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Fulltext Primary malignant melanoma of the pleura: a rare case

Low QJ, Ng BHS, Cheo SW

Borneo Journal of Medical Sciences, 2017;11(2):1-3.
MyJurnal

Primary pleural melanoma is a very rare condition
and highly aggressive tumour. A patient presented
with productive cough, haemoptysis, pluritic chest
pain and breathlessness. On investigation, she was
diagnosed as left-sided lung mass with pleural
effusion. Pleural biopsy confirmed malignant
melanoma of pleura and she was subsequently
referred to the oncology team for palliative
chemotherapy. In conclusion, primary pleural
melanoma remains a rare disease with no proven
effective treatment regime available.

Matched MeSH terms: Pleura*
Fulltext Intrapleural central venous catheter malposition

Leang LT

Med J Malaysia, 1989 Jun;44(2):147-50.
PMID: 2626123

Percutaneous insertion of central venous catheter (CVC) is a valuable procedure in managing critically ill patients. However, placement of CVC is not without its complications. The author reports a case in which a CVC was inserted into the right pleural cavity which was not detected by the usual clinical methods of confirming catheter placement and an antero-posterior (A-P) chest x-ray.

Matched MeSH terms: Pleura/injuries*
Diagnostic utility of pleuroscopic guided pleural biopsy versus pleural fluid cell block in the diagnosis of malignant pleural effusion

Ng BH, Low HJ, Abeed NNN, Soo CI, Azmi MI, Sharil NS, et al.

Med J Malaysia, 2025 Mar;80(2):168-173.
PMID: 40145158

INTRODUCTION: Pleural biopsy using flex-rigid pleuroscopy or pleural effusion cell block analysis is useful for diagnosing malignant pleural effusion. However, the current literature lacks documented comparisons between pleural biopsies and cytological cell blocks. This study aims to compare the diagnostic accuracy of pleural biopsy and cytological cell block in identifying malignant pleural effusion.
MATERIALS AND METHODS: A retrospective review was conducted on patient data from those who underwent pleuroscopy at Hospital Canselor Tuanku Muhriz from January 2021 to December 2023. We included patients with pleural effusion who underwent both cell block and pleural biopsy with a confirmed diagnosis of malignancy through histopathological examination. At least 200 ml of pleural fluid was collected, followed by the biopsy of six or more pleural tissue samples.
RESULTS: Out of the 196 pleuroscopy procedures analysed, 91 patients were diagnosed with malignant pleural effusion. Malignancy was diagnosed in 50 (54.9%) cases using cell block analysis, whereas pleural biopsy identified malignancy in 81 (89%) cases. The diagnostic yield was significantly higher for pleural biopsy compared to pleural fluid cell block [89% (81/91) vs. 54.9% (50/91); p < 0.001]. Among patients with negative results on pleural fluid cell block, 33 (36.3%) had positive results on pleural biopsy. The definitive diagnoses of malignancy included 64 (70.3%) cases of lung adenocarcinoma, 4 (4.4%) cases of lung squamous carcinoma, 2 (2.2%) cases of small cell lung cancer, 2 (2.2%) cases of mesothelioma, and 19 (20.9%) cases of metastatic carcinoma. Eight (8.8%) patients exhibited negative findings on both pleural fluid cell block and pleural biopsy. Further diagnoses were achieved through computed tomography-guided needle tru-cut biopsy of the lung in 6 patients (6.6%), transbronchial lung biopsy in 1 patient (1.1%), and cervical lymph node biopsy in 1 patient (1.1%).
CONCLUSION: Pleural biopsy exhibits superior diagnostic accuracy compared to pleural fluid cell block analysis for malignant pleural effusion. In cases where cell block results are negative but suspicion remains high, pleural biopsy remains a crucial diagnostic tool.

Matched MeSH terms: Pleura/pathology
Fulltext A case of miliary adenocarcinoma of lung masquerading as miliary tuberculosis

Nik Azlan, N.M.

