Peritonitis due to rupture of retroperitoneal teratoma: computed tomography diagnosis

Retroperitoneal benign cystic teratoma is relatively rare in adults. We report a case of traumatic rupture of primary retroperitoneal teratoma into peritoneum that produced chemical peritonitis. It was demonstrated by computed tomography, which showed fat-fluid levels in the peritoneum. We suggest that the demonstration of fat-fluid levels in the peritoneum could be a reliable sign of intraperitoneal rupture of abdominal teratoma and subsequent chemical peritonitis.     

Two cases of mature mediastinal teratoma complaining of sudden chest pain]

We report two cases of mature mediastinal teratoma complaining of sudden chest pain. Both cases had cystic lesions, multilocular and unilocular, and pleural effusion. One case had fat density by CT and MRI and calcification was not recognized in either case. Surgical resection of the tumor revealed pancreatic tissue in both cases, suggesting that pancreatic enzymes might have led to the rupture of the tumor. The diagnosis of teratoma and its rupture should be considered in the cases of cystic lesion in mediastinal with sudden onset of chest pain.     

Increased CA 125 in a patient with tuberculous peritonitis: case report and review of published works.

A case of a middle aged woman with weight loss, ascites, and a pleural effusion is presented where a clinical diagnosis of ovarian cancer was made. Her CA 125 was greatly increased at 873 IU/ml and the ascites was a lymphocytic exudate but cytology failed to show malignant cells. Operative biopsy showed numerous noncaseating granulomas in the omentum but no mycobacterial organisms were seen. Empiric antituberculous treatment was started before positive culture results were received and when treatment had ended both the ascites and pleural effusion had resolved and the CA 125 had fallen to 7 IU/ml. Review of published works showed several other examples of tuberculous peritonitis associated with increased CA 125 and the possible cause of raised CA 125 in this condition is discussed.     

Síndrome de Tjalma (pseudo-pseudo Meigs) como manifestación inicial de lupus eritematoso sistémico de inicio juvenil

Tjalma syndrome or pseudo-pseudo Meigs’ syndrome is a clinical condition characterized by pleural effusion, ascites and elevated CA-125 with no associated benign or malignant ovarian tumor in a patient with systemic lupus erythematosus (SLE). Tjalma described the first case of a patient with SLE, pleural effusion, ascites and elevated CA-125. We report the first case in a 14-year old patient who presented with ascites and pleural effusion refractory to treatment and elevated CA-125, in the absence of an ovarian tumor, that warranted aggressive management.     

Pseudo-Meigs syndrome: particular management of ovarian metastases in colorectal cancer

Ascites and/or pleural effusion with ovarian metastases in colorectal cancer are usually related to peritoneal carcinomatosis. Pseudo-Meigs syndrome is a characterized by non-malignant ascites and/or pleural effusion caused by pelvic tumors other than solid benign ovarian tumors. We treated two patients who developed this syndrome in a context of colorectal cancer. After ovarian metastasis resection, ascites and pleural diffusion disappeared. In the presence of acellular ascites with ovarian metastases from colorectal cancer, diagnosis of pseudo-Meigs syndrome may allow surgical treatment with curative intent.     

Meigs’ syndrome: a rare cause of recurrent pleural effusion in scleroderma

Meigs’ syndrome represents a triad of pleural effusion, ascites, and an ovarian tumor, usually benign, occurring together. We describe here a case of Meigs’ syndrome in a patient with systemic sclerosis, the first such report to our knowledge, in systemic sclerosis. A 53-year-old woman with systemic sclerosis presented with recurrent right-sided pleural effusion, which led to symptoms of shortness of breath, chest tightness, and a non-productive cough. Physical examination revealed a palpable, mobile mass in the right lower quadrant, in addition to typical physical features of scleroderma. Thoracentesis yielded exudative pleural fluid with cytology negative for malignancy. Pleural biopsy was consistent with inflammatory changes, but negative for malignancy. CT scan of the chest, abdomen, and pelvis revealed a soft tissue mass in the pelvis, which appeared to arise from the left ovary. The patient’s cancer antigen 125 (CA-125) level was elevated at 222 U/mL (normal range, 0–30 U/mL). The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology of the left ovarian mass was consistent with an ovarian fibrothecoma, a benign tumor of the ovary. At her 1-month follow-up appointment, the patient had complete resolution of the right-sided pleural effusion. To date, at 10 months past the initial presentation, she has not had recurrence of pleural effusion. Although rare, Meigs’ syndrome should be considered as a possible cause of recurrent serositis in women with rheumatologic diseases. Removal of the ovarian tumor leads to prompt resolution of the serositis.     

