Recurrent Pleuritic Chest Pain, Lobar Consolidation, and Pleural Effusion in a 50-Year-Old Woman

Abstract

Case Presentation: A 50-year-old woman with a history of permanent atrial fibrillation (AF) treated with radiofrequency catheter ablation (RFCA) 6 months ago was admitted to the respiratory department of a tertiary hospital because of recurrent episodes of pleuritic chest pain in the preceding 5 months. The patient reported multiple visits to a regional hospital, where she was treated with broad-spectrum antibiotics after discovery of a left alveolar consolidation on chest radiograph (Fig 1), subsequently imaged with CT scan (Fig 2). On treatment failure and appearance of a left-sided pleural effusion during outpatient follow-up, the patient was re-admitted. Pleural fluid was obtained via thoracocentesis characterized by exudative features and lymphocytic predominance. Abdomen CT scan, with IV and per os contrast agent, was devoid of findings consistent with malignancy, and serum autoantibody levels were below positivity cut off values (antinuclear, cyclic citrullinated peptide antibody, rheumatoid factor, and anti-neutrophil cytoplasmic antibodies). The patient underwent flexible bronchoscopy without endobronchial pathology on visual inspection. Microbiologic studies and cytological examination of samples obtained by bronchial washing/aspiration yielded no clinically relevant information. Lung perfusion/ventilation scintigraphy was ordered to exclude chronic thromboembolic pulmonary hypertension; however, a deficit in vascularization for the left inferior lobe was found, prompting further investigation (Fig 3). Progression of left inferior lobe consolidation and the presence of a small pericardial effusion became evident on reimaging after a 2-month interval. The patient was empirically started on corticosteroids. After emergence of left hilar lymphadenopathy (< 1 cm), a PET-CT scan was performed. The left lower inferior lobe consolidation, whose metabolic activity pattern was consistent with that of inflammation (standardized uptake value equal to 4.4) (Fig 4), as well as the left sided-pleural effusion were markedly improved compared with previous imaging 20 days after corticosteroid initiation (Fig 2). On the grounds of recalcitrant pleuritic pain and pleural effusion recurrence during corticosteroid tapering, the patient was referred to the respiratory department of our university hospital to have her condition diagnosed. © 2022 American College of Chest Physicians