May 2018 Pulmonary Case of the Month
Tuesday, May 1, 2018 at 8:00AM
Rick Robbins, M.D. in amyloidosis, chyle, chylous, fat biopsy, heart failure, lymphangiogram, multiple myeloma, pleural effusion, triglycerides, ultrasound

Kenneth K. Sakata, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA


History of Present Illness

A 70-year-old man was referred because of new anemia and a heme-positive stool. Esophagogastroduodenoscopy (EGD) was performed which revealed gastritis. Ascites developed and a chest x-ray noted a left pleural effusion. He was managed with weekly high-volume thoracentesis and paracentesis. He was referred to pulmonary medicine.

Past Medical History, Social History and Family History

He has a history of coronary artery disease having undergone coronary bypass grafting in 2016. He also has type 2 diabetes mellitus managed by diet and recently diagnosed orthostasis. He smokes about ½ pack of cigarettes per day but does not drink alcohol. He denies any inhalational exposures. He is Native American and works as a judge. There is no family history of any similar disorders.

Physical Examination

A point of contact ultrasound is performed (Figure 1).

Figure 1. Image from the point of contact ultrasound.

What should be done next? (Click on the correct answer to proceed to the second of seven pages)

  1. Needle biopsy of pleural mass
  2. Thoracentesis
  3. Thoracic surgery consultation for video-assisted thorascopic surgery (VATS)
  4. 1 and 3
  5. All of the above

Cite as: Sakata KK. May 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(5):237-44. doi: PDF 

Article originally appeared on SOUTHWEST JOURNAL of PULMONARY & CRITICAL CARE (
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