Medicine & Health, 2020;15(1):274-279.
MyJurnal

Adenokarsinoma paru-paru miliari adalah sangat jarang dan agresif. Adenokarsinoma paru-paru biasanya menunjukkan sifat ketulan pada peparu yang berkaitan dengan kerosakan paru-paru dan efusi pleura. Adenokarsinoma ini jarang jarang berpunca daripada tapak selain daripada tapak primer, tidak seperti kanser-kanser lain contohnya kanser tiroid, koriokarsinoma dan sarcoma. Kami membentangkan di sini kes seorang suri rumah berusia 50 tahun yang mengadu batuk-batuk, hilang selera makan dan sukar untuk bernafas selama 1 bulan. Perawat perubatan primer telah merawat beliau sebagai jangkitan kuman pada paru-paru. Disebabkan keadaan yang tidak pulih dan semakin melarat, beliau dibawa ke Jabatan Kecemasan. Oksigen beliau dikesan sebanyak 93% atas udara bilik. Berdasarkan sejarah pesakit dan penemuan X-ray paru-paru, rawatan untuk tuberculosis miliari telah di beri walaupun ujian Mantoux dan kahak negatif. Berikutan peningkatan tanda-tanda dan intubasi, bronkoskopi kemudian mendedahkan diagnosis adenokarsinoma paru-paru. Sebagai pelajaran, penampilan miliari radiografi tidak dikelirukan kepada tuberkulosis sahaja, kerana sebab-sebab berbahaya yang lain perlu disiasat. Bronkoskop dengan analisis histopatologi diperlukan, terutamanya jika Mantoux dan sputum adalah negatif.

Matched MeSH terms: Pleura
Fulltext Spontaneous pneumothorax and pneumomediastinum after a trivial injury: a case report

Ahmad Faizal Rakawi, Abdul Aziz Marwan, Ummi Nadira Daut

Malaysian Journal of Medicine and Health Sciences, 2020;16(108):84-86.
MyJurnal

Spontaneous pneumothorax and pneumomediastinum is defined as presence of free air or gas in the pleural cav- ity and mediastinal structures respectively. Spontaneous pneumothorax seems to be associated with anatomical abnormalities such as subpleural blebs or bullae, however not for spontaneous pneumomediastinum which may developed without an apparent precipitating cause. Both usually may occur in young healthy adults without serious underlying lung disease. We report a case of spontaneous pneumothorax and pneumomediastinum after a trivial injury. He was initially presented with dyspnea after two weeks of initial trivial trauma. Chest radiograph showed left apical pneumothorax with pneumomediastinum with no evidence of rib fracture. His condition was deemed non-traumatic by surgical colleague, thus admitted to medical ward for observation and eventually discharged well.

Matched MeSH terms: Pleura
Fulltext An Accidental Finding of Pulmonary Sequestration in an Adult

Amran, A.R.

International Medical Journal Malaysia, 2006;5(1):1-6.
MyJurnal

Pulmonary sequestration is defined as a segment of ç separated from the tracheobronchial tree and receiving its blood supply from a systemic artery rather than a pulmonary arterial branch. Classically, it has been described in two forms: (1) intralobar sequestration (ILS), in which the sequestrated part of lung lies within normal pulmonary visceral pleura, and (2) extralobar sequestration (ELS), in which the abnormal segment of lung is completely separate and enclosed in its own pleural investment. The term sequestration was coined by Pryce in 1946 to describe a disconnected bronchopulmonary mass or cyst with an anomalous systemic artery. Since this original description, terminology has become confusing as investigator has recognized many variants of sequestration not strictly meeting the original description. The spectrum now recognized as a continuum, with normal vessels supplying abnormal lung at one end and abnormal vessels supplying normal lung at the other end. Recently, we incidentally found an asymptomatic, intralobar pulmonary sequestration during CT pneumocolon.

