MEIGS SYNDROME

Nur Ayu Virginia I, S. Ked

1118011089
Vidianka Rembulan, S. Ked
1118011139

Perceptor:
dr. Dedy Zairus, Sp.P

CLINICAL WORK OF INTERNAL MEDICINE

SMF PULMONOLOGY
PERIOD MAY 2015 TO JULY 2015
ABDUL MOELOEK HOSPITAL
BANDAR LAMPUNG

PATIENT STATUS
PATIENT IDENTITY
Initial Name
: Mrs. I
Sex : Female
Age : 28 years old
Nationally : Indonesia (javanese)
Marital Status : married
Religion : Moeslem
Occupation : Farmer
Educational Background
: Junior High School
Address : Gedung Meneng, Tulang Bawang

ANAMNESIS
Taken from: Autoanamnesis
Date

: July 8th 2015

Time
: 15.00 WIB
Chief Complain
:
Shortness of breath since 1 weeks ago
Additional Complain
:
Abdominal pain, abdominal swelling, cough,
nausea

History of Present Illness

Patient was admitted with shortness of breath that

worsened in the last 1 week. Shortness of breath can

be felt even when resting, especially when patient is
lying down, happens intermittently, not affected by
weather, and not only appear at night. Patient felt
better and much more relieved in sitting position
rather than lying down. Patient also felt chest pain
and coughing that happen together with shortness of
breath. Chest pain does not radiates to back, shoulder
or jaw and felt like sharp sensation. Pain worsens if
patient cough or breathe. Patient has cough with
greenish sputum since one week ago, and no
presence of blood. Cough happens at any time, not

Patients stomach got bigger and swollen since seven

months ago. Pain can be felt in all regio, stomach felt like
twisting and happens intermittent. Patient also felt
nausea, but not vomiting. Patient said she has decreased
appetite because her stomach feels uncomfortable each
time she eats or inserts food, so the patient feels her
body gets thinner but her stomach continued to swells.
Patient had been treated in Abdul Moeloek Hospital and
diagnosed with Ovarian Cancer. Patient have also been
treated in pulmonology for the same symptoms three
weeks ago, and has been treated with pleural puncture
with liquid volume approximately 1500 cc. Patient deny
have previous high blood preassure, diabetes mellitus,
lung tuberculosis and asthma.

The History of Illness :

Small pox
(+)
(-) Chicken pox

(-) Malaria

(-) Kidney stone

(-) Disentri

Hernia
(-)

(-) Difthery

(-) Hepatitis

Prostat
(-)

(-) Pertusis

(-) TifusAbdomina

(-) Measles
(+) Influenza

lis
(-) Skirofula
(-) Siphilis

Melena
(-)
(-) Diabetic
Alergy
(-)

(-) Tonsilitis
Kholera

(-) Gonore

(-)
(-) Hipertension.
(-) Vaskular

(-)
Pneumonia

Tumor

(-) Duodeni Ulcer

Disease
(-) Tuberculosis

Familys diseases History :

Father has died, the cause is not known
Mother still alive, healthy.
Three siblings still alive, healthy.
Children are still alive, healthy.

Is there any family who suffer :

No family members that have the same
symptoms with the patient

(-)

Anestesi

(-)

Hard to bite

(-)
(-)
(-)
(-)
(-)

Parestesi
Weak muscle
Afasia
Amnesis
Others

(-)
(-)
(-)
(-)
(-)

Ataksia
Hipo/hiper-estesi
Tick
Vertigo
Disartri

(-)

Convultion

(-)

Syncope

Body Check Up
General Check Up
Height : 165 cm
Weight : 50 kg
Blood Pressure

: 120/80mmHg
Pulse : 104 x/minute, regular
Temperature : 36.7 0C
Breath (Frequence&type) :36x/minute
Nutrition Condition : low
Consciousness : Compos Mentis
Cyanotic : (-)
General Edema : normal
The way of walk : weak
Mobility : Active
The age predicyion based on check up : 26 years old

Mentality Aspects
Behavior : Normal
Nature of Feeling : Normal
The thinking of process : Normal

Skin
Color : Brown
Keloid : (-)
Pigmentasi
: (-)
Hair Growth : Normal, Black, Simetris
Arteries : Touchable
Touch temperature : Afrebris
Humid/dry : Dry
Sweat : Normal
Turgor : Normal
Icterus : An icterus
Fat Layers : Thin
Efloresensi: (-)
Edema : (-)
Others : (-)