Pseudo-Meigs syndrome and elevated levels of tumor markers associated with benign ovarian tumors--two case reports

Elevated tumor markers for a post-menopausal woman presenting with a multilocular adnexal mass, ascites, and pleural effusion were interpreted as being highly suspicious of malignancy. This paper describes two cases of ovarian tumors presenting with all signs of malignancy. Following surgical excision of the masses, and histopathological assay, a benign pure struma ovarii and a mucinous cystadenoma were diagnosed by pathologists. The immediate and complete resolution of symptoms were achieved post-operatively, and the previously-evident abnormal tumor markers rapidly declined to the normal range, the two tumors were subsequently classified as pseudo-Meigs' syndromes.     

Meigs syndrome revisited

The association of a benign ovarian tumor with ascites and hydrothorax that resolve after tumor resection is known as Meigs syndrome, and its importance was first emphasized by Meigs and Cass in 1937. The importance of Meigs syndrome is that the presence of ascites and pleural effusion does not necessarily indicate that a pelvic mass is malignant. The benign tumors in Meigs syndrome are usually fibromas or fibrothecomas and constitute 4% of all ovarian neoplasms. The authors present a case of Meigs syndrome with an ovarian fibroma. They focus on the evaluation of pleural fluid in the setting of an ovarian mass and then briefly discuss the imaging of ovarian fibromas and fibrothecomas.     

Clinical experience of Pseudo-Meigs＇ Syndrome due to colon cancer

We report a rare case of Pseudo-Meigs＇ Syndrome caused by ovarian metastasis from sigmoid colon cancer, which was accompanied by peritoneal dissemination. A 58-year-old female patient presented with massive right pleural effusion, ascites and a huge pelvic mass. Under the diagnosis of an advanced ovarian tumor, bilateral oophorectomy was performed and sigmoidectomy was also carried out after intraoperative diagnosis of peritoneal dissemination involving the sigmoid colon. How- ever, immunohistochemical staining revealed that the ovarian lesions were metastasis from the primary advanced colon cancer. Postoperatively, ascites and pleural effusion subsided, and the diagnosis of Pseudo-Meigs＇ Syndrome due to a metastatic ovarian tumor from colon cancer was determined. The patient is now undergoing a regimen of chemotherapy for colon cancer without recurrence of ascites or hydrothorax 10 mo after the surgery. Pseudo-Meigs＇ Syndrome due to a metastaticovarian tumor from colon cancer is rare but clinically important because long-term alleviation of symptoms can be achieved by surgical resection. This case report suggests that selected patients, even with peritoneal dissemination, may obtain palliation from surgical resection of metastatic ovarian tumors.     

Pseudo-Meigs' syndrome secondary to metachronous ovarian metastases from transverse colon cancer

Pseudo-Meigs' syndrome associated with colorectal cancer is extremely rare. We report here a case of pseudo-Meigs' syndrome secondary to metachronous ovarian metastases from colon cancer. A 65-year-old female with a history of surgery for transverse colon cancer and peritoneal dissemination suffered from metachronous ovarian metastases during treatment with systemic chemotherapy. At first, neither ascites nor pleural effusion was observed, but she later complained of progressive abdominal distention and dyspnea caused by rapidly increasing ascites and pleural effusion and rapidly enlarging ovarian metastases. Abdominocenteses were repeated, and cytological examinations of the fluids were all negative for malignant cells. We suspected pseudo-Meigs' syndrome, and bilateral oophorectomies were performed after thorough informed consent. The patient's postoperative condition improved rapidly after surgery. We conclude that pseudo-Meigs' syndrome should be included in the differential diagnosis of massive or rapidly increasing ascites and pleural effusion associated with large or rapidly enlarging ovarian tumors.     

Pseudo-Meigs’ syndrome secondary to metachronous ovarian metastases from transverse colon cancer

Pseudo-Meigs’ syndrome associated with colorectal cancer is extremely rare. We report here a case of pseudo-Meigs’ syndrome secondary to metachronous ovarian metastases from colon cancer. A 65-year-old female with a history of surgery for transverse colon cancer and peritoneal dissemination suffered from metachronous ovarian metastases during treatment with systemic chemotherapy. At first, neither ascites nor pleural effusion was observed, but she later complained of progressive abdominal distention and dyspnea caused by rapidly increasing ascites and pleural effusion and rapidly enlarging ovarian metastases. Abdominocenteses were repeated, and cytological examinations of the fluids were all negative for malignant cells. We suspected pseudo-Meigs’ syndrome, and bilateral oophorectomies were performed after thorough informed consent. The patient’s postoperative condition improved rapidly after surgery. We conclude that pseudo-Meigs’ syndrome should be included in the differential diagnosis of massive or rapidly increasing ascites and pleural effusion associated with large or rapidly enlarging ovarian tumors.     

