Replying to valerie dromey 03/08/2025 - 20:57
Thanks Valerie.
Really lovely to hear from you. I hope you are well.
I agree the mild PT increase isn’t the most urgent concern here, especially with a non-haemorrhagic effusion, though the pallor is still something to keep in mind. Your points on possible metastatic disease and the impression of an enlarged cardiac silhouette are well taken, although the radiology report describes the cardiac silhouette, pleural space, and mediastinum as normal.
Radiographs show multiple, well-defined, smoothly marginated soft tissue nodules scattered throughout the right middle lung lobe, the largest measuring about 1.4 cm. These were seen on all projections. The radiologist’s interpretation was that these likely represent metastatic neoplasia, less likely granulomas. The included cranial abdominal serosal detail is markedly reduced, consistent with the peritoneal effusion.
Given these findings, I think the thoracic films do support metastatic disease, which obviously pushes the prognosis toward guarded to poor. If there hadn’t been clear evidence of metastatic spread, I might have been inclined to pursue more advanced imaging such as abdominal/thoracic CT with angiography to map out the adrenal mass in relation to the caudal vena cava and surrounding structures, and also to perform adrenal functional testing (e.g., plasma or urine metanephrines) to rule in or out a pheochromocytoma.
We did analyse the peritoneal fluid—clear modified transudate (TP ~32 g/L, PCV <1%) with bland cytology—consistent with either right-sided heart failure or increased hydrostatic pressure from caval or portal hypertension.
I share your thoughts on diuretics. If echo suggested significant cardiac involvement, I’d consider a cautious trial, but if the ascites is primarily from caval obstruction, serial abdominocenteses might provide better relief without compromising perfusion in this already hypotensive patient.
Thank you again for your brilliant comments!
Scott 🙂