Lymphatic Gland
Submandibula : no enlargement
Neck : no enlargement
Supraclavicula : no enlargement
Armpit : no enlargement

Head
Face Expression : normal
Face Symmetric : Symmetric
Hair : Black
Temporal artery : Normal
Eye
Exopthalmus : (-)
Enopthalmus : (-)
Palpebra : edema (-)/(-)
Lens : Clear/Clear
Conjunctiva : Anemis +/+
Visus : Normal
Sklera : Icteric -/-

Ear
Deafnes
: (-)
Foramen
: (-)
Membrane tymphani: intact
Obstruction : (-)
Serumen
: (-)
Bleeding
: (-)
Liquid
: (-)
Mouth
Lip
: normal
Tonsil
: (-)
Palatal
: Normal
Teeth
: (-)
Trismus
: (-)
Farings
: Unhiperemis
Liquid Layers
: (-)
Tongue
: Normal

Lung
Inspection : Left : asymmetric, retraction (-)

Right : asymmetric, retraction (-)

Palpation : Left : decreased fremitus, pain (-)
Right : normal fremitus, pain (-)
Percussion : Left : dullness
Right : resonance
Auscultation : Left : decreased vesicular breath sound,
wheezing (-), rhonchi (-)
Right : vesikuler breath sound, wheezing (-), rhonchi (-)
Cor
Inspection : Ictus cordis not visible
Palpation : Ictus Cordis not palpable
Percussion : Right: ICS IV parasternum dextra
Left: ICS V midclavicula sinistra
Auscultation : Heart Sound 1 &2 normal, murmur (-), gallop
(-).

Artery
Temporalic artery : No abnormalities
Caritic artery : No abnormalities
Brachial artery : No abnormalities
Radial artery : No abnormalities
Femoral artery : No abnormalities
Poplitea artery : No abnormalities
Posterior tibialis artery : No abnormalities

Stomach
Inspection : distended, swollen
Palpation : Stomach Wall : pain (+)
Heart : Hepatomegali (-)
Limfe : Splenomegali (-)
Kidney: Ballotement (-)
Percussion : Shifting Dullness (+)
Auscultation : Intestine Sounds (+)

Genital (based on indication)

Male : no indication
Penis
: no indication
Testis
: no indication

Movement Joint
Arm

Right

Left

Muscle

Normal

Normal

Tones

(+)

(+)

Mass

(-)

(-)

Joint

Normal

Normal

Movement

Active

Active

Strength

Heel and Leg

Wound/injury

: not found

Varices

: (-)

Joint

: Normal

Movement

: Active

Strength/Power

:5

Edema

: (-)

Others

: (-)

Reflexs
Right

Left
Tendon Reflex
Normal
Normal
Bisep
Normal
Normal
Trisep
Normal
Normal
Pattela
Normal
Normal
Achiles
Normal
Normal
Cremaster
Normal
Normal
Skin Reflex
Normal
Normal
Patologic Reflex
Not Found
Not Found

Laboratory
Hematology (29-7-2015) Normal
Haemoglobin : 10,5 gr/dl
Leucocyte
Erythocyte
Hematocrit
Trombocyte

12-16 gr/dl
: 10.500 /ul 4500-10700 / ul
: 2,6 mil/ul4,7-6,1 mil/ul
: 23% 42-52%
:443.000/ul 150.000-450.000/ul

MCV

:89 fl 79-99 fl
MCH
: 32 pg27-31 pg
MCHC :32 g/dl
33-37 g/dl
Variety count

Basophils : 0 % 0-1%
Eusinophils
: 0% 1-3%
Bands : 0 % 2-6%
Segmens : 81 % 50-70%
Lymphocytes : 13 % 20-40%

Monocytes
: 5 % 2-8%
LED
: 54
<20 ml/jam

GDN

: 112
<110 mg/dl
Total Protein
: 6,8
6,4-8,3 mg/dL
Albumin
: 3,0
3,5-5,2 mg/dL
Globulin
: 3,8
2,3-3,5 mg/dL
Sodium
: 132
135-145 mg/dL
Potassium
: 4,8
3,5-5,0 mg/dL
Calcium
: 12,6
8,6-10,0 mg/dL
Chloride
: 96
96-106 mg/dL

RONTGEN THORAX PA
Left pleural effusion, no presence of

infiltrate and nodul in right lung, normal cor

USG ABDOMEN (14-3-2015)

Massa complex intra abdomen with ascites
PLEURAL FLUID SITOLOGY (20-6-2015)
Metastase carcinoma
RIVALTA TEST (8-7-2015)
Cell count : 220 sel/uI

0-5 sel/ UI
Glucose : 14 mg/dl 50-80 mg/dL
Protein : 4,3 gr/ UI
PMN : 43%
MN : 57%
RIVALTA TEST : POSITIF
pH
: 7.6

Normal

RESUME
Patient Mrs. I admitted with shortness of breath that worsened in the last 1 week.

