Crouching Tiger, Hidden Dragon - Malignant Pleural Mesothelioma as a Culprit for Recurrent Spontaneous Pneumothorax and Hydropneumothorax.

SESSION TYPE: Cancer Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Spontaneous pneumothorax can be caused by lung tissue weakness - rupture of thin cysts called blebs on lung surface. Chest pain, dyspnea and occasionally palpitations are classical symptoms of pneumothorax but it can also present silently.CASE PRESENTATION: A 58 year old Caucasian male working as a chemical engineer presented with palpitations and rapid heart rate of 190 per minute which was resolved with valsalva maneuver in ER. He did not have any chest pain or dyspnea. Chest X ray followed by CT scan of the chest showed large left pneumothorax. Patient had previous small 15% pneumothorax before 1 year discovered incidentally during coronary calcium scoring imaging study. At that time, patient was asymptomatic and pneumothorax got resolved without any interventions. He had no problems in the interim. After one year, patient again presented with left sided hydropneumothorax. Patient underwent thoracoscopy which eventually converted into small thoracotomy with lysis of adhesions, stapling of apical bleb and resection of lingular bleb and associated calcified nodule and talc Pleurodesis. Pathology report did not show any malignant cells. He underwent thoracentesis multiple times for recurrent left sided pleural effusion but still the cause for his recurrent pneumothorax, hydropneumothorax and pleural effusions was a mystery. Fluid cytology was negative for any malignancy. Bronchoscopy also did not show any abnormalities. Eventually, patient underwent decortication procedure due to recurrent pleural effusion, and to our surprise, cytology results showed malignant mesothelioma with epitheloid variantDISCUSSION: Malignant pleural mesothelioma is a neoplasm with most common clinical presentation being nonpleuritic chest pain and dyspnea. Common radiological findings include unilateral pleural effusion. Our patient presented with pneumothorax which is a rare presentations to begin with. He also had recurrent pneumothorax and hydropneumothorax. The pleural mesothelioma is accounted for 11 % spontaneous pneumothorax. The patient in the case, never had any known asbestos exposure. The incidence of atypical presentation of malignant mesothelioma is increasing in recent years but the overall rate of malignant mesothelioma is slowly decreasing since 1990s. Histopathological investigation should always be considered in recurrent pneumothorax.CONCLUSIONS: Awareness of malignant pleural mesothelioma presenting as a recurrent spontaneous pneumothorax or hydropneumothorax would increase the rate of early diagnosis and treatment.1) Sheard JD, Taylor W, Soorae A, Pearson MG. Pneumothorax and malignant mesothelioma in patients over the age of 40. Thorax. 1991;46:584DISCLOSURE: The following authors have nothing to disclose: Mihir Patel, Hetvi Joshi, Jayantilal MehtaNo Product/Research Disclosure InformationEast Tennessee State University, Johnson City, TN.