An 80-year-old male presented with a 2-month history of productive cough, dyspnea on exertion, and chest discomfort on walking, as well as a 1-month history of loss of appetite and right shoulder pain. Examination revealed decreased breath sounds and vocal fremitus on the right side of the chest. Imaging showed a right paracardiac consolidation with pleural effusion and a mediastinal mass. Biopsy of the mass revealed features suggestive of thymoma. The provisional diagnosis was thymoma presenting with right-sided pleural effusion.
1. By
Dr Subrata Das M.D Consultant(Internal Medicine)
&
Dr.Nagu Penakacherla MBBS, MEd(USA), DNB
Senior Registrar
Internal Medicine Department
Sakra World Hospital
2. 80 Year old Male patient presented with C/O
Productive cough since 2 months
Dysnea on exertion sine 2 month
Chest discomfort on walking since 1 month
Right shoulder pain since 1 month
Loss of apetite since 1 month
3. c/o Cough since 2 months associated with sputum
expectoration whitish in color not blood stained and
episodic all through the day.
c/o chest pain- 6 months
- intermittent
- Right sided
- pricking
- radiating to right shoulder
- not ass.with sweating/palpitation
- aggravating with walking /relieves on
rest
c/o breathlessness- 2 months
- insidious
- gradually progressing from NYHA Class II to Class III
recently from a week.
-not ass.with orthopnoea/PND
o C/o LOA Since 1 month
4. No H/o
hemoptysis
Syncope
Leg swelling
Abdominal distension
↓ed urine output
Dysphagia
Headache/vomiting
No h/s/o weakness/sensory/motor
abnormalities/cerebellar involvement
5. k/c/o DM Type 2 on Treatment
Not a k/c/o Bronchial Asthma/Pulmoanry
Tuberculosis /Coronary Artery Disease
No h/o sugeries/Radiotheray
No h/o chronic drug intake
7. Conscious, dyspnoeic, oriented, afebrile
No pallor/cyanosis/clubbing/icterus/pedal
edema
VITALS:
BP- 140/90 mmHg
PR- 90/min, regular, normal volume, no
spl.characters
RR- 22/min
JVP- not raised
Temp- 98.4 F
Spo2 -95% on Room Air.
8. INSPECTION:
Trachea app.to be in the midline.
Apical impulse –not visible
Chest movements- Decreased in Right side
compared to left.
Increased Respiratory Rate.
No chest wall deformity
No scars/sinuses
No distended veins
9. PALPATION:
Trachea- midline
Apical impulse- left 5th ICS at MCL
Chest movements –Decreased on right side
Chest measurements- WNL
No Tactile Fremitus
VF- ↓ed in right infraclavicular & mammary
regions
No Intercostal tenderness
10. PERCUSSION:
Dullnote + in right infraclavicular &
mammary regions
No percussion tenderness
No shifting dullness is noted
Traube’s space- normal tympanitic note +
11. AUSCULTATION:
Breath sounds ↓ed in right infraclavicular &
mammary regions
VR ↓ed in the same regions
Egophony is present in the right side of the
chest.
No BBS
12. CVS- S1,S2 +, no murmurs
P/A- soft, no organomegaly, no FF clinically
CNS- Conscious, coherent and oriented, No
sensory and motor abnormalities.
19. X ray Chest – Right paracardiac
consolidation with Right sided Pleural
Effusion with loculated component along
lateral chest wall.
2D ECHO done was Normal.
CT Chest done outside was reviewed here
again which showed Calcified Anterior
Mediastinal Mass Measuring 8.7 X 6.8 X 6.7
cm.
20. USG guided Pleural fluid tapping was done
and analysis revealed its Exudative effusion.
CT guided Biopsy done and Histopathology
report sent revealed Features suggestive of
Thymoma and Type A according to WHO
Classification.
27. A neoplasm of the Thymic epithelial cells .
Results from dysregualtion of the proliferation
and maturation of T- lymphocytes .
This process results in either Autoimmunity or
Immune defeciency
As a result , thymomas are associated with
autoimmune diseases in 70% of the patients
during diagnosis .
Thymomas are ussually encapsulated and
spread by local extension .
29. Local symptoms :
Dyspnea .
Dysphagia .
Cough .
SVC obstruction .
Thymomas tend to be highly vascular →
bleeding and necrosis .
Paraneoplastic :
MG.
Hypogammaglobulenemia .
Good syndrome .
Oppurtunistic infections
30. CBC- anemia, thrombocytopenia,
granulocytopenia (in pure red cell aplasia)
Peripheral smear study
Quantitative immunoglobulin assay to r/o
immunodeficiency
Anti ACh receptor antibodies/repititive
nerve stimulation tests/Edraphonium
ameliorative tests to r/o myasthenia gravis
Bone marrow aspiration to r/o pure red cell
aplasia