Shortness of breath can be felt even when resting, especially when patient is lying
down, happens intermittently, not affected by weather, and not only appear at
night. Patient felt better and much more relieved in sitting position rather than
lying down. Patient also felt chest pain and coughing that happen together with
shortness of breath. Patient has cough with greenish sputum since one week ago,
and no presence of blood. Cough happens at any time, not specifically at night.
Patients stomach got bigger and swollen since seven months ago. Pain can be felt
in all regio, stomach felt like twisting and happens intermittent. Patient also felt
nausea, but not vomiting. Patient said she has decreased appetite because her
stomach feels uncomfortable each time she eats or inserts food, so the patient
feels her body gets thinner but her stomach continued to swells. Patient had been
treated in Abdul Moeloek Hospital and diagnosed with Ovarian Cancer. Patient
have also been treated in pulmonology for the same symptoms three weeks ago,
and has been treated with pleural puncture with liquid volume approximately
1500 cc. Patient deny have previous high blood preassure, diabetes mellitus, lung
tuberculosis and asthma.
BP : 120/80 mmHg, RR: 36x/min, HR: 104x/min, T:36,7 C, thorax examination :
asymmetric, breath left behind, vokal fremitus decrease, dullness, decreased
breath sounds (left lung), abdomen : distended, swollen, ascites (+), shifting
dullness (+), pain in all regio

DIAGNOSE
Working Diagnose
Meigs Syndrome

Basic Diagnose
Anamnesa: history of ovarian cancer, shortness of breath,

cough with phlegm; greenish, thick, blood appearance (-),

chest pain left, abdominal pain, abdominal enlargement
Vital signs - Tachypnea, tachycardia
Lungs - Dullness to percussion; decreased tactile fremitus;
decreased vocal resonance; decreased breath sounds
Abdomen: swollen, pain, ascites , shifting dullness
Thorax PA radiology: pleural effusion sinistra
Differential Diagnose
Cirrhosis Hepatis

TREATMENT PLAN
1) General Treatment
Bed Rest, half sitting.
Pro Laparoscopy
2) Special Treatment
IVFD RL gtt 10X/minute
O2 nasal canul 3 liter/min
Ceftriaxone 2 x 1 gr
Ranitidine 2 x 1 ampule
Furosemid ampul 3 x 40 mg
Spironolacton 1 x 100 mg
KSR 2 x 1

PROGNOSE
Quo ad Vitam: Dubia ad malam
Quo ad Functonam
Quo ad Sanationam

: Dubia ad malam
: Dubia ad bonam

MEIGS SYNDROME
DEFINITION

Meigs syndrome is defined as the triad of

benign ovarian tumor with ascites and

pleural effusion that resolves after
resection of the tumor. The ovarian tumor
in Meigs syndrome is a fibroma.

HISTORY
In 1934, Salmon described the association of

pleural effusion with benign pelvic tumors. In

1936, Meigs and Cass described 7 cases of
ovarian fibromas associated with ascites and
pleural effusion. In 1954, Meigs proposed
limiting true Meigs syndrome to benign and
solid ovarian tumors accompanied by ascites
and pleural effusion, with the condition that
removal of the tumor cures the patient without
recurrence. Histologically, the benign ovarian
tumor might be a fibroma, thecoma,
cystadenoma, or granulosa cell tumor.

PATHOPHYSIOLOGY

FREQUENCY
In the US:Ovarian tumors are more prevalent in upper

socioeconomic groups. Ovarian fibroma is found in 2-5% of

surgically removed ovarian tumors, and Meigs syndrome is
observed in about 1% of them.
Internationally:Prevalence is unknown.
Mortality/Morbidity:Meigs syndrome, being a benign
condition, has a very good prognosis if properly managed,
though it mimics a malignant condition. Life expectancy
after surgical removal of the tumor is the same as in the
general population.
Age:Incidence of ovarian tumor begins to increase in the
third decade and increases progressively to peak in the
seventh decade. Case reports have been made of Meigs
syndrome in prepubertal girls with benign teratomas and
cystadenomas.

