Pleural EffusionPleural Effusion

S. A. SaleemiS. A. Saleemi

PLEURAL EFFUSIONPLEURAL EFFUSION•Fluid production exceeds absorption.

•Fluid is formed in the parietal pleura and absorbed in parietal pleural lymphatics.

•Lymphatics have the capacity to absorb 20 times more than what is Produced.

•Fluid can also enter the pleural cavity from interstitial spaces of lung through visceral pleura.

•Peritoneal fluid can enter the pleural cavity via diaphragm pores.

Mechanism of Pleural effusionsMechanism of Pleural effusions

increased hydrostatic pressure(LVF)increased hydrostatic pressure(LVF) decreased oncotic pressure in microcirculation decreased oncotic pressure in microcirculation (hypoalbuminemia)(hypoalbuminemia) decrease in pleural pressure (atelectasis)decrease in pleural pressure (atelectasis) increased permeability of microcirculation increased permeability of microcirculation ( pneumonia)( pneumonia) impaired lymphatic drainage from pleural space impaired lymphatic drainage from pleural space (malignancy)(malignancy) movement of fluid from abdomen to pleural movement of fluid from abdomen to pleural space ( cirrhosis) space ( cirrhosis)

In health, the volume of pleural fluid in humans is small (<1 ml), forming a film about 10 micro thick between the visceral

and parietal pleural surfaces.

VolumeVolume

Cells/mm³Cells/mm³ %mesothelial cells%mesothelial cells

%monocytes%monocytes

%lymphocytes%lymphocytes

%granulocytes%granulocytes

% eosinophils% eosinophils

ProteinProtein %albumin%albumin

GlucoseGlucose

LDHLDH

0.1-0.2 ml/kg0.1-0.2 ml/kg

1000-50001000-50003-70%3-70%

30-70%30-70%

2-30%2-30%

~~ 10% 10%

0 %0 %

1-2 gm/dl1-2 gm/dl50-70%50-70%

~plasma level~plasma level

<50% plasma level<50% plasma level

Normal composition of pleural fluid

parameterparameter transudatetransudate exudateexudate

Total proteinTotal protein <30 g/l<30 g/l >30 g/l>30 g/l

Pleural-serum Pleural-serum protein ratioprotein ratio

<0.5<0.5 >0.5>0.5

LDHLDH <200 u/l<200 u/l >200 u/l>200 u/l

Pleural-serum Pleural-serum LDH ratioLDH ratio

<0.6<0.6 >0.6>0.6

cholestrolcholestrol <45mg/dl<45mg/dl >45 mg/dl>45 mg/dl

Bilirubin pleural-Bilirubin pleural-serum rationserum ration

<0.6<0.6 >0.6>0.6

Differentiation between transudate and exudate

Light CriteriaLight Criteria1- Pleural fluid protein-to-serum protein ratio more than 0.5

2- Pleural fluid LDH-to-serum LDH ratio more than 0.6

3-Pleural fluid LDH level greater than two third the upper limit of normal serum level

Modified 1997 (NO SERUM LEVELS)(by Haffner)1-Pl. fluid protein more than 2.9g/dl(29g/L

2- Pl. fluid LDH more than 66% of upper limit of normal serum reference range

3- Pl. fluid cholestrol more than 45 mg/dl

Serum-effusion albumin gradient (SAG)Serum-effusion albumin gradient (SAG)

In general Light’s criteria occasionally In general Light’s criteria occasionally misidentify a transudative effusion as an misidentify a transudative effusion as an exudative effusion as in cardiac failure exudative effusion as in cardiac failure with diuretic therapywith diuretic therapyClinically if a patient should have a Clinically if a patient should have a transudative effusion, but meets Light’s transudative effusion, but meets Light’s criteria for an exudative effusion, measure criteria for an exudative effusion, measure serum - pleural fluid albumin gradientserum - pleural fluid albumin gradientSerum- effusion albumin gradient of more Serum- effusion albumin gradient of more than 1.2 g/dl is used to diagnose presence than 1.2 g/dl is used to diagnose presence of transudate effusion.of transudate effusion.

