Pleural Fluid Characteristics Research Articles

Protocolo diagnóstico y tratamiento del derrame pleural agudo

Pleurae are the two layers of serous membranes that line the lungs, mediastinum, diaphragm and chest wall. Pleural cavity is the space between both membranes. Pleural effusion is a buildup of fluid in the pleural space. Clinical history and physical examination are the basis in the evaluation of pleural effusion. Complementary tests are required to diagnosis. Treatment varies with symptomatology (dyspnea), etiology (hemodynamic, infectious, or inflammatory), and pleural fluid characteristics.

URINOTHORAX: A RARE CAUSE OF PLEURAL EFFUSION AFTER ELECTIVE NEPHROLITHOTOMY

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Diseases SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Urinothorax is a rare condition that consists of the accumulation of urine in the pleural space usually due to trauma or obstruction of the genitourinary tract[1,2]. Its rarity makes diagnosis and treatment challenging. Below, we present a case of unilateral urinothorax after elective nephrolithotomy. CASE PRESENTATION: A 54-year-old female with recurrent urinary tract infections, nephrolithiasis, and chronic kidney disease presented to the hospital for elective nephroureteral catheter placement and nephrolithotomy for a 2cm right kidney stone. On admission, a 24fr catheter was placed into the right renal pelvis. Post-procedure, she appeared well and complained of mild pain around the catheter site. Imaging confirmed satisfactory position of the catheter. The next day, she underwent right percutaneous nephrolithotomy. During the procedure, the catheter was replaced with a dual-lumen access catheter using fluoroscopy. The surgeon noted that the tract was more medial than the usual tract. The stone was treated with lithotripsy and a sterile catheter was replaced into the renal pelvis. Post-operatively, she complained of dyspnea and pain at the catheter site. She rapidly developed respiratory distress and hypoxia, requiring supplemental oxygen via a non-rebreather. Examination and imaging were consistent with a right pleural effusion. The existing nephroureteral catheter was downsized and a chest tube was inserted with drainage of 2L of serosanguinous fluid from the pleural space. The patient improved and the effusion remained stable. Two days later, she developed acute respiratory distress due to re-accumulation of pleural fluid. A nephrostogram revealed no communication between the catheter and pleural space. Pleural fluid studies demonstrated a transudate with pH 7.4, LDH 177, creatinine 2.8 (serum creatinine 1.4). Her symptoms improved over the next three days. A repeat CT showed improvement in the effusion but loculations were noted. Surgical intervention was considered but deferred. The chest tube was removed and she was discharged. She did well with resolution of the loculations and did not require surgical decortication. DISCUSSION: Given the rare (likely underdiagnosed) nature of a urinothorax, knowledge surrounding its clinical course, pleural fluid characteristics, and best treatment is lacking. A recent review concluded that most cases of urinothorax are unilateral, of traumatic (commonly surgical) origin, have a high LDH, pleural fluid/serum creatinine ratio >1.0, and/or pH <7.3[2]. Dyspnea was the primary symptom[2]. Successful treatment focused on the underlying uropathy, with or without thoracentesis[2]. Decortication was performed in a small number of patients with a favorable outcome in all[2]. CONCLUSIONS: This case demonstrates a rare complication of urologic procedures for which increased awareness and clinical suspicion may aid in its timely diagnosis and management. Reference #1: Austin A, Johani SN, Brasher PB, Argula RG, Huggins JT, Chopra A. The urinothorax: a comprehensive review with case series. Am J Med Sci. 2017;354(1):44-53. Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systemic review. J Thorac Dis. 2017;9(5):1209-1218. DISCLOSURES: No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by George Lieb, source=Admin input

Chylothorax as a Risk Factor for Thrombosis in Adults: A Proof-of-Concept Study

Postoperative chylothorax in children is associated with an increased risk of vascular thrombosis, hypothesized to be from loss of antithrombin into chylous fluid resulting in a hypercoagulable state. In adults, an increased thrombotic risk with chylothorax has not been described. Adults undergoing Ivor-Lewis esophagogastrectomy have two strong thrombotic risk factors-active malignancy and postoperative state-allowing for relative homogeneity in baseline thrombotic risk; therefore, we studied the association of chylothorax with thrombosis in this population. We performed a single-center retrospective cohort study at a tertiary care academic center. Patients included adults undergoing Ivor-Lewis esophagogastrectomy between January 1, 2006, and December 31, 2012. We collected demographics, pleural fluid characteristics, and relevant imaging within 30 days after the operation. Using nominal logistic regression, we studied the effects of chylothorax, age, sex, body mass index, American Society of Anesthesiologists Physical Status Classification, operative duration, and hospital length of stay on the incidence of postoperative thrombosis. We identified 608 patients who underwent Ivor-Lewis esophagogastrectomy. Of these, 524 (86.2%) had no pleural fluid analysis, 48 (7.9%) had nonchylous effusions, and 36 (5.9%) had chylothoraces, with incident acute vascular thrombosis within 30 days postoperatively occurring in 22 of 524 (4.2%), 2 of 48 (4.2%), and 8 of 36 (22.2%), respectively (p= 0.001). In multivariate analyses, after adjusting for the above factors, chylothorax was associated with significantly higher odds of any vascular thrombosis (odds ratio, 5.46; p= 0.0013) and deep venous thrombosis/pulmonary embolism (odds ratio, 6.76; p=0.0016). Chylothorax is associated with a significantly higher incidence of vascular thrombosis in adults undergoing Ivor-Lewis esophagogastrectomy. Vascular thrombosis was associated with a significantly higher 90-day mortality rate.

