided pleural effusion with layering of 3 cm of free-flowing pleural fluid and no parenchymal infiltrates on right lateral decubitus chest radiograph.
Thoracentesis yields 1.0 L of minimally turbid, yellow fluid with test results as follows:
Laboratory Studies
Pleural fluid cell count
Leukocyte count 3000/μL (3 × 109/L) with 5% neutrophils, 85% lymphocytes, 1% mesothelial cells, and 1% macrophages
Total protein
5.5 mg/dL (55 g/L)
Lactate dehydrogenase
290 U/L
Glucose
80 mg/dL (4.44 mmol/L)
pH
7.36
Pleural fluid Gram, fungal, and acid-fast bacilli stains are negative. Tuberculin skin test is pending. Serologic tests for fungal organisms are negative. Cytologic evaluation for malignant cells is negative.
Which of the following is the most likely diagnosis?
A Tuberculosis
B Pneumococcal parapneumonic effusion
C Pulmonary embolism
D Malignant pleural effusion
E Pleural effusion due to coccidiodomycosis
On physical examination, his temperature is 38 °C (100.4 °F), pulse rate is 96/min and regular, respiration rate is 22/min at rest, and oxygen saturation is 94% on room air. There is diminished breath sound and vocal fremitus over the right hemithorax. The left lung is clear.
Peripheral blood leukocyte count is 9000/μL (9 × 109/L), with 60% neutrophils and 35% lymphocytes. Liver function test results are normal. Chest radiograph shows a moderate right-sided pleural effusion with layering of 3 cm of free-flowing pleural fluid and no parenchymal infiltrates on right lateral decubitus chest radiograph.
Thoracentesis yields 1.0 L of minimally turbid, yellow fluid with test results as follows:
Laboratory Studies
Pleural fluid cell count
Leukocyte count 3000/μL (3 × 109/L) with 5% neutrophils, 85% lymphocytes, 1% mesothelial cells, and 1% macrophages
Total protein
5.5 mg/dL (55 g/L)
Lactate dehydrogenase
290 U/L
Glucose
80 mg/dL (4.44 mmol/L)
pH
7.36
Pleural fluid Gram, fungal, and acid-fast bacilli stains are negative. Tuberculin skin test is pending. Serologic tests for fungal organisms are negative. Cytologic evaluation for malignant cells is negative.
Which of the following is the most likely diagnosis?
A Tuberculosis
B Pneumococcal parapneumonic effusion
C Pulmonary embolism
D Malignant pleural effusion
E Pleural effusion due to coccidiodomycosis