Causes of transudative pleural effusionsCauses of transudative pleural effusionsVery common causesVery common causes– Left ventricular failureLeft ventricular failure– Liver cirrhosisLiver cirrhosis– HypoalbuminaemiaHypoalbuminaemia– Peritoneal dialysisPeritoneal dialysis

Less common causesLess common causes– HypothyroidismHypothyroidism– Nephrotic syndromeNephrotic syndrome– Mitral stenosisMitral stenosis– Pulmonary embolismPulmonary embolism

Rare causesRare causes– Constrictive percarditisConstrictive percarditis– UrinothoraxUrinothorax– Superior vena cava obstructionSuperior vena cava obstruction– Ovarian hyperstimulationOvarian hyperstimulation– Meigs’ syndromeMeigs’ syndrome

Causes of exudative pleural effusionsCauses of exudative pleural effusions

Common causesCommon causes– MalignancyMalignancy– Parapneumonic effusionsParapneumonic effusions

Less common causesLess common causes– Pulmonary infarctionPulmonary infarction– Rheumatoid arthritisRheumatoid arthritis– Autoimmune diseasesAutoimmune diseases– Benign asbestos effusionBenign asbestos effusion– PancreatitisPancreatitis– Post-myocardial infarction syndromePost-myocardial infarction syndrome

Rare causesRare causes– Yellow nail symdromeYellow nail symdrome– Drug (see box1 )Drug (see box1 )– Fungal infectionsFungal infections

Drugs known to cause pleural effusionsDrugs known to cause pleural effusions

Over 100 reported cases globallyOver 100 reported cases globally– AmiodaroneAmiodarone– NitrofurantoinNitrofurantoin– PhenytoinPhenytoin– MethotrexateMethotrexate

20-100 reported cases globally20-100 reported cases globally– CarbamazepineCarbamazepine– ProcainamideProcainamide– PropylthiorucilPropylthiorucil– PenicillaminePenicillamine– GCSFGCSF– CyclophosphamideCyclophosphamide– BromocriptineBromocriptine * pneumotox.com (2001)* pneumotox.com (2001)

Approximate annual incidence of various Approximate annual incidence of various types of pleural effusions in the USAtypes of pleural effusions in the USA

Congestive heart failureCongestive heart failure

Other causesOther causes

PneumoniaPneumonia

Malignant diseaseMalignant disease

Pulmonary embolismPulmonary embolism

Cirrhosis with ascitesCirrhosis with ascites

Gastrointestinal diseaseGastrointestinal disease

Collagen vascular diseaseCollagen vascular disease

TuberculosisTuberculosis

Asbestos pleuritisAsbestos pleuritis

MesotheliomaMesothelioma

TOTALTOTAL

500,000500,000

400,000400,000

200,000200,000

150,000150,000

50,00050,000

25,00025,000

6,0006,000

2,5002,500

2,0002,000

1,5001,500

37.537.5

63.663.6

100.0100.0

48.048.0

24.024.0

18.018.0

6.06.0

3.03.0

0.70.7

0.30.3

0.250.25

0.20.2

100.0100.0

Percentage of noncardiac

Etiology Number Percentage effusions

Frequency distribution of Frequency distribution of noncardiac effusionsnoncardiac effusions

Storey et al.Storey et al.

Hirsch et al.Hirsch et al.

Lamy et al.Lamy et al.

Engel,Engel,

LoddenkemperLoddenkemper,,

TOTALTOTAL

115115

295295

194194

646646

250250

15001500

5656

3939

4646

34.534.5

3434

4242

66

3131

33.533.5

26.526.5

3939

2929

Authors Number Neoplastic Infectious Various Idiopathic % % % %

1616

99

1212

1515

1818

1414

2222

2121

2020

12.512.5

99

1515

Useful Tests in the Evaluation of Pleural Useful Tests in the Evaluation of Pleural EffusionsEffusions

TestTest Abnormal ValuesAbnormal Values Frequently Associated Frequently Associated ConditionCondition

