CRA92 A CASE SERIES OF MALIGNANT PLEURAL EFFUSION DIAGNOSED WITH BLIND CLOSED PLEURAL BIOPSY IN RESOURCE LIMITED SETTING

Boon Tung Low¹, Siew Teck Tie²

1. Internal Medicine Department, Hospital Miri, Miri, Sarawak, Malaysia
2. Divisions of Respiratory Medicine, Department of Medicine, Sarawak General Hospital. Kuching, Sarawak, Malaysia

Introduction
Despite the growing adoption of medical thoracoscopy for exudative pleural effusion, Miri Hospital in northern Sarawak continues to primarily utilize closed pleural biopsy. This disparity stems from several factors, including the hospital's considerable distance (800km) from the state's main referral center, Sarawak General Hospital (a 9-hour drive or 1-hour flight away), the absence of a dedicated respiratory medicine service, and various logistical and financial hurdles.

Case 1
A 68-year-old gentleman with a history of normal pressure hydrocephalus was initially hospitalized for acute hydrocephalus, requiring an external ventricular drain. His hospital stay was complicated by ventriculitis and Klebsiella pneumoniae bacteremia, leading to prolonged ventilation. He subsequently developed a large left exudative pleural effusion, with a biopsy confirming metastatic lung adenocarcinoma.

Case 2
A 48-year-old man, initially diagnosed with a right exudative pleural effusion five months ago, declined referral to Kuching for further intervention despite a CECT Thorax suggesting malignancy. He returned five months later with worsening symptoms with massive reaccumulation of pleural effusion, and a subsequent closed pleural biopsy confirmed metastatic lung adenocarcinoma.

Case 3
A 69-year-old lady came in with left-sided chest pain and fever, which doctors initially diagnosed as a left parapneumonic effusion. However, a closed left pleural biopsy, with results available a week later, revealed metastatic lung adenocarcinoma.

Conclusion
In resource-limited environments where medical thoracoscopy isn't an option, closed pleural biopsy remains a crucial tool for diagnosing malignancy. Evidence from our case series indicates that this technique can significantly shorten the diagnostic pathway, enabling quicker and more effective patient care.