Correct!
4. 1 and 3
Correct!
4. 1 and 3
The chest x-ray shows a large right pleural effusion. This is shown by the volume expansion of the right chest with a shift of the trachea to the left. A collapsed right lung shows volume loss. The right pleural effusion was confirmed by a thoracic CT scan (Figure 3).
Figure 3. Representative image from thoracic CT scan in soft tissue windows showing large right pleural effusion.
Thoracentesis was performed, with 2000 ml of serosanguinous fluid drained and sent for analysis. The fluid was found to be exudative and lymphocyte-predominant (analysis: WBC 9000 cells/mm3, RBC 201000 cells/mm3, PMN 11%, Lymphocytes 82%, Eosinophils 0%, Mono/Macrophages 7%, LDH 388 IU/L (vs serum LDH 131 IU/L), Protein 7.4 g/dL (vs serum protein 6.9 g/dL)). Plasma cells made up 35% of the lymphocyte count. Cytology showed atypical lymphocytic cells with marked nuclear enlargement and membrane irregularities (Figure 4).
Figure 4. Pleural fluid showing atypical lymphocytic cells as seen in different preparations. A: Diff Quick (x600). B: Papanicolau (x600). C: Cell block (x600). The cells show marked nuclear enlargement and membrane irregularities. Polymorphonuclear leukocytes in the background allow for estimation of nuclear enlargement.
Which of the following is the most likely diagnosis that explains the pleural effusion? (Click on the correct answer to proceed to the fifth and final panel)