A case of Meigs' syndrome with preceding pericardial effusion in advance of pleural effusion

Abstract

Background: Meigs' syndrome is defined as the presence of a benign ovarian tumor with pleural effusion and ascites that resolve after removal of the tumor. The pathogenesis of the production of ascites and pleural effusion in this syndrome remains unknown. Aside from pleural effusion and ascites, pericardial effusion is rarely observed in Meigs' syndrome. Here, we report the first case of Meigs' syndrome with preceding pericardial effusion in advance of pleural effusion.

Case presentation: An 84-year-old Japanese non-smoking woman with a history of lung cancer, treated by surgery, was admitted due to gradual worsening of dyspnea that had occurred over the previous month. She had asymptomatic and unchanging pericardial effusion and a pelvic mass, which had been detected 3 and 11 years previously, respectively. The patient was radiologically followed-up without the need for treatment. Two months before admission, the patient underwent a right upper lobectomy for localized lung adenocarcinoma and intraoperative pericardial fenestration confirmed that the pericardial effusion was not malignant. However, she began to experience dyspnea on exertion leading to admission. A chest, abdomen, and pelvis computed tomography scan confirmed the presence of right-sided pleural and pericardial effusion and ascites with a left ovarian mass. Repeated thoracentesis produced cultures that were negative for any microorganism and no malignant cells were detected in the pleural effusions. Pleural fluid accumulation persisted despite a tube thoracostomy for pleural effusion drainage. With a suspicion of Meigs' syndrome, the patient underwent surgical resection of the ovarian mass and histopathological examination of the resected mass showed ovarian fibroma. Pleural and pericardial effusion as well as ascites resolved after tumor resection, confirming a diagnosis of Meigs' syndrome. This clinical course suggests a strong association between pericardial effusion and ovarian fibroma, as well as pleural and peritoneal fluid.

Conclusions: In female patients with unexplained pericardial effusion and an ovarian tumor, clinicians should consider the possibility of Meigs' syndrome. Although a malignant disease should be suspected in all patients with undiagnosed pleural and/or pericardial effusion, Meigs' syndrome is curable by tumor resection and should be differentiated from malignancy.

Keywords: Meigs’ syndrome; Ovarian fibroma; Pericardial effusion; Pleural fluid.

Fig. 1

Representative photographs during the clinical course. Chest X-ray and computed tomography (CT) scan 4 months before admission, which was 2 months before the lung cancer operation, revealed cardiac enlargement with a nodular shadow (arrow) in the right lung field (a) and a large volume of pericardial effusion (b). On admission, a chest X-ray showed the right pleural effusion as well as blunting of the left costophrenic angle (c), and a chest CT scan showed that the pericardial effusion had decreased compared with that before the lung operation (d). No relapse of the pleural and pericardial effusion was confirmed by chest X-ray or a CT scan 8 months after removal of the fibroma (e, f)

Fig. 2

Magnetic resonance imaging of the pelvis before surgery for lung cancer. An abdominal mass with low signal intensity on T2-weighted images and ascites was observed

Fig. 3

Pathologic findings of the ovarian fibroma. Macroscopic appearance showed a solid and smooth mass (a). Microscopic findings with hematoxylin and eosin staining showed spindle cells that were arranged in intersecting bundles (b)