Gastric schwannoma as a rare differential diagnosis of pleural effusion

We report a case of solitary gastric schwannoma that initially manifested with recurrent left pleural effusion caused by an inflammatory reaction. A 75-year-old female was primarily admitted with progressive dyspnoea and left sided effusion. History as well as clinical examination, gastroscopy, computed tomography (CT) and transabdominal ultrasound of the abdomen suggested the diagnosis of a benign tumour of the stomach. The tumour was resected and a fundectomy with a security distance of 3-5 cm performed. Histological assessment revealed a large intramural schwannoma of the gastric wall, arising from the submucosal layer. There was no evidence of malignancy. During a three year follow-up the patient has not shown any evidence of relapse or pleural effusion. This is a very rare manifestation of this benign tumour, representing a rare differential diagnosis in a case of left sided pleural effusion.     

Severe ascites with hypothyroidism and elevated CA125 concentration: a case report

Ascites caused by hypothyroidism is rare and the pathogenesis is unclear. Several reports have presented cases of progressive ascites with hypothyroidism and elevated tumor markers. We report a 31-year-old female case with massive ascites and elevated serum CA 125 concentrations. The patient had no typical feature of hypothyroidism except an accumulation of ascitic fluid which showed elevated total protein concentration and a high serum-ascites albumin gradient (SAAG). There was no finding of malignancy. Following thyroid hormone replacement, the ascites was completely resolved accompanied by reduced concentrations of serum CA125. In general, primary hypothyroidism with ascites presents with coexisting massive pericardial or pleural effusion. The massive ascites and increased serum CA125 concentrations may have led us to make the incorrect diagnosis of ovarian malignancy. The evaluation of thyroid function is useful to determine the pathology of high-protein ascites or elevated tumor markers, and ascites may be treatable by thyroid replacement therapy.     

Chylopericardium presenting as cardiac tamponade secondary to an anterior mediastinal cystic teratoma

Cardiac tamponade, the accumulation of fluid in the pericardial space, leads to impaired venous return, loss of left ventricular preload, and hemodynamic collapse. The many causes of tamponade include malignancy, infection, inflammation, connective tissue disorders, and uremia. Herein, we report the case of a young woman who presented with syncope. She was found to have cardiac tamponade secondary to a chylous pericardial effusion that was due to a mature and benign anterior mediastinal cystic teratoma. Numerous reports have described pericardial effusions secondary to an anterior mediastinal cystic teratoma; however, to our knowledge, this is the 1st case of a teratoma causing chylopericardium that presented as tamponade.     

A case of tuberculous peritonitis

We report a case of a 73-year-old man with tuberculous peritonitis. He had sought treatment at a clinic near his house for his fever and abdominal distension. Massive ascites were found and he was referred to our hospital. The endoscopy and abdominal CT scan performed on admission revealed no abnormal findings except the massive ascites. Mycobacterium tuberculosis (MT) DNA was detected in the ascitic fluid by polymerase chain reaction (PCR) and ascitic adenosine deaminase (ADA) activity was 127.6 U/l. He was diagnosed as tuberculous peritonitis and transferred to the Department of Respiratory Medicine. A chest CT scan showed predominant right pleural effusion with no other abnormal findings in bilateral lung fields. His sputum were all positive by smear acid-fast staining, MT DNA and culture on MT. His final diagnosis was tuberculous peritonitis, pulmonary tuberculosis, and tuberculous pleuritis. Treatment was started by anti-tuberculosis drugs with combined use of isoniazid, rifampicin, ethambutol, and pyrazinamide. The therapy was continued for 6 months. The culture for MT (Mycobacteria Growth Indicator Tube) converted to negative after 2 weeks of treatment and the C-reactive protein level became normal after a month. The pleural effusion and ascites disappeared after 2 and 3 months, respectively. Tuberculous peritonitis is a relatively rare disease, however when we encounter unexplained ascites, MT PCR and the measurement of ADA should be done considering a rapid diagnosis of tuberculous peritonitis, before invasive diagnostic laparoscopy.     