Matched MeSH terms: Pleura
Fulltext Solitary fibrous tumor of the paranasal sinus presenting as an antrochoanal polyp

Mansharan Kaur Chainchel Singh

Malaysian Journal of Medical Research, 2018;2(2):91-94.
MyJurnal

Solitary fibrous tumours (SFTs) are unusual mesenchymal tumours that were first described as primary spindle-cell neoplasms of the pleura. These tumours have been described in many other locations, including the urogenital system, orbit, mediastinum, and upper respiratory tract. These tumours are generally benign in nature, however some of them can be locally invasive and have the potential to be malignant. Although about 12%-15% of them occur in the head and neck area, SFT of the nasal cavity and paranasal sinuses are extremely rare. We present a case of a solitary fibrous tumour arising from the right maxillary sinus in a 50 year old Chinese man.

Matched MeSH terms: Pleura
Fulltext Clavicle fracture and subclavian vessels disruption with massive haemothorax mimic intrathoracic injury

Faisham WI, Mohammad P, Juhara H, Munirah NM, Shamsulkamaruljan H, Ziyadi GM

Malays J Med Sci, 2011 Apr;18(2):74-7.
PMID: 22135591

We report a case of open fracture of the clavicle with subclavian artery and vein laceration and perforation of the parietal pleural below the first rib that caused massive haemothorax. Emergency thoracotomy and exploration followed by repair of both vessels were able to salvage the patient and the extremity.

Matched MeSH terms: Pleura
Fulltext Total pleurectomy as the surgical treatment for recurrent secondary spontaneous pneumothorax in a child with severe pulmonary Langerhans cells histiocytosis

Abdul Aziz DA, Abdul Rahman NA, Tang SF, Abdul Latif H, Zaki FM, Annuar ZM, et al.

BMJ Case Rep, 2011;2011.
PMID: 22674944 DOI: 10.1136/bcr.09.2011.4734

Pulmonary Langerhans cell histiocytosis (LCH) in children is more extensive and is a rare cause of spontaneous secondary pneumothorax (SSP) which tends to be recurrent and refractory to conventional treatment. Its occurrence in paediatric patients posed great challenge to the choice of surgical management. Surgery in the form of pleurodesis is only considered if SSP does not improve after chemotherapy and after considering all relevant risk and benefits of surgery to patients. Chemical pleurodesis will not give the expected effect to eradicate SSP in this patient. Therefore mechanical pleurodesis is the treatment of choice. There are various techniques to perform mechanical pleurodesis; from pleural abrasion to pleurectomy. In the authors' experience, bilateral total pleurectomy provided the best outcome for this 9-year-old patient with persistent respiratory distress from SSP due to extensive pulmonary LCH.

Matched MeSH terms: Pleura/surgery*
Fulltext Medical thoracoscopy: Pahang experience

Ng TH, How SH, Kuan YC, Hasmah H, Norra H, Fauzi AR

Med J Malaysia, 2008 Oct;63(4):298-301.
PMID: 19385488 MyJurnal

Medical thoracoscopy has gain its popularity in Malaysia recently. This paper presents our early experience in thoracoscopy using semi-rigid fiberoptic thoracoscope. All thoracoscopy records since October 2006 were retrieved. The patients' records, thoracocentesis investigations results, thoracoscopic findings and all pleural biopsy results were reviewed. Twenty-four thoracoscopic procedures on 22 patients in whom two patients had repeated thoracoscopy. Ten patients were confirmed carcinoma. Eight patients had inconclusive thoracoscopic pleural biopsy results. Three patients underwent pleurodesis for malignant effusion. One patient had adhesiolysis for empyema. There was no procedure-related deaths or intraoperative accidents. Thoracoscopy is a relatively safe procedure.

Matched MeSH terms: Pleura/pathology; Tuberculosis, Pleural/diagnosis; Pleural Effusion, Malignant/diagnosis
Fulltext Pleural effusion in 100 Malaysian patients

Ngoh HL

Med J Malaysia, 1991 Dec;46(4):301-8.
PMID: 1840436

In a retrospective study of 100 patients with pleural effusion the final diagnosis was tuberculosis in 49, malignancy in 43, malignancy with tuberculosis, bacterial infection, hydrothorax with cirrhosis, reaction to pneumothorax in one each, and unknown in 4. Most of the effusions analysed were exudates (94%). Pleural biopsy was diagnostic in 46% of tuberculous effusions (13/28) and 67% of malignant effusions (20/30). Tuberculosis accounted for 87% of cases in patients aged 40 years and under. In this age group, patients with exudative pleural effusion and a positive tuberculin test are likely to have tuberculosis and early therapeutic trial is justified.