Red blood cells, per Red blood cells, per mmmm33

>100.000>100.000 Malignancy, trauma, Malignancy, trauma, pulmonary embolismpulmonary embolism

White blood cells, per White blood cells, per mmmm33

>10.000>10.000 Pyogenic infectionPyogenic infection

neutorphils, %neutorphils, % >50>50 Acute pleuritisAcute pleuritis

lymphocytes, %lymphocytes, % >90>90 Tuberculosis, Tuberculosis, malignancy, lymphomamalignancy, lymphoma

eosinophilia, %eosinophilia, % >10>10 Asbestos effusion, Asbestos effusion, hydro-pneumothorax, hydro-pneumothorax, resolving infectionresolving infection

mesothelial cellsmesothelial cells absentabsent TuberculosisTuberculosis

Cont:-Cont:-

Glucose, mg/dlGlucose, mg/dl <40<40 Empyema, TB, Empyema, TB, malignancy, rheumatoid malignancy, rheumatoid arthritisarthritis

pHpH <7.20<7.20 Esophageal rupture, Esophageal rupture, empyema, TB, empyema, TB, malignancy, rheumatoid malignancy, rheumatoid arthritisarthritis

Amylase, PF/SAmylase, PF/S >1>1 Pancreatitis,Pancreatitis,

esophageal ruptureesophageal rupture

BacteriologicBacteriologic PositivePositive Etiology of effusionEtiology of effusion

CytologyCytology PositivePositive Diagnostic of malignancyDiagnostic of malignancy

Pleural fluid eosinophilia (>10%)Pleural fluid eosinophilia (>10%)

Usually due to air or blood in the pleural spaceUsually due to air or blood in the pleural space

Consider drug reactionsConsider drug reactions– Dantrolene, bromocriptine, nitrofurantoinDantrolene, bromocriptine, nitrofurantoin

Frequent with asbestos pleural effusionFrequent with asbestos pleural effusion

Rarely paragonimiasis or Churg-Strauss Rarely paragonimiasis or Churg-Strauss syndromesyndrome– also low glucose and pHalso low glucose and pH

Frequently no diagnosis obtainedFrequently no diagnosis obtained

Appearance of pleural fluidAppearance of pleural fluid

FluidFluid Suspected diseaseSuspected disease

Putrid odourPutrid odour Anaerobic empyemaAnaerobic empyema

Food particlesFood particles Oesophageal ruptureOesophageal rupture

Bile stainedBile stained Cholothorax (biliary Cholothorax (biliary fistula)fistula)

MilkyMilky Chylothorax/Chylothorax/pseudochylo- thoraxpseudochylo- thorax

““Anchovy sauce” like Anchovy sauce” like fluidfluid

Ruptured amoebic Ruptured amoebic abscessabscess

Pleural infectionsPleural infections

Pleural infection was first described by Hippocrates in 500BC.

Open thoracic drainage was the only

treatment for this disorder until the 19th century when closed chest tube drainage was first described.

open surgical drainage was associated with a mortality rate of up to 70%.

Characteristics of parapneumonic pleural Characteristics of parapneumonic pleural effusionseffusions

StagesStages Macroscopic Macroscopic appearanceappearance

Pleural fluid Pleural fluid characteristicscharacteristics

CommentsComments

Simple Simple parapneumonicparapneumonic

Clear fluidClear fluid pH >7.2pH >7.2

LDH <1000 IU/lLDH <1000 IU/l

Glucose >2.2 mmol/LGlucose >2.2 mmol/L

No organism on No organism on culture or Gram stainculture or Gram stain

Will usually resolve Will usually resolve with antibiotics alonewith antibiotics alone

Perform chest tube Perform chest tube drainage for symptom drainage for symptom relief if requiredrelief if required

Complicated Complicated parapneumonicparapneumonic

Clear fluid or Clear fluid or cloudy/turbidcloudy/turbid

pH <7.2pH <7.2

LDH >1000 IU/lLDH >1000 IU/l

Glucose <2.2 mmol/lGlucose <2.2 mmol/l

May be positive Gram May be positive Gram stain/culturestain/culture

Requires chest tube Requires chest tube drainagedrainage

EmpyemaEmpyema Frank pusFrank pus May be positive Gram May be positive Gram stain/culturestain/culture