CLINICAL
History:Patients may have a family history of

ovarian cancer. The chief complaints are vague

and generally present over a period of time.
Fatigue
Shortness of breath
Increased abdominal girth
Weight loss
Nonproductive cough
Bloating
Amenorrhea for premenopausal women
Menstrual irregularity

Physical:Positive signs include the following:

Vital signs
Tachypnea
Tachycardia
Lungs
Dullness to percussion
Decreased tactile and vocal fremitus
Decreased breath sounds are noted, suggesting pleural

effusion. Pleural effusion is seen mostly on the right side

but can also be left-sided.

Abdomen
Examination can be positive for a pelvic mass, small or

large, or no mass may be felt.

Ascites will be present, with shifting dullness and/or fluid
thrill.

Pelvis: Examination reveals a pelvic mass.

DIFFERENTIAL DIAGNOSES
Cirrhosis
Colon Cancer, Adenocarcinoma
Hypoalbuminemia
Lung Cancer, Non-Small Cell
Lung Cancer, Oat Cell (Small Cell)
Nephrotic Syndrome
Ovarian Cancer
Pleural Effusion
Tuberculosis

Other Problems to be Considered:

Congestive heart failure

WORK UP

Lab Studies:

Complete blood count: This provides information

about levels of hemoglobin, hematocrit and

platelets. A low hemoglobin count requires further
workup, including reticulocyte count, total ironbinding capacity, and iron and ferritin levels. If
anemia is present in patients with Meigs syndrome
it is most likely due to iron deficiency. Anemia can
be corrected emergently by blood transfusion in
those patients undergoing surgery for Meigs
syndrome. Anemia can be treated with iron
supplementation postoperatively.

Basic metabolic profile: Studies of sodium,

potassium, chloride, bicarbonate, blood urea

nitrogen, creatinine, and glucose levels are
included. These electrolytes are checked before
the patient undergoes surgery. Corrections of
these electrolytes are made, if necessary.
Prothrombin time: Prothrombin time is checked
before surgery. If elevated, it is a marker of
coagulopathy. Elevated prothrombin time is
corrected before surgery, either by giving
vitamin K to the patient or by transfusing fresh
frozen plasma.

Serum CA 125. Tumor marker serum CA

125 can be elevated in Meigs

syndrome, but the degree of elevation
does not correlate with malignancy. CA
125 level is not used as a screening
test. (The highest reported level of CA
125 after laparotomy was 336 U/mL).
Pathologic conditions related to
elevated CA 125
Pelvic inflammatory disease (PID)
Peritoneal damage or regeneration, eg,

abdominal surgery
Ovarian malignancy

Imaging Studies:

Chest radiography confirms pleural effusion.

Abdominal and pelvic ultrasound confirms

the ovarian mass and ascites.

CT scan of the abdomen and pelvis
CT scan confirms ascites and ovarian, uterine,

fallopian tube, or broad ligament mass.

No signs of distant metastasis are seen.

Procedures:

Paracentesis: Ascitic fluid mostly is

transudative. Fluid is negative for malignant

cells but can be positive for reactive
mesothelial cells.
Thoracentesis: Pleural fluid usually is
transudative. It can be exudative and
negative for malignant cells.
Papanicolaou smear: Smear is normal.

Histologic Findings:Ovarian tumors are

divided into the following histologic

subgroups, and Meigs syndrome can be
seen with any of the benign tumors.
Coelomic epithelial tumors
Germ cell tumors
Gonadal-stromal cell tumor

TREATMENT
Medical Care:
Provide symptomatic relief of ascites and pleural effusion by

means of therapeutic paracentesis and thoracentesis.

Surgical Care:
Exploratory laparotomy with surgical staging is the treatment of

choice.
Perform biopsy of the ovarian mass during exploratory laparotomy.
Biopsy findings are consistent with benign tumor. Lymph node
biopsies and omentum and pelvic washings if done during surgery
are negative for malignancy.
In women of reproductive age, perform unilateral salpingooophorectomy.
In postmenopausal women, options include bilateral salpingooophorectomy with total hysterectomy and unilateral salpingooophorectomy.