Matched MeSH terms: Pleura/pathology; Pleural Effusion/diagnosis*; Pleural Effusion/etiology
Fulltext Pulmonary melioidosis presenting with pleural effusion: A case report and review of literature

Soo CI, Abdul Wahab S, Abdul Hamid F

Respir Med Case Rep, 2015;16:54-6.
PMID: 26744655 DOI: 10.1016/j.rmcr.2015.07.005

Melioidosis is a serious infection, which can involve multiple systems. We report a case of pulmonary melioidosis with the initial presentation mimicking a partially treated pneumonia complicated by right-sided pleural effusion. The patient is a 49-year old man who did not respond to parenteral ceftriaxone and tazobactam/piperacillin therapy. However, upon culture and sensitivity results from blood and pleural samples isolated Burkholderia pseudomallei; antimicrobial therapy was de-escalated to parenteral ceftazidime. Within 72 h duration, his fever subsided and other respiratory symptoms improved tremendously. This case highlights the importance of early recognition of B. pseudomallei in pulmonary infection in order for prompt institution of appropriate antibiotics treatment; thus reducing morbidity and mortality.

Matched MeSH terms: Pleura; Pleural Effusion
Fulltext Empyema thoracis presented as giant back abscess

Abd Karim SH, Wan Zain WZ, Mohd Hashim MN, Zakaria AD, Hayati F, Ng CY

Radiol Case Rep, 2021 May;16(5):1061-1064.
PMID: 33680277 DOI: 10.1016/j.radcr.2021.02.030

Empyema thoracis (ET) is defined as pus in the pleural space, either localized or involving the entire pleural cavity, due to diverse etiologies. In severe form, it may infiltrate the extrapulmonary region. Clinical guideline describes 3 stages of parapneumonic effusion before developing into an ET, namely the exudative stage, the fibrinopurulent stage, and the organizing/late stage. We highlight a 59-year-old gentleman who presented a back swelling masquerading as a deep-seated abscess, in which the diagnosis of ET had not been established early. The principles of treatment are treating the underlying condition such as pneumonia, pleural drainage and debridement, full re-expansion of the collapsed lung by performing chest physiotherapy, and improving nutrition. ET is a condition with a dynamic process due to diverse etiologies, either localized or involving the entire pleural cavity. The gold standard in diagnosing ET is the pleural aspiration of fluid from the pleural space, whereas the management of ET may include non-surgical and/or surgical treatments based on the basic principles of ET treatment.

Matched MeSH terms: Pleura; Pleural Effusion; Empyema, Pleural; Pleural Cavity
Fulltext Indwelling pleural catheter and successful autopleurodesis of refractory inflammatory lupus effusion

Ng BH, Nik Abeed NN, Abdul Hamid MF, Soo CI, Low HJ, Ban AY

Respirol Case Rep, 2020 Oct;8(7):e00621.
PMID: 32685166 DOI: 10.1002/rcr2.621

Indwelling pleural catheter (IPC) is a useful tool for refractory malignant pleural effusions (MPEs). It allows palliation by intermittent symptomatic relief of the effusion and improves quality of life. Its use in benign pleural effusions comes mainly from retrospective studies, case series, and case reports. Lupus effusion is common, causes minimal symptoms, and usually responds to either steroid therapy or immunosuppressants. Refractory lupus effusion is less common and treatment may require invasive surgical pleurectomy. We describe a 52-year-old woman whose first presentation of systemic lupus erythematosus (SLE) was a pleural effusion refractory to steroids and immunosuppressants. She successfully achieved spontaneous pleurodesis with intermittent IPC drainage at three months.