Requires chest tube Requires chest tube drainagedrainage

No additional No additional biochemical tests biochemical tests necessary on pleural necessary on pleural fluid (do not measure fluid (do not measure pH)pH)

Classification of and Therapies for Parapneumonic Effusion and Empyema

Appearance and RadiologicClass Type Studies Appearance Treatment

1 Insignificant pleural Thoracentesis noteffusion (<10 mm indicatedthick) on decubitusradiograph)

2 Typical para- Glucose >40 mg/dL Antibiotics alonepneumonicpH >7.2pleural effusion Gram stain and culture(>10 mm thick) negative

Classification of and Therapies for Parapneumonic Effusion and Empyema (cont.)

Appearance and RadiologicClass Type Studies Appearance Treatment

3 Bordeline ph 7.0-7.2 and/or No loculations Antibiotics and complicated LDH >1000IU/L and repetitionpleural effusion Glucose >40 mg/dL

Gram stain and culturenegative

4 Simple compli- ph<7.0 and/or Not loculated, Tube thoracostomycated pleural Glucose <40 mg/dL nonpurulent and antibiotics or

effusion and/or serial thoracentesisGram stain culturepositive

Classification of and Therapies for Parapneumonic Effusion and Empyema (cont;)

Appearance and RadiologicClass Type Studies Appearance Treatment5 Complex complicated pH<7.0 and/or Multiloculated Tube thoracostomy a

pleural effusion Glucose <40 mg/dL nonpurulent & thrombolytic agentand/or In rare instancesGram stain or culture surgical interventionpositive

6 Simple empyema Frank pus Single loculation or Tube thoracostomy with or without decortication

7 Complex empyema Frank pus Multiple locules Tube thoracostomy &thrombolytic agentsOften thoracoscopy or decortication

LoculationSeptation

Resolution of pleural effusionResolution of pleural effusion

DiseaseDisease Incidence%Incidence% TherapyTherapy Resolution timeResolution time

ParapneumonicParapneumonic 9-669-66 AntibioticsAntibiotics 2-8 weeks2-8 weeks

TubeculosisTubeculosis 3-233-23 No therapyNo therapy 2-4 months2-4 months

Anti-TB treatmentAnti-TB treatment 1-2 months1-2 months

Post CABGPost CABG 40-9040-90 Self limitingSelf limiting 8 weeks(6w-20m)8 weeks(6w-20m)

RARA 4-74-7 NSAID, PrednisoneNSAID, Prednisone 3-4m(1m-5y)3-4m(1m-5y)

SLESLE 16-3716-37 SteroidsSteroids 1-6w1-6w

PEPE 10-5010-50 HeparinHeparin 3-7d3-7d

PCISPCIS 40-6840-68 NSAID, SteroidsNSAID, Steroids 1w-4m1w-4m

SarcoidosisSarcoidosis 0-7.50-7.5 Self limiting,steroidsSelf limiting,steroids 1-3m1-3m

Chest 119(5), 2001

<2 months<2 months 2-6 months2-6 months 6m-1year6m-1year Benign persistentBenign persistent

ParapneumonicParapneumonic

CHFCHF

Acute pancreatitisAcute pancreatitis

PCISPCIS

Post CABGPost CABG

PEPE

SLESLE

SarcoidosisSarcoidosis

Traumatic chylothoraxTraumatic chylothorax

Uremic effusionUremic effusion

TBTB

PCISPCIS

Post CABGPost CABG

RARA

sarcoidosissarcoidosis

RARA

Benign Benign asbestosisasbestosis

Trapped lungTrapped lung

LymphangiectasiaLymphangiectasia

Noonan’s syndromeNoonan’s syndrome

LAMLAM

Yellow nail syndromeYellow nail syndrome

Resolution of pleural effusion by time interval

Chest 119(5), 2001

Resolution of parapneumonic pleural effusionResolution of parapneumonic pleural effusion

organismorganism Incidence%Incidence% TherapyTherapy Resolution time Resolution time (Range)(Range)

