An 18-year-old patient with a PMH significant for childhood medulloblastoma requiring cerebellar resection, radiation, and chemotherapy all around age 5 and mild developmental delay presented to the emergency room with 2 weeks of dyspnea and 2 days of non-productive cough. Chest X-ray showed a large right-sided pleural effusion. She was tachycardic with a heart rate of 109, but otherwise, her vital signs were unremarkable. CBC, BMP, and LFTs were unremarkable. Serum protein was 8.3 and serum LDH 142. Urine HCG is negative.
The next step in the diagnostic workup is to sample the pleural effusion.
A: Gram stain and culture, cell count and differential, glucose, protein, LDH, and cytology. These are basic tests that should be sent as the first step in the diagnostic workup of any newly unexplained pleural effusion. Their purpose is to evaluate for infection and cancer, as well as to determine if the pleural effusion is transudative or exudative. Further workup generally depends on these initial results. Other testing can be thoughtfully ordered as part of the initial workup depending on the clinical situation.
Pleural fluid studies showed a normal glucose level and only a few nucleated cells suggested against infection. Protein was 5.1 and LDH was 88, meeting Light’s criteria for an exudate. CT abdomen and pelvis showed ascites and a large pelvic mass. Transvaginal ultrasound showed a large pelvic mass that seemed to be associated with both ovaries and possibly the uterus. CA-125 level was 842 (normal range 0–46).
A: Most likely diagnoses are metastatic reproductive organ cancer and Meig’s syndrome. The next step is exploratory surgery with biopsy.
Exploratory laparotomy was done, and bilateral ovarian masses were identified. Bilateral salpingo-oophorectomy was performed. Pathology revealed both tumors to be sclerosing stromal tumors, which were benign.
