Propylthiouracil-Associated Eosinophilic Pleural Effusion: A Case Report

Fibrin glue-induced eosinophilic pleural effusion after pulmonary resection: A case report

INTRODUCTION AND IMPORTANCE

Prolonged air leakage after pulmonary resection is a common complication, and fibrin glue is used as a sealant to reduce this. Fibrin glue-induced adverse events are generally rare. Herein, we describe a rare case of fibrin glue-induced eosinophilic pleural effusion (EPE).

CASE PRESENTATION

A 77-year-old man underwent partial pulmonary resection for right lower lobe lung cancer, and the pulmonary staple stump was subsequently covered with fibrin glue. Antibacterial drugs were administered for the treatment of postoperative pneumonia. However, re-elevation of the inflammatory cell number was observed, and computed tomography revealed an increase in right pleural effusion. Although thoracoscopy was performed based on a possibility of empyema, no empyema was observed. The eosinophil count in the pleural effusion was 11%; thus, the patient was diagnosed with EPE, which was resolved after thoracic drainage, without corticosteroid administration. Fibrin glue was identified as the causative agent, using a drug-induced lymphocyte stimulation test.

CLINICAL DISCUSSION

EPE is defined as an eosinophil count of ≥10% in the pleural effusion. If pleural effusion on the surgical side, with fever or an elevated inflammatory cell number, is observed in the early postoperative period after pulmonary resection, empyema should be considered foremost. In this case, the administration of antibacterial drugs was ineffective, and the patient was eventually diagnosed with EPE.

CONCLUSION

EPE should be considered as a rare fibrin glue-induced adverse event after pulmonary resection. It is recommended that the leukocyte fraction be examined, if pleural effusion is collected for postoperative pleural effusion.

Carbimazole-induced eosinophilic pleural effusion

We report the case of a 41-year-old woman who presented with a unilateral exudative effusion with prominent eosinophils on pleural cytology. Carbimazole had been started 4 weeks prior to presentation. No immediate cause was identified on imaging or laboratory testing. The effusion persisted at 2-month follow-up. Further investigation at this time, including autoimmune serology was negative. At 2-month follow-up, the effusion was loculated on ultrasound imaging and had a low fluid pH on diagnostic aspiration, in keeping with an empyema. The patient received treatment for pleural empyema, including antibiotics, intercostal drain insertion and video-assisted thoracoscopic pleural biopsy. Carbimazole was stopped, and following treatment for the empyema, the effusion did not reaccumulate.This case illustrates the diagnostic difficulties that pleural effusions may present. It demonstrates that drug reactions should be considered in the differential diagnosis following thorough investigation for other potential causes and also describes the complications that may occur.

Methimazole associated eosinophilic pleural effusion: a case report

Background

Adverse reactions associated to anti-thyroid drugs include fever, rash, arthralgia, agranulocytosis and hepatitis that are thought to be hypersensitivity reactions. Five cases of pleural effusion associated to thionamides have also been reported, two with propylthiouracil and three with carbimazole.

Case presentation

We report here a case of a 75-year-old man admitted because of unilateral pleural effusion. The patient had a recent diagnosis of hyperthyroidism and 6 days after starting methimazole complained of pleuritic chest pain. He had elevated C-reactive protein and erythrocyte sedimentation rate and normal white blood cell count and liver enzymes. Chest radiography showed a moderate right pleural effusion and the ultrasound revealed a loculated effusion that was shown to be an eosinophilic exudate.

Conclusions

The temporal relationship between methimazole intake and the development of pleural effusion combined with the extensive exclusion of alternative causes, namely infectious, neoplastic and primary auto-immune diseases, led to the diagnosis of hypersensitivity reaction to methimazole. The thionamide was stopped and corticosteroid was started with complete resolution of the pleural effusion in 3 months.

Awareness of this rare adverse reaction of anti-thyroid drugs is important and methimazole can be added to the list of possible etiologies of drug-induced eosinophilic pleural effusion.

Carbimazole-induced exudative pleural effusions

Carbimazole, an antithyroid drug, is associated with a significant number of side effects, but pleuropulmonary complications are rare. We report the case of a 42-year-old Caucasian man who developed dyspnoea secondary to bilateral exudative pleural effusions while on carbimazole therapy. Extensive investigations, including a vasculitic screen, ruled out other potential causes for this patient's clinical presentation. This patient's pleural effusions gradually resolved within a few months of stopping carbimazole therapy, suggesting a role for the latter in the aetiopathogenesis of his presentation. Clinicians should consider discontinuing treatment with carbimazole and introducing alternative antithyroid therapy in this setting, once other potential causes of a pleural effusion have been systematically ruled out.

Carbimazole induced pleural effusion: a case report

Objective. To describe a patient with unilateral exudative pleural effusion that developed after commencement of carbimazole. Methods. We describe the presentation and clinical journey of an elderly woman who presented to the chest physicians initially with pleural effusion but was followed up by the endocrinology team. Result. The patient was a 77-year-old Caucasian woman who presented with symptoms of breathlessness and a confirmed unilateral pleural effusion while being on treatment for thyrotoxicosis. Her symptoms needed recurrent hospital admission for investigations and drainage, but no potential cause was identified after extensive investigations. A drug-induced exudative effusion consequent to carbimazole intake was diagnosed as discontinuation of the drug lead to complete resolution of the effusion with no recurrence. Conclusion. Physicians and Endocrinologist must bear in mind that this potentially rare complication of carbimazole while treating patients of thyrotoxicosis as appearance of similar features in their patients while being on carbimazole should lead to the discontinuation of the drug, and alternative treatment strategy should be considered.

Current awareness: Pharmacoepidemiology and drug safety

In order to keep subscribers up‐to‐date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of pharmacoepidemiology and drug safety. Each bibliography is divided into 20 sections: 1 Reviews; 2 General; 3 Anti‐infective Agents; 4 Cardiovascular System Agents; 5 CNS Depressive Agents; 6 Non‐steroidal Anti‐inflammatory Agents; 7 CNS Agents; 8 Anti‐neoplastic Agents; 9 Haematological Agents; 10 Neuroregulator‐Blocking Agents; 11 Dermatological Agents; 12 Immunosuppressive Agents; 13 Autonomic Agents; 14 Respiratory System Agents; 15 Neuromuscular Agents; 16 Reproductive System Agents; 17 Gastrointestinal System Agents; 18 Anti‐inflammatory Agents ‐ Steroidal; 19 Teratogens/fetal exposure; 20 Others. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted.