Our Answer

We performed a pleural tap.

The pleuralal fluid was orange and turbid in appearance, with a pH of 8.00 (Not On Ice and so of questionable Accuracy). WBCs were 3750 cells/ul, with 55% PMN, 44% lymphocytes. RBCs were 23,000 cells/ul. Protein was 30.52 g/L (ratio of pleural to serum protein of < 0.5). LDH was 156 U/L (ratio of pleural to serum of < 2/3). Gram stain and culture were negative, and pathology exam revealed no malignant cells. Although the protein and LDH suggested a transudate, the cell suggested an exudate.

An ECHO was also done and showed a right pleural effusion, mild tricuspid regurgitation, trivial pulmonary regurgitation, grossly normal ventricular systolic function, and small pericardial effusion.

She was then admitted to the hospital for observation while awaiting her test results. In hospital, the fever did not persist, but cough and dyspnea did. She was given supplemental oxygen at night at a rate of 1 L/m. Her chest radiograph stayed unchanged. Blood culture showed no growth of bacteria. C-reactive protein was 221 mg/L (elevated), and D-dimers were 1600 ng/ml (highly elevated).

Any other investigations you would like to do at this point?

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