Dyspnea and Mild Intermittent Cough in a Nonagenarian

A 95-year-old woman was seen for a mild intermittent cough and a 2-day history of increased shortness of breath at rest. Previously, the patient reported mild dyspnea upon exertion, especially when getting out of bed. She reported no chest pain, diaphoresis, or hemoptysis. Her medical history was significant for mild chronic renal insufficiency, anemia, osteoarthritis, hypertension, and breast cancer of her left breast 15 years earlier, which was treated with a mastectomy, chemotherapy, and radiation. Her only medication was acetaminophen for her osteoarthritis. She had been receiving antihypertensive medications, but these were discontinued when she developed orthostatic hypotension. The patient had been living at a skilled nursing facility for 4 years. She was able to eat independently and could transfer to a wheelchair without assistance, but required some help with dressing and grooming.

Physical Examination

On physical examination, the patient had a blood pressure of 160/80 mm Hg, heart rate of 72 beats per minute, respiratory rate of 24 breaths per minute, and a pulse oximetry reading of 94% on room air. She appeared mildly dyspneic at rest. Her lung fields were clear to auscultation bilaterally, but a grade 4/6 holosystolic ejection murmur was noted. She had 1+ pitting edema of both ankles. Laboratory studies revealed a white blood cell count of 4300/µL (normal, 4500-11,000/µL), a normal chemistry panel, and a B-type natriuretic peptide level of 22,630 pg/mL (normal, <167 pg/mL). An electrocardiogram showed normal sinus rhythm with a heart rate of 75 beats per minute, bifascicular block, and borderline left ventricular hypertrophy. A portable chest radiograph revealed several discrete, well-demarcated masses in the right lung fields (Figures).

Based on the case description and figures, what is your diagnosis?

A.Hemothorax

B.Chylothorax

C.Pseudotumors

D.Fibrous tumors originating from the visceral pleura of the interlobar fissure

[See next page for answer and discussion]

Answer: Pseudotumors (C)

The clinical diagnosis of pseudotumors in this patient is based on the radiographic findings of fluid in the fissures (Figure 1). The diagnosis was confirmed by a computed tomography scan, which showed three homogenous densities of -10 Hounsfield units (HU) to -20 HU abutting the fissures, consistent with pseudotumors. The patient was hospitalized and treated with intravenous furosemide. Her dyspnea improved and a chest radiograph taken on hospital day 5 showed the masses had disappeared (Figure 2).

Pseudotumors are sharply marginated collections of pleural fluid contained within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure.¹ They result from transudation from the pulmonary vascular space and have a biconvex contour. More than 75% occur in minor (horizontal) fissures and are seen on both the frontal and lateral radiographs; however, those that occur in major (oblique) fissures may only be readily visible on the lateral view.¹ In rare cases, pseudotumors occur in minor and major fissures simultaneously. The case patient’s pseudotumors measured approximately 6 cm each, but most lesions have been reported to be <4 cm.¹

Pseudotumors are often incidental radiographic findings in patients with congestive heart failure. Interlobar pleural effusions do not correspond to left heart failure severity and may be the only sign of cardiac decompensation.¹ The differential diagnosis of loculated pleural effusions in fissures includes transudates from left ventricular failure or renal failure, exudates, hemothorax, chylothorax, malignant pleural effusions, and fibrous tumors originating from the visceral pleura of the interlobar fissure. If a pseudotumor is correctly diagnosed, it will have little impact on patient management; however, pseudotumors may be easily misdiagnosed as lung masses. When a misdiagnosis occurs, it can lead to expensive imaging studies, invasive procedures (eg, biopsies), unwarranted use of antibiotics, and needless patient and family anxiety.

Although pseudotumor is an uncommon presentation of congestive heart failure, it may be seen more frequently in geriatric patients and in residents of long-term care facilities because there is a high incidence of congestive heart failure in this population.

Dr. Bernacki is director of quality initiatives, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.

The author reports no relevant financial relationships.

Reference

1.Haus BM, Stark P, Shofer SL, Kuschner WG. Massive pulmonary pseudotumor. Chest. 2003;124(2):758-760. www.learningradiology.com/archives05/COW%20159-Pseudotumor/pseudotumorcorrect.htm. Accessed October 19, 2011.