Een man met aanhoudende prikkelhoest en dyspneu

A 56-year-old male presented with complaints since 2 months of an irritable dry cough, wheezing and dyspnoea after hard running. There were no other complaints. He had no prior medical history and did not use any medication. He worked as an electrician all his life; 30 years ago he had indirect contact with asbestos. He has no pets, does not drink alcohol nor smokes. Clinical examination was unremarkable, except that auscultation of the thorax revealed decreased breath sounds on the right side compared to the left. Posterior anterior plain radiograph showed a unilateral pleural effusion. CT of the thorax disclosed the same pleural effusion plus a small infiltrate of the right middle lobe. In the differential diagnosis we considered a parapneumonic or a malignant effusion. Pleural aspiration revealed a lymphocytic effusion with no bacterial growth; cytologic examination could not differentiate between a reactive mesothelium or a mesothelioma. Serum analysis showed a white blood cell count of 22,4 × 10³/μL, with 90% lymphocytes. We decided to wait for 14 days to repeat the plain thorax radiograph. The patient returned 14 days later with the same symptoms, the radiograph revealing again the unilateral pleural effusion. Bronchial biopsies were taken, which showed subacute inflammation. Finally we made the diagnosis of a malignant mesothelioma via thoracoscopic biopsies of the pleura. This case report shows that when a patient presents with a sustained irritable cough, associated with mild intermittent dyspnoea, the physician should be aware of the possibility of a serious underlying disease.