S pneumoniaeS pneumoniae 30-6030-60 B-lactams, B-lactams, macrolidesmacrolides

4-8 weeks4-8 weeks

M pneumoniaeM pneumoniae 4-204-20 Macrolide, Macrolide, tetracyclinestetracyclines

2-3 weeks2-3 weeks

L pneumoniaeL pneumoniae 12-3512-35 MacrolidesMacrolides 3-4 weeks3-4 weeks

AdenovirusAdenovirus 2-182-18 Self limitingSelf limiting 2-3 weeks2-3 weeks

Chest 119(5), 2001

Tuberculous pleural effusionTuberculous pleural effusion

AFB stain positive in only 10-20%AFB stain positive in only 10-20%

AFB culture positive 25-50%AFB culture positive 25-50%

Diagnostic yield increases to 90% with Diagnostic yield increases to 90% with addition of pleural biopsy histology and addition of pleural biopsy histology and biopsy cultures for AFBbiopsy cultures for AFB

Pleural fluid markers for Pleural fluid markers for tuberculosistuberculosis

Adenosine Deaminase (ADA)Adenosine Deaminase (ADA)

Gamma interferonGamma interferon

PCR for DNA of M. tuberculosisPCR for DNA of M. tuberculosis

Pleural fluid ADAPleural fluid ADA

T-lymphocyte enzymeT-lymphocyte enzymePatients with TB have levels above 45 IU/L Patients with TB have levels above 45 IU/L unless they are immunologically suppressedunless they are immunologically suppressedHigh levels also seen with empyema and High levels also seen with empyema and rheumatoid pleuritisrheumatoid pleuritisSpecificity increased if combined with PF Specificity increased if combined with PF lymph/poly ratio greater than 3lymph/poly ratio greater than 3Pleural fluid ADA helpful in areas of high TB Pleural fluid ADA helpful in areas of high TB prevelanceprevelanceFluid ADA levels not useful in HIV patients with Fluid ADA levels not useful in HIV patients with TBTB

Pleural fluid gamma interferonPleural fluid gamma interferon

Produced by lymphocytesProduced by lymphocytes

Lymphocytes specifically sensitized to PPD produce Lymphocytes specifically sensitized to PPD produce gamma interferon when incubated with PPDgamma interferon when incubated with PPD

PF levels above 140pg/ml are very suggestive of TBPF levels above 140pg/ml are very suggestive of TB

Elevated whether or not the patient is Elevated whether or not the patient is immunosuppressedimmunosuppressed

Is more expensive than ADAIs more expensive than ADA

PCR for the diagnosis of PCR for the diagnosis of tuberculous pleuritistuberculous pleuritis

With PCR one can identify the presence of With PCR one can identify the presence of DNA from M. tuberculosis in the pleural fluidDNA from M. tuberculosis in the pleural fluid

Study from spain on 107 pleural fluidsStudy from spain on 107 pleural fluids– PCR positive in 17/21 with TBPCR positive in 17/21 with TB– PCR positive in only two others and they probably PCR positive in only two others and they probably

had TBhad TB– PCR was not superior to an ADA level >45PCR was not superior to an ADA level >45

Querol JM et al. Am J Respir Crit Care Med 1995;152:1977

Diagnosis of tuberculous pleuritisDiagnosis of tuberculous pleuritis

If pleural fluid ADA >70 units - diagnosticIf pleural fluid ADA >70 units - diagnostic

If pleural fluid gamma interferon is high - If pleural fluid gamma interferon is high - diagnosticdiagnostic

Granulomas on pleural biopsy - diagnosticGranulomas on pleural biopsy - diagnostic

If lymphocytic effusion and positive PPD, If lymphocytic effusion and positive PPD, treat for TB pleuritis if pleural fluid ADA is treat for TB pleuritis if pleural fluid ADA is above 40above 40

Pleural effusions in HIV infectionPleural effusions in HIV infection

A pleural effusion is seen in 7–27% of A pleural effusion is seen in 7–27% of hospitalised patients with HIVhospitalised patients with HIVLeading causes areLeading causes are

Kaposi sarcomaKaposi sarcoma parapneumonic effusionparapneumonic effusion TuberculosisTuberculosis LymphomaLymphoma pneumocystic carinii pneumoniapneumocystic carinii pneumonia

Chylothorax and PsudochylothoraxChylothorax and Psudochylothorax

Fluid Triglyceride >110 mg /dl - DiagnosticFluid Triglyceride >110 mg /dl - Diagnostic

Presence of Chylomicron - DiagnosticPresence of Chylomicron - Diagnostic

Fluid Triglyceride 50-110 mg/dl – probable Fluid Triglyceride 50-110 mg/dl – probable

Fluid Triglyceride <50 mg/dl – Not chylothoraxFluid Triglyceride <50 mg/dl – Not chylothorax

Laboratory differentiation of chylothorax and Laboratory differentiation of chylothorax and pseudothoraxpseudothorax

FeatureFeature PseudochylothoraxPseudochylothorax ChylothoraxChylothorax

TriglyceridesTriglycerides <0.56 mol/l <0.56 mol/l (50mg/dl)(50mg/dl)

>1.24 mmol/l >1.24 mmol/l (110 mg/dl)(110 mg/dl)

CholesterolCholesterol >5.18 mmol/l >5.18 mmol/l (200 mg/dl)(200 mg/dl)

>5.18 mmol/l >5.18 mmol/l (200 mg/dl)(200 mg/dl)

Cholesterol Cholesterol crystalscrystals

Often presentOften present AbsentAbsent

ChylomicronsChylomicrons AbsentAbsent PresentPresent

Causes of chylothorax and pseudochylothoraxCauses of chylothorax and pseudochylothorax

ChylothoraxChylothorax– Neoplasm: lymphoma, metastatic carcinomaNeoplasm: lymphoma, metastatic carcinoma– Trauma: operative, penetrating injuriesTrauma: operative, penetrating injuries– Miscelaneous: tuberculosis, sarcoidosis, Miscelaneous: tuberculosis, sarcoidosis,

lymphangioleiomyomatosis, cirrhosis, obstruction of lymphangioleiomyomatosis, cirrhosis, obstruction of central veins, amyloidosiscentral veins, amyloidosis

PseudochylothoraxPseudochylothorax– TuberculosisTuberculosis– Rheumatoid arthritisRheumatoid arthritis– Poorly treated empyemaPoorly treated empyema

Malignant pleural effusionMalignant pleural effusion

Malignant pleural effusionMalignant pleural effusion

Pleural fluid cytologyPleural fluid cytology

Very useful testVery useful test1st specimen positive in 60% and if three 1st specimen positive in 60% and if three specimens submitted, may be positive in >80%specimens submitted, may be positive in >80%Very effective with adenocarcinomaVery effective with adenocarcinomaLess effective with lymphoma, squamous cell Less effective with lymphoma, squamous cell carcinoma, mesothelioma or Hodgkin’s diseasecarcinoma, mesothelioma or Hodgkin’s diseasecytology much better than needle biopsy in most cytology much better than needle biopsy in most series looking at malignant effusionsseries looking at malignant effusions– in one series of patients with malignancy, pleural in one series of patients with malignancy, pleural

biopsy positive in only 20/118 (17%) with negative biopsy positive in only 20/118 (17%) with negative cytologycytology

– rarely is needle biopsy indicatedrarely is needle biopsy indicated

Sensitivity of pleural fluid cytology in malignant pleural Sensitivity of pleural fluid cytology in malignant pleural effusioneffusion

ReferenceReference No.of patientsNo.of patients No. caused by No. caused by malignancymalignancy