Usefulness of Medical Thoracoscopy in the Management of Pleural Effusion Caused by Chronic Renal Failure

Although pleural effusion (PE) can be caused by several pathologies like congestive heart failure, infections, malignancies, and pulmonary embolism, it is also a common finding in chronic kidney disease (CKD). Diagnostic thoracentesis is of limited value in the differential diagnosis, and the role of more invasive investigations like medical thoracoscopy (MT) is still unclear. To evaluate the usefulness of MT in unexplained PE in CKD. In the electronic database of our Institution, we retrospectively searched for patients with CKD who underwent MT for unexplained PE between January 2008 and August 2016. Ten patients were included in the present study. The average age was 72.4 years, the male:female ratio 9:1 and the average blood creatinine value 5.96 mg/dL. The average follow-up was 18 months.A thoracentesis showed an exudate was found in 9 patients and in 1 case pleural fluid characteristics were not recorded for technical reasons; in none of them the cytologic or microbiological analyses were considered diagnostic.The clinical suspicion was a neoplastic (5) or an infectious disease (5). In 4 patients with recurrent PE, MT was performed to obtain talc pleurodesis.No immediate procedure-related complications were recorded; 1 patient developed empyema after 2 months. In 6 cases final diagnosis was chronic uremic pleuritis, hydrothorax in 2, and chronic lymphocytic pleurisy in 2. MT represents a safe and effective diagnostic and therapeutic procedure in patients with CKD, that itself is a common cause of exudative effusion, and those patients may not require MT.

Lipoteichoic acid upregulates plasminogen activator inhibitor-1 expression in parapneumonic effusions.

Parapneumonic effusion (PPE) is commonly caused by Gram-positive bacteria (GPB) and often presents with pleural loculation, which is characterized by overproduction of plasminogen activator inhibitor (PAI)-1. Lipoteichoic acid (LTA), a surface adhesion molecule of GPB, binds to the pleural mesothelium and triggers inflammation. However, the effects of LTA on PAI-1 expression in PPE and underlying mechanisms remain unclear. Thirty consecutive patients with PPE were enrolled, including uncomplicated culture negative (CN, n = 11), Gram-negative bacteria (GNB, n = 7) and GPB (n = 12) groups stratified by pleural fluid characteristics and bacteriology, and the effusion PAI-1 levels were measured. In addition, human pleural mesothelial cells (PMC) were treated with LTA and the expression of PAI-1 and activation of signalling pathways were assayed. The median levels of PAI-1 were significantly higher in GPB (160.5 ng/mL) and GNB (117.0 ng/mL) groups than in the uncomplicated CN (58.0 ng/mL) group. In human PMC, LTA markedly upregulated PAI-1 mRNA and protein expression and enhanced elaboration of Toll-like receptor 2 (TLR2). Furthermore, LTA increased c-Jun N-terminal kinase (JNK) phosphorylation, induced activating transcription factor 2 (ATF2)/c-Jun nuclear translocation and activated PAI-1 promoter activity. Pretreatment with TLR2 siRNA significantly inhibited LTA-induced JNK phosphorylation and PAI-1 protein expression. Culture-positive PPE, especially that caused by GPB, has a significantly higher level of PAI-1 than uncomplicated CN PPE. LTA upregulates PAI-1 expression through activation of TLR2/JNK/activator protein 1 (AP-1) pathway in human PMC. Better understanding of the modulation of PAI-1 synthesis by LTA in PPE may provide potential therapies for infected pleural effusions.

Does repeated pleural culture increase the diagnostic yield of Mycobacterium tuberculosis from tuberculous pleural effusion in HIV-negative individuals?

