An elderly female with dyspnoea and anaemia.

An 84-yr-old Caucasian female had been investigated elsewhere for increasing breathlessness and lethargy. She complained of exertional dyspnoea over several months. She denied cough, fevers, night sweats or weight loss. She was born in Bombay (of English parents) and came to London in 1965. She had a 40 pack yr smoking history. Investigations revealed a hypochromic microcytic anaemia (Hb 9.3 g.dL, mean corpuscular volume (MCV) 78.9 fL, mean corpuscular haemoglobin (MCH) 26.8 pg) and a reticulocytosis (134 310.L) and the chest radiograph (CXR) revealed a right pleural effusion. Barium swallow and upper and lower gastrointestinal endoscopies were normal. Pleural aspiration and biopsy had been performed on two occasions. The effusion was an exudate (protein 49 g.L) but all microbiological and histocytological analysis of both pleural fluid and pleural biopsies were negative for alcohol and acid fast bacilli and malignancy. The effusion reaccumulated after each aspiration and she was referred on to the Chest Clinic for further investigation. Symptomatology had changed little and her weight was unchanged. On examination she was pale but with no clubbing or lympadenopathy. The chest was hyperexpanded with decreased percussion and air entry at both bases. The remaining examination was normal. Repeat posterior-anterior and lateral CXR were taken (fig. 1) and a computed tomography (CT) scan of the thorax obtained (fig. 2). A CT guided fine needle aspiration of one of the masses was undertaken (fig. 3).