% diagnosed % diagnosed by cytologyby cytology

Salyer et alSalyer et al1010 271271 9595 72.672.6

Prakash et alPrakash et al1212 414414 162162 57.657.6

Nance et alNance et al1111 385385 109109 71.071.0

HirschHirsch3939 300300 117117 53.853.8

Total:Total: 13701370 371371 61.661.6

Malignant pleural effusionMalignant pleural effusion Observation

Observation is recommended if the patient is asymptomatic or there is no recurrence of symptoms after initial thoracentesis. [C]

Therapeutic pleural aspiration

Repeat pleural aspiration is recommended for the palliation of breathlessness in patients with a very short life

expectancy. [C]Caution should be taken if removing more than 1.5 L

on a single occasion. [C]The recurrence rate at 1 month after pleural

aspiration alone is close to 100%. [B]Intercostal tube drainage without pleurodesis is not

recommended because of a high recurrence rate. [B]

Chemical Chemical agentagent

Total Total patients (n)patients (n)

Successful Successful (%) (%)

dosedose

TalcTalc 165165 9393 2.5-10g2.5-10g

DoxycyclineDoxycycline 6060 7272 500mg500mg

tetracyclinetetracycline 359359 6767 500mg500mg

BleomycinBleomycin 199199 5454 15-250 units15-250 units

Success rates of commonly used pleurodesis agents

Rheumatoid arthritis associated pleural effusions

• Suspected cases should have a pleural fluid pH, glucose and complement measured.

• Rheumatoid arthritis is unlikely to be the cause of an effusion if the glucose level in the fluid is above 1.6 mmol/l (29 mg/dl).

EntityEntity Frequency (%)Frequency (%)

Rheumatoid Rheumatoid ArthritisArthritis

8585

EmpyemaEmpyema 8080

Malignant Malignant effusioneffusion

3030

TuberculousTuberculous 2020

LupusLupus 2020

Frequency of low glucose values in pleural effusions

SLE associated pleural SLE associated pleural effusioneffusion

The presence of LE cells in pleural fluid The presence of LE cells in pleural fluid is diagnostic of SLE.is diagnostic of SLE.

The pleural fluid ANA level should not The pleural fluid ANA level should not be measured as it mirrors serum levels be measured as it mirrors serum levels and is therefore unhelpful.and is therefore unhelpful.

Hepatic hydrothoraxHepatic hydrothorax

Pleural effusion associated with liver Pleural effusion associated with liver cirrhosiscirrhosis

Mostly associated with ascites Mostly associated with ascites

Can occur without ascitesCan occur without ascites

Diagnostic tap of both pleural effusion and Diagnostic tap of both pleural effusion and ascitesascites

Difficult to treat Difficult to treat

Pleurodesis usually unsuccessfulPleurodesis usually unsuccessful

MANAGEMENT OF PERSISTENT MANAGEMENT OF PERSISTENT UNDIAGNOSED PLEURAL EFFUSIONUNDIAGNOSED PLEURAL EFFUSION

• In persistently undiagnosed effusions the possibility

of pulmonary embolism and tuberculosis should be

reconsidered since these disorders are amenable to

specific treatment.

• Undiagnosed pleural malignancy proves to be the

cause of many “undiagnosed” effusions with sustained

observation.

Presence of transudate effusion indicates the existence Presence of transudate effusion indicates the existence of systemic disease.of systemic disease.Exudative effusion is caused by a local pleural process.Exudative effusion is caused by a local pleural process.Spontaneous bacterial empyema can complicate Spontaneous bacterial empyema can complicate hepatic hydrothorax.hepatic hydrothorax.TB and malignancy are the two commonest causes of TB and malignancy are the two commonest causes of unexplained exudative effusion.unexplained exudative effusion.TB effusion is caused with equal frequency by primary TB effusion is caused with equal frequency by primary & reactivated TB& reactivated TBHemothorax if HCT > 20%Hemothorax if HCT > 20%

Pleural Effusion Pearls

Pleural Effusion Pearls

Massive pleural effusions are most commonly due to malignancy. [B]

The majority of malignant effusions are symptomatic. [C]

Very low glucose in the absence of infection is highly suggestive of RA

Thank youThank you