BackgroundDespite recent advances in methods for culturing Mycobacterium tuberculosis (MTB), the diagnostic yield of tuberculous pleural effusion (TBPE) remains unsatisfactory. However, unlike repeated sputum cultures of pulmonary tuberculosis, little is known about the role of repeated pleural cultures. We examined whether repeated pleural cultures are associated with increased MTB yield from TBPE.MethodsA multicenter, retrospective cohort study was performed from January 2012 to December 2015 in South Korea. Patients were categorized into two groups: single- or repeated-culture groups. The diagnostic yield of MTB and clinical, radiological, and pleural fluid characteristics were evaluated.ResultsAmong the 329 patients with TBPE, 77 (23.4%) had repeated cultures and 252 (76.5%) had a single culture. Pleural culture was performed twice in all 77 patients in the repeated-culture group at a 1-day interval (inter-quartile range, 1.0–2.0). In the repeated-culture group, the yield of MTB from the first culture was 31.2%, which was similar to that in the single-culture group (31.2% vs. 29.8%, P = 0.887). However, the yield of MTB from the second culture (10/77, 13.0%) was more than that from the first. These results may be attributable to the insufficient immune clearance for MTB invasion into the pleural space between the first and second cultures. Over time, the yield of the second cultures decreased from 17.4% to 6.7% and then 6.3%. Finally, the overall yield of MTB in the repeated- and single-culture groups was 44.2% and 29.8% respectively (P < 0.001).ConclusionsThe results showed that repeated pleural cultures increased MTB yield from TBPE in human immunodeficiency virus-negative individuals. Furthermore, repeated cultures may increase yield when carried out for two consecutive days.

Urinothorax: a systematic review.

The characteristics of patients with urinothorax (UT) are poorly defined. A systematic review was performed searching for studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of UT. Case descriptions and retrospective studies were included. The review included 78 studies with a total of 88 patients. Median age was 45 years, male/female ratio was 1.6:1 and in 76% of cases the etiology was trauma. Pleural effusion (PE) was predominantly unilateral (87%) and occupied over 2/3 of the hemithorax in most cases (64.4%). PF was straw-colored (72.7%) or hematic (27.3%) with urine-like odor in all cases. PF was transudate in 56.2% of cases (18/32) and among 14 exudates (43.8%), 3 were concordant exudates, 1 protein-discordant and 10 LDH-discordant, with lymphocyte (44.4%) and neutrophil (38.5%) predominance. The PF/serum (PF/S) creatinine ratio was >1 in all cases except one (97.9%). The diagnosis was established on the basis of PF/S creatinine ratio >1 (56.6%), urinary tract contrast extravasation (12%), abnormal computed tomography (8.4%), laparotomy findings (6%), and association of obstructive uropathy with PE (6%). The outcome was favorable (74/77; 96.1%) when treatment was direct towards the uropathy (alone or associated with thoracentesis/thoracic drainage). Outcome was unfavorable in the 15 patients who were only treated with thoracentesis/thoracic drainage. UT is usually traumatic, unilateral, and PF does not have a specific pattern or cellularity predominance, with a PF/S creatinine ratio almost always >1. Treatment should include the uropathy, with or without PF evacuation.

Predictive Factors and Treatment Outcomes of Tuberculous Pleural Effusion in Patients With Cancer and Pleural Effusion

BackgroundPatients with cancer are at an increased risk of tuberculosis. As pleural effusion has great clinical significance in patients with cancer, the differential diagnosis between tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE) is important. However, the predictive factors and treatment outcomes of TPE in patients with cancer have rarely been studied. Materials and MethodsConfirmed TPE cases identified at cancer diagnosis and during anticancer management from 2008-2015 were retrospectively investigated. Patients in the study included coexisting TPE and cancer (n = 20), MPE (n = 40) and TPE without cancer (n = 40). Control groups were patients with MPE, and patients with TPE without cancer. Clinical, laboratory and pleural fluid characteristics were compared among groups. Treatment outcomes were compared between patients with TPE with and without cancer. ResultsIn the final analysis, serum C-reactive protein (S-CRP) ≥3.0mg/dL and pleural fluid adenosine deaminase (ADA) ≥40U/L were independent predictors for identifying TPE in patients with cancer having pleural effusion. The combination of S-CRP with pleural fluid ADA using an “or” rule achieved a sensitivity of 100%, whereas both parameters combined in an “and” rule had a specificity of 98%. Treatment outcomes were not different between the TPE groups with and without cancer. ConclusionsS-CRP and pleural fluid ADA levels may be helpful for predicting TPE in patients with cancer with pleural effusion. The combination of these biomarkers provides better information for distinguishing between TPE and MPE in these patients. Treatment outcomes of TPE in patients with cancer are comparable to those in patients without cancer.

Mixing It Up: Coadministration of tPA/DNase in Complicated Parapneumonic Pleural Effusions and Empyema.

