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

6.  Married
 Taking mixed diet
 Non-smoker
 Non-alcoholic

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.

17. What could be the Provisional Diagnosis???

18.  Hb – 14g/dl
 Total Count- 9300
 Platelet Count- 2,60,000
 Peripheral Smear – N
 ESR -14
 SERUM Creatitine – 0.7
 Na/K – 128/5.3
 Ca- 9.3
 LDH – 179
 TSH & PT/INR - N

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.

21. Any Questions ???

24. The most commonly used
staging system for thymoma is
called the Masaoka system

26.  Thymoma
 Lymphoma
 Germ cell tumor
 Thyroid and Parathyroid tumor

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 .

28.  30 % local symptoms
 30 % abnormal chest radiographs
 30 % Myasthenia Gravis (paraneoplastic
syndrome)

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

33. Thank You