INTRODUCTION: Medical thoracoscopy has proven useful in diagnosing both malignant and benign causes of pleural effusions. This technique has advantages over traditional video-assisted thoracoscopy (VATS) because of its ability to be performed under moderate sedation, obviating the need for intubation and single-lung ventilation, while achieving a high diagnostic yield and low complication rates.(1) Frequently, cryptogenic exudative effusions are later found to be related to malignancy or tuberculosis. We report an unusual case of recurrent exudative pleural effusion due to amyloid, where medical thoracoscopy was essential to the diagnosis and treatment.
CASE PRESENTATION: A 61 year-old female with a past medical history of primary AL amyloidosis with cardiac involvement diagnosed by tongue biopsy 10 years prior was referred to the interventional pulmonology clinic for recurrent pleural effusion and dyspnea occurring during the previous six months. Her amyloid had initially been treated with stem cell transplant followed by trials of melphalan and steroids with partial response. More recently, she demonstrated good hematologic response to a regimen of bortezomib, cytoxan, and dexamethasone. Four previous large volume thoracenteses had yielded temporary symptomatic relief. Fluid analysis indicated an exudative effusion in the absence of infection or malignancy. Physical exam revealed a Mallampati IV anatomy, macroglossia, as well as decreased breath sounds and decreased fremitus over the right hemithorax 2/3 of the way up. For diagnosis and management, we proceeded with medical thoracoscopy in the endoscopy suite under moderate sedation with ultrasonographic guidance. The procedure was done using a semi-rigid thoracoscope through a 10 mm trocar. The patient required only 0.5 mg of midazolam and 200 mcg of fentanyl throughout the procedure. Local anesthesia was achieved with 25mL of 1% lidocaine. 1500 ml of serous turbid fluid was drained. Most of the pleural space was visualized and revealed normal-appearing pleura. Multiple biopsies of the parietal pleura were obtained. A Pleurx catheter was placed under vision, and five grams of sterile talc was then insufflated with thoracoscopic guidance. A 24 F chest tube was also placed to ensure full lung re-expansion. Post-operatively, the intent was to pull the 24F chest tube at 24 hours, however due to inadequate lung re-expansion, the tube was removed at day 5 and she was discharged home with daily Pleurx drainage. Three days after discharge, she achieved adequate pleurodesis, and her Pleurx was removed.
DISCUSSION: Medical thoracoscopy was first described in the medical literature in the early 1900s by Jacobeus (2). Previously more popular in Europe; medical thoracoscopy has become more readily available in North America due mostly to rapid expansion of the field of interventional pulmonology and the availability of a semi-rigid thoracoscope. Nonetheless, medical thoracoscopy remains an underutilized procedure despite having significant benefits over VATS in many patients. As demonstrated in this case, the patient’s co-morbidities, in particular, macroglossia, necessitated an alternative to deep sedation and intubation. Thoracoscopy was not only instrumental in obtaining a diagnosis through pleural biopsy, but was also effective in treating the recurrent effusion by talc insufflation and pleurx catheter placement, while requiring only minimal sedation. Given the reduced morbidity and relative ease of this procedure in the hands of a trained interventional pulmonologist, medical thoracoscopy should be considered first whenever access to the pleural space is necessary for diagnosis or treatment. VATS should clearly be utilized for more complicated effusions.
CONCLUSIONS: This is a unique case of pleural amyloid successfully diagnosed and treated by medical thoracoscopy. This approach should be considered as a useful, less morbid alternative to managing cryptogenic pleural effusions.
Reference #1 Michaud G et al. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010 Nov;138(5):1242-6.
Reference #2 Jacobeus HC . Ueber die Möglichkeit die Zystoskope beiuntersuchung seröser höhlungen anzuwenden . Munch Med Wochenschr . 1910 ; 40 : 2090 - 2092
DISCLOSURE: The following authors have nothing to disclose: Melhem Imad, Sonali Bose, Daniel Jamieson, Lonny Yarmus, David Feller-Kopman
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