A 47 year old man with nonproductive cough and right-sided chest pain

Abstract

A 47 yr old man was admitted to our hospital because of persisting nonproductive cough, dyspnoea on exertion and right-sided chest pain of several weeks duration. He was febrile (37.5°C) and had noticed a weight loss of 5 kg within the last 2 months. The only pertinent medical history was a cluster headache, for which he was treated intermittently with methysergide. He had taken a cumulative dose of approximately 630 mg over a 21 month period. He was working as a clerk, had no history of asbestos exposure, and smoked one packet of cigarettes per week. Clinical examination was normal, except for a dullness on percussion, diminished breath sounds, and pleural friction at the right base of the thorax.Laboratory studies showed an erythrocyte sedimentation rate (ESR) of 120 mm·h -1 , a normochromic normocytic anaemia with haemoglobin of 103 g·L -1 . Arterial oxygen tension (Pa,O 2 ) and arterial carbon dioxide tension (Pa,CO 2 ) were normal. A chest radiograph revealed a moderate pleural effusion in the right base, with a mass-like lesion in the dorsobasal part of the lung. Adenopathies were absent. Pleural fluid analysis showed a white blood cell count (WBC) of 5,200×10 6 cells·L -1 , with 99% lymphocytes, glucose 0.46 g·L -1 , pH of 7.37, total protein 40 g·L -1 , and lactate dehydrogenase (LDH) 1,520 U·L -1 . Search for malignant cells was negative, as were stains and cultures for bacteria, mycobacteria and fungi.Bronchoscopy was normal, except for an erythematous mucosa in the right lower lobe. Transbronchial biopsies and subsequent open lung biopsy disclosed nonspecific parenchymal fibrosis. Computed tomography (CT) of the thorax was taken on admission ( fig. 1) and after 5 months ( fig. 2). Pleuroscopy revealed a marked diffuse, white thickening both of the parietal and visceral pleura, with multiple fibrinous adhesions. Biopsies yielded only nonspecific fibrosis. There were no signs of malignancy, granulomas or vasculitis. Stains and cultures for bacteria, mycobacteria and fungi remained negative. CASE FOR DIAGNOSISDepts of *Pneumology and **Radiology, AZ-Middelheim, Antwerp, Belgium.

Asbestos, ergot drugs and the pleura

“…When administered in the long term, ergolines can also induce distinctive pleuropulmonary changes in a few patients, including parietal [14,15] or visceral [15] pleural thickening, pleural effusion [14][15][16][17], rounded atelectasis [14], and fibrosis of the lung adjacent to pleural lesions [15,18,19]. Of note, and in contrast to what is seen in asbestos-related diseases [5], pleural changes induced by ergolines rarely, if ever, calcify [14], possibly because they develop over shorter periods of time.…”

“…Often, the ESR is increased to a greater extent in ergotinduced [14,15], as opposed to asbestos-induced, pleural changes [24] (55.0 versus 25.7 mm in the series by PFITZEN-MEYER et al [14] and HILLERDAL [24], respectively) (table 1), but a significant overlap probably exists. How-ever, only in ergoline-induced pleural changes, will the rise in ESR improve (within a few weeks) following drug withdrawal [1,14].…”

“…The histological transcript of radiographic pleural thickening or plaques is pleural fibrosis, whether ergolines or asbestos are the cause [4,14,15]. Thus, these two terms may be used interchangeably in this text.…”

“…Of note, and in contrast to what is seen in asbestos-related diseases [5], pleural changes induced by ergolines rarely, if ever, calcify [14], possibly because they develop over shorter periods of time. A marked elevation of the erythrocyte sedimentation rate (ESR) is common in association with ergoline-induced pleural changes, occasionally with figures over 100 mm in one hour [14,15].…”

“…Ergot drugs such as methysergide, ergotamine, dihydroergotamine, bromocriptine, nicergoline, pergolide, and dopergine, collectively known as ergolines, are utilized to treat symptoms or syndromes such as cluster headache, migraine, Parkinson's disease, or the organic brain dysfunction syndrome [14,15]. When administered in the long term, ergolines can also induce distinctive pleuropulmonary changes in a few patients, including parietal [14,15] or visceral [15] pleural thickening, pleural effusion [14][15][16][17], rounded atelectasis [14], and fibrosis of the lung adjacent to pleural lesions [15,18,19].…”