Matched MeSH terms: Pleura; Pleural Effusion; Pleural Effusion, Malignant
Fulltext Inadvertent diaphragmatic rent following thoracic surgery for empyema thoracis successfully repaired with mesh

Henry Tan Chor Lip, Tan Jih Huei, Simon Jerome Vendargon

Malaysian Journal of Medicine and Health Sciences, 2020;16(3):322-324.
MyJurnal

Iatrogenic diaphragmatic entry following thoracic surgery is rare with only two cases reported till date. This case reports on a 46-year-old male with persistent pleural sepsis due to right empyema thoracis despite best medical ef- forts. Following a right thoracotomy and decortication, the right diaphragm was inadvertently incised due to dense adhesions between the diaphragm and thickened cortex. To our knowledge, this is the third case reported of iatro- genic diaphragmatic entry following thoracic surgery for empyema thoracis. The pearls from this case report is that any evidence of empyema thoracis involving the lower lobe on imaging should warn the surgeons to be aware of inadvertent entry into the peritoneal cavity, as the diaphragm can be adherent to the cortex trapping the lower lobe.

Matched MeSH terms: Pleura; Empyema, Pleural
Fulltext Resolution of pleura-peritoneal fistula via transient daytime ambulatory peritoneal dialysis regime (DAPD) - 8 years follow up

Lim TS, Thong KM

Pak J Med Sci, 2016 11 25;32(5):1302-1304.
PMID: 27882041 DOI: 10.12669%2Fpjms.325.11096

Pleural effusion or hydrothorax is a relatively rare but well-recognized complication associated with peritoneal dialysis (PD). We describe the successful long term resolution of a patient who developed pleural effusions after starting continuous ambulatory peritoneal dialysis (CAPD), by altering the PD prescription to normal volume daytime ambulatory peritoneal dialysis (DAPD) transiently before resuming the usual CAPD exchanges four months later. After 8 years of follow up, there is no sign of recurrence of the effusion. Normal volume DAPD present as an attractive alternative and cheap method for resolution of pleura-peritoneal fistula.

Matched MeSH terms: Pleura; Pleural Effusion
Pedunculated parietal pleural lesion: a rare presentation of bronchogenic cyst

Abdul Rahman MR, Yaman MN, Dimon MZ, Zabir AF, Min JO, Hamid HA

Ann Thorac Surg, 2011 Aug;92(2):714-5.
PMID: 21801925 DOI: 10.1016/j.athoracsur.2011.02.028

We present a 35-year-old man with a preoperative diagnosis of a right lower lobe cystic mass. Misled by a radiological suggestion of an intraparenchymal lesion, he had a thoracotomy and right lower lobectomy. An intraoperative finding of a pedunculated cyst arising from the parietal pleural with subsequent histopathology confirmation of a benign bronchogenic cyst, however, would have made a less invasive surgical excision more appropriate.

Matched MeSH terms: Pleura/pathology; Pleural Diseases/diagnosis*; Pleural Diseases/pathology; Pleural Diseases/surgery
Pleural fluid lactate as a point-of-care adjunct diagnostic aid to distinguish tuberculous and complicated parapneumonic pleural effusions during initial thoracentesis: Potential use in a tuberculosis endemic setting

Kho SS, Chan SK, Yong MC, Cheah HM, Lee YG, Tie ST

Respir Investig, 2020 Sep;58(5):367-375.
PMID: 32107195 DOI: 10.1016/j.resinv.2020.01.004