Pleural effusion due to the ovarian hyperstimulation syndrome

Ovulation induction is a treatment that aimed to increase the pregnancy probability by increasing the follicular grow up and maturation. The most frequent complication is ovarian hyperstimulation syndrome (OHSS). Pleural effusion and abdominal ascites accumulation is frequently accompany this syndrome. A young patient receiving ovulation induction therapy was admitted to our department with sudden chest pain and dyspnea. Exudative pleural effusion was determined in the right and we suggest that pleural effusion was accumulated due to OHSS because of the presence of abdominal ascites, hemoconcentration, recent application of ovulation induction therapy and elimination of other causative factors for pleural effusion. The disappearance of pleural effusion spontaneously in a week support our idea. We reviewed the literature about the pleural effusion due to ovarian hyperstimulation syndrome. In the differential diagnosis of pleural effusion in young female patients, the accumulation of pleural effusion due to the recent ovulation induction story should be kept in mind which is especially important in the differential diagnosis of pulmonary embolism.     

Diagnostic significance of pleural fluid eosinophilia during initial thoracocentesis

A prospective study of pleural fluid eosinophilia (PFE) during initial thoracocentesis in 162 patients of pleural effusion was undertaken to determine its value in establishing an etiological diagnosis. Eighteen of the 162 cases showed pleural fluid eosinophilia (PFE), twelve could not be labelled with any definitive etiology even after extensive investigations, four belonged to the para-pneumonic group and resolved with treatment. Of the 32 patients with malignancy, PFE was seen in a single case of pleural mesothelioma. None of the patients with tuberculosis, empyema, systemic lupus erythematosus or amoebiasis had PFE. These findings suggest that PFE seen at initial thoracocentesis favours a benign diagnosis, with a rare chance of malignancy. Tuberculosis is unlikely in such patients.     

Tuberculous peritonitis

We report a case of tuberculous peritonitis in a 24-year-old male patient. On admission, he was complaining of abdominal fullness and fever. Ultrasound tomography and computed tomography (CT) scan of the abdomen showed massive ascites with multiple septa. The most interesting feature of this case was the diffuse and intense uptake of gallium-67 in the abdomen. Though the initial chest X-ray showed only slight bilateral pleural effusion, and cultures from ascites, stool, sputum, and pleural effusion were negative for Mycobacterium tuberculosis, CT scan of the lung showed a small consolidation shadow with contractile change, similar to tuberculosis. A few days after the CT scan of the lung, the sputum was positive for Mycobacterium tuberculosis. Finally we diagnosed active tuberculous peritonitis, and then started antituberculous therapy. In patients with massive ascites and fever of unknown origin, tuberculous peritonitis must be considered. Gallium-67 scintigraphy has been shown to be useful when there is a high index of suspicion of tuberculous peritonitis.     

Mediastinal teratoma with recurrent encysted pleural effusion

A 25 year old man with no previous history was admitted for a recurrent right sided encysted pleural effusion. Thoracocentesis revealed an exudative lipase-rich-fluid. Because of the persistence of abundant pleural fluid after several thoracocentesis a diagnostic mediastinotomy was performed. This revealed a necrotic cystic mediastinal tumor composed of well differentiated pancreatic tissue, nervous tissue, digestive and respiratory glands, and a dermoid mass with hair and sebacious glands. This led to a diagnosis of benign, mature mediastinal teratoma. We suggest that the chronic pleural effusion was maintained by a fistula from the tumour into the pleural cavity and the secretion of proteolytic enzymes by the well-differentiated pancreatic tissue.     

Eosinophilic pleural effusion in adults at Srinagarind Hospital

The presence of pleural eosinophilia remains a controversy in etiology and prognosis. We conducted this study to evaluate the etiology of eosinophilic pleural effusion and to define the factors that determine malignancy in eosinophilic pleural effusion. Between 1 August 1994 and 1 July 2000, 50 patients were diagnosed with eosinophilic pleural effusion; 35 men and 15 women averaging 56.4 years of age. Most (96%) had exudative pleural effusion. Malignancy was the most common (46%) established cause followed by tuberculosis (10%), parapneumonic effusion (8%), and empyema thoracis (2%). We encountered only one case of pneumothorax and parasitic pleural effusion (from Strongyloides stercoralis). Unknown causes constituted 22% of cases. The etiology of those who had previously undergone thoracocentesis did not differ from those having their first thoracocentesis. Patients with malignant pleural effusion had significant longer duration of clinical symptoms (> or = 1 month) and weight loss than benign pleural effusion. The median duration of symptoms in benign pleural effusion was 14 days. Fever was more characteristic in patients with benign than in those with malignant pleural effusion. The percentage of eosinophils in pleural fluid and blood did not differ between the two groups. Pleural fluid eosinophils in malignant vs benign pleural effusion were 26.6% (range 10% to 63%), and 30.6% (range 10% to 93%), respectively. We concluded that, pleural eosinophilia did not indicate benign conditions which would spontaneously resolve. Malignant pleural effusion should be considered especially in areas malignancy is prevalent.