Atypical Pleural Effusion in an Immunocompetent Patient With Valley Fever: A Case Study and Review of the Literature

Valley fever is a fungal infection, commonly of the lungs, caused by Coccidioides immitis or Coccidioides posadasii. This disease is endemic to the southwestern United States, Central America, and South America. Infected individuals are typically asymptomatic but may develop community-acquired pneumonia. On rare occasions, coccidioidomycosis can present with severe complications in addition to the pulmonary manifestation. In this study, a 58-year-old immunocompetent male presented to the Emergency Department with a cough, night sweats, and pleuritic chest pain. Despite the administration of broad-spectrum antimicrobials, he developed a large right pleural effusion that did not resolve following thoracentesis. Serology was positive for Coccidioides, and the patient was referred to a thoracic surgeon due to persistent effusion. It is rare for patients with coccidiomycosis to develop a large pleural effusion requiring surgical intervention, especially in immunocompetent individuals. This case highlights the importance of monitoring patients with unresolved acute pneumonia in endemic areas and considering Coccidioides as a possible etiology.

A Rare Case of Chylothorax Following a Redo Laparoscopic Nissen Fundoplication

Gastroesophageal reflux disease (GERD) is a highly prevalent disease. Mechanical etiology, including hiatal hernia, can be resistant to empiric proton pump inhibitor (PPI) trials; Nissen fundoplication is commonly used to treat mechanical GERD. Chylothorax is a rare complication of abdominal surgeries, including anti-reflux procedures. In this case report, a 75-year-old female presented with shortness of breath following a redo laparoscopic Nissen fundoplication. Chest CT pulmonary angiography (CTPA) showed bilateral large pleural effusions that were managed by fluid restriction, repeated thoracocentesis, and chest tube insertion; the pleural fluid analysis was significant for fluid triglycerides high at 232 mg/dL which was diagnostic for chylothorax. The patient was treated conservatively. Appropriate management of chylothorax is crucial to avoid subsequent respiratory failure, immunodeficiency, and malnutrition. Chylomicrons and triglycerides in the pleural fluid can be diagnostic for chylothorax. Treatment of chylothorax includes three main approaches: controlling the cause, conservative treatment, and surgical interventions.

Severe Ovarian Hyperstimulation Syndrome in the Setting of In Vitro Fertilization Treatment

Ovarian hyperstimulation syndrome (OHSS) is one of the complications of pharmacological ovarian stimulation used in fertility treatments. This syndrome is characterized by increased vascular permeability secondary to stimulation, resulting in a fluid shift from the intravascular space to the third-space compartments. Patients developing OHSS can experience severe complications, including ascites, pleural effusions, and shock. Here, we present a case of OHSS in the setting of recent transvaginal oocyte retrieval, leading to severe ascites, pleural effusion, and hypotension requiring urgent intervention.

Pleural Effusion: A Rare Presentation of Mature Teratoma in a Young Patient

Mediastinal masses always present a diagnostic challenge to clinicians and radiologists. There are wide varieties of pathologies ranging from benign to malignant conditions. Teratomas are one of the rare causes of mediastinal tumors. In this case, we report a young male who presented to the emergency room with acute pleuritic chest pain. The chest X-ray showed massive right-sided pleural effusion. Subsequently, bedside chest ultrasound ruled out septations and helped drain the fluid. The pleural fluid analysis demonstrated transudate chemistry. A computerized tomography (CT) of the chest was performed, revealing a complex anterior mediastinal mass suspected of Mature Teratoma. The tumor was surgically removed in its entirety, and pathology confirmed it a mature teratoma. The patient remained asymptomatic on postoperative follow-up.

Rapidly recurring massive pleural effusion as the initial presentation of sarcoidosis: A case report

RATIONALE

Sarcoidosis is a multisystem granulomatous disease with unknown etiology. It affects mainly the lungs, but it can affect almost any other organ. Nevertheless, pleural involvement with the development of pleural effusion is relatively rare. It is usually mild and responsive to treatment with systemic steroids. Here we present a case of rapidly recurring massive unilateral pleural effusion caused by sarcoidosis that was resistant to systemic steroids.

PATIENT CONCERNS

A 55-year-old lady presented with shortness of breath of 2-months duration. No other respiratory symptoms were reported. On physical examination, there were signs of left-sided pleural effusion, splenomegaly, and inguinal lymph nodes. These findings were confirmed by chest x-ray showing massive pleural effusion. Work up of the effusion revealed an exudative effusion with lymphocyte predominance. Pan-computed tomography scan revealed multiple thoracic, abdominal and inguinal lymphadenopathy; additionally, a left-sided pleural effusion and an enlarged spleen; that contained variable hypodense nodular lesions. Positron emission tomography-computed tomography showed intense uptake in the spleen and the lymph nodes. Inguinal lymph node biopsy showed non-necrotizing granulomatous inflammation. Due to suspicion of malignancy, left medical thoracoscopy was done, and biopsy of the parietal pleura showed nonspecific inflammation without evidence of malignancy or tuberculosis.

DIAGNOSIS

Sarcoidosis was diagnosed based on the finding of the non-necrotizing granulomatous inflammation with no evidence of malignancy or infection on several microbiological and pathological samples.

INTERVENTIONS

The patient was treated with repeated pleural fluid drainage. Steroids failed to prevent pleural effusion recurrence. Surgical left side pleurodesis was eventually performed.

OUTCOMES

At more than 1 year follow up, the patient showed no recurrence of pleural effusion or development of any other symptoms.

LESSONS

Sarcoidosis may rarely present with massive pleural effusion, as this presentation is rare; it is imperative to rule out other causes of massive pleural effusion. Massive pleural effusion in sarcoidosis may be steroid-resistant. Pleurodesis may have a role in such a scenario.