BACKGROUND: Tuberculous pleural effusions (TBEs) and parapneumonic pleural effusion (PPEs) have similar clinical presentations and fluid biochemistry. A pleural biopsy is usually required to diagnose TBE but complete fluid evacuation may not be necessary, contrasting with complicated PPE (CPPE). A point-of-care test that distinguishes between TBE and CPPE enables the appropriate procedures to be performed during the initial diagnostic thoracentesis. Lactate is a metabolic product measurable by a blood-gas analyzer. This study measured pleural fluid (Pf) lactate levels in TBE and compared them with those in PPE/CPPE. We hypothesized that Pf lactate would be significantly higher in PPE because of active metabolic activities than in TBE which is driven by delayed hypersensitivity.
METHODS: All patients undergoing an initial diagnostic thoracentesis over 18 months with Pf lactate measured using a calibrated point-of-care blood gas analyzer were assessed.
RESULTS: The diagnoses of the enrolled patients (n = 170) included TBE (n = 49), PPE (n = 47), malignancy (n = 63), and transudate (n = 11). Pf lactate level in TBE, median 3.70 (inter-quartile range 2.65-4.90) mmol/l, was significantly lower than in PPE and CPPE. In the subgroup of TBE and CPPE patients whose initial Pf pH and glucose could suggest either condition, Pf lactate was significantly higher in those with CPPE. Pf lactate (cutoff ≥7.25 mmol/l) had a sensitivity of 79.3%, specificity 100%, positive predictive value 100%, and negative predictive value 89.1% for discriminating CPPE from TBE (area under the curve 0.947, p

Matched MeSH terms: Pleura/metabolism*; Pleural Effusion/diagnosis*; Tuberculosis, Pleural/diagnosis*
Fulltext Transudative pleural effusion in a patient with pleural tuberculosis

Meryl Grace Lansing, Liew Sat Lin Constance, Chang Chee Keong, Pradip Subramaniam

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):97-97.
MyJurnal

Introduction:Light’s criteria for pleural fluid analysis has long been the standard for distinguishing transudates from exudates. In pleural tuberculosis, the resulting pleural fluids are usually exudates. We present a case of presumed transudative effusion which was eventually diagnosed as pleural tuberculosis. Case description: A 59-year-old man with end-stage renal failure (ESRF) on regular haemodialysis presented with a one-day history of acute onset dys-pnoea associated with pleuritic chest pain and cough. Chest radiograph revealed bilateral pleural effusions and thoracentesis was done. The pleural fluid result was interpreted as transudative effusion according to Light’s criteria because his pleural fluid to serum protein ratio was less than 0.5. AFB 1+ was seen in the pleural fluid with negative gram stain and culture. This resulted in conflicting opinions on whether to start this patient on anti-tuberculous ther-apy (ATT) and there was even a suggestion to get a second opinion for the possibility of AFB fluid contamination. The initial diagnosis was written as fluid overload secondary to ESRF but ATT was started anyway to cover for pleural TB. On further analysis of his pleural fluid, the pleural protein 32 g/L which on its own is a marker of exudative effusion. Subsequent investigations revealed the presence of exudative ascitic fluid which further raised the suspicion for a concomitant peritoneal TB. Conclusion: Premature conclusion that the pleural fluid was transudative occurred prob-ably due to the bilateral nature of the pleural effusion associated with a known tendency for the patient to develop pulmonary overload secondary to his ESRF. This case is a reminder that Light’s criteria also requires serum and fluid LDH measurement for the diagnosis of transudative pleural effusion. More importantly, a high level of suspicion for TB is important when evaluating patients from areas where TB is prevalent and a positive AFB result should not be taken lightly.

Matched MeSH terms: Pleura; Pleural Effusion; Tuberculosis, Pleural
The Cobblestone Heart

Tan WJ, Suz CS, Azza O, Zuki M

Med J Malaysia, 2021 03;76(2):241-244.
PMID: 33742636

Sarcoidosis is a chronic, multisystem disorder. A 38 years old lady presented at Hospital Raja Perempuan Zainab II, Kota Bharu ,Malaysia with cough and breathless for 2 months and constitutional symptoms of weight loss and loss of appetite. She was initially treated as smear negative pulmonary tuberculosis for 5 months. However, her clinical condition deteriorated with worsening New York Heart Association (NYHA) class 1 to class 3. Subsequently, workout of computed tomography( CT) thorax showed multiple perilymphatic distribution of nodules and multiple mediastinal lymphadenopathy coupled with pleura biopsy showed non caseating granuloma and cardiac magnetic resonance imaging (MRI) with positive late gadolinium enhancement revised the diagnosis of pulmonary sarcoidosis with cardiac involvement. Patient's functional status and cough improved with immunosuppresant was given in tapering dose fashion.

Matched MeSH terms: Pleura

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