Abstract: We present the clinical case of a 58-year-old female patient, a smoker with occupational exposure to respiratory toxins, who was admitted to our clinic following evaluation in an emergency department, where she was diagnosed with a moderate right pleural effusion. Upon admission, the patient exhibited respiratory symptoms, including progressive dyspnea with a moderate exertion threshold, right posterior pleuritic chest pain radiating anteriorly, occasional episodes of low-grade fever, and persistent febrile symptoms lasting approximately two weeks. In this clinical context, the diagnostic process was guided by the presence of right pleural effusion syndrome, which was refractory to conservative medical therapy. This necessitated a careful and stepwise expansion of investigations, ultimately leading to the diagnosis of malignant pleural mesothelioma. This case underscores the diagnostic challenges posed by pleural effusion, the necessity of adhering to the diagnostic algorithm, and the critical role of the multidisciplinary team. The diagnostic approach, often complex and challenging, necessitates a multidimensional strategy that integrates the correlation and synthesis of data obtained through anamnesis, alongside advanced diagnostic procedures such as pleural biopsy, which remains the gold standard. This comprehensive process is essential for formulating a diagnostic suspicion, with the final diagnosis intended to be one of exclusion.
Introduction: Malignant pleural mesothelioma (MPM) is an uncommon but highly aggressive malignancy that arises in the pleural lining of the lungs, primarily due to inhaled asbestos fibers. These microscopic fibers embed in the pleura, initiating cellular inflammation and genetic damage that, over many years, often 20 to 50, can progress to mesothelioma. MPM is notoriously challenging to diagnose early, as initial symptoms like chest pain, dyspnea, and pleural effusions are often nonspecific and mimic other pulmonary conditions.
The disease is generally staged I through IV, with higher stages indicating greater spread to lymph nodes, nearby structures, or distant sites, which complicates treatment. Standard therapies include surgery, such as pleurectomy/decortication or extrapleural pneumonectomy, combined with chemotherapy (often pemetrexed and cisplatin) and radiation therapy. Recent advancements in immunotherapy, particularly checkpoint inhibitors, are providing new hope, albeit limited, for extending survival. Despite ongoing research, the prognosis for MPM remains poor, making early diagnosis and experimental therapies critical areas of focus in mesothelioma management.
Case Presentation: A 58-year-old female patient was admitted to our clinic for specialized investigations and appropriate therapeutic management following the diagnosis of a right pleural effusion, indicated at an emergency medical service where she initially presented. She was a smoker with a 15-pack-year history and 15 years of occupational exposure to respiratory toxins from working in the tobacco industry, multiple comorbidities, including grand mal epilepsy, stage II hypertension, hypertensive heart disease with preserved ejection fraction, grade I obesity, a hysterectomy in 2001 for uteroplacental apoplexy, and surgically induced menopause at age 34.
The patient reported an insidious onset of symptoms, including progressive dyspnea with moderate exertion (mMRC score 2), right posterior chest pain radiating to the anterior chest, and intermittent episodes of low-grade fever (37.2°C to 38°C). Given her poor general condition and these symptoms, she presented to the emergency department, where a chest X-ray was performed, and antibiotic and symptomatic treatment was also initiated. The X-ray (not provided) revealed changes suggestive of a moderate right pleural effusion. [Footnotes omitted.]
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