A recent randomized controlled trial showed 12 serial doses of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is safe and effective in managing complicated parapneumonic pleural effusions and empyema (CPEE). However, this regimen is laborious, requiring trained personnel to open/close the chest tube 8 times daily for 3 days. We present our observational data using a simplified regimen of coadministered tPA/DNase. This is a retrospective observational study of patients who received coadministered tPA/DNase for CPEE from January 2012 to April 2015 at the University of Texas Medical Branch. Patient demographics, pleural fluid, radiologic and treatment characteristics, and outcomes were collected. Data are presented as proportions and percentages. Our primary outcome was successful treatment without need of surgery and discharge home alive. Secondary outcomes were dose and length of treatment and hospital stay, treatment complications, and 90-day mortality. The study included 39 patients. All pleural effusions were loculated, 59% macroscopically purulent, 50% had a positive organism in Gram stain, and 40% were culture positive. A median of 6 (interquartile range, 3.5 to 6) doses were coadministered mainly via small bore chest tube (≤14 Fr in 79%) with a median of 14.5 (interquartile range, 9.5 to 21.5) hospital days. Overall, 85% were successfully treated without need for surgery. Treatment failures occurred in 15%: 3/39 (7%) received surgery; 3/39 (7%) died. Only 1 (2.5%) complication of hemorrhagic pleural effusion resolved after discontinuation of intrapleural treatment. Our study shows intrapleural coadministration of tPA/DNase was effective and safe in management of CPEE.

Neutrophilic Loculated Tuberculous Pleural Effusion: Incidence, Characteristics and Differentiation From Complicated Parapneumonic Effusion

ObjectivesTuberculous pleural effusion (TPE) is generally characterized by lymphocytic exudative effusion, either free-flowing or loculated. However, patients can also have neutrophilic loculated TPE, although little data are available concerning the incidence and characteristics of this form of TPE. It is important to differentiate between neutrophilic loculated TPE and complicated parapneumonic effusion (PPE), which also shows neutrophilic loculated effusion but needs a different management approach. The present study evaluated the incidence and characteristics of neutrophilic loculated TPE and differentiated it from complicated PPE. Materials and MethodsBetween 2009 and 2014, a cohort of patients with TPE was retrospectively reviewed in a South Korean referral hospital. Clinical, laboratory, computed tomography and pleural fluid findings of patients with neutrophilic loculated TPE were compared to those of patients with neutrophilic free-flowing TPE and complicated PPE, respectively. ResultsNeutrophilic TPE was observed in 33 (10%) out of 344 patients with TPE. Of these, 10 (30%) patients exhibited loculation of the pleural fluid. These patients showed distinct pleural fluid characteristics. The classical pleural fluid biomarker levels were more intense than those observed in 23 patients with neutrophilic free-flowing TPE, but similar to those of 54 patients with complicated PPE. A high mycobacterial burden was observed in the pleural fluid, and favorable outcomes were achieved with antituberculosis drug administration alone. Nodular parenchymal lesions and pleural fluid adenosine deaminase levels were independent discriminators of neutrophilic loculated TPE and PPE. ConclusionsThese results may be helpful to understand and manage patients with neutrophilic loculated TPE and differentiate them from patients with complicated PPE.

Complicated pleural infection: Analysis of two consecutive cohorts managed with a different policy

Abstract Introduction The treatment of complicated pleural infection (CPI) is controversial. Clinical guidelines recommend drainage, but with the lowest grade of evidence. Recent reports have observed good outcomes with antibiotics alone. We retrospectively compared the outcomes in two consecutive cohorts treated with different policies: the first treated according to pleural fluid characteristics (2005–2009, interventional-prone, group 1) and the second according to clinical assessment (2010–2013, conservative-prone, group 2). Methods The clinical records of all children treated for CPI in our hospital between 2005 and 2013 were thoroughly reviewed. Primary outcomes were the proportion of children drained and the length of hospital stay (LHS). Results One hundred and nine patients (64 group 1 and 45 group 2) were analyzed. A chest tube was placed in 83% of patients in group 1 and 47% in group 2 (P Conclusion Our results add to few recent observations reporting good outcomes in many children treated with antibiotics alone and challenge the need to drain most children with CPI. Clinical trials are now needed to identify when a drainage procedure would be useful.

Pleural Effusion in Meigs' Syndrome-Transudate or Exudate?: Systematic Review of the Literature.

Although Meigs’ syndrome is regarded as a well-defined entity, contradictory data on pleural fluid characteristics have been presented, with some papers classifying it as a transudate, whereas others stating that it is an exudate.The aims of the study were: (1) to evaluate pleural fluid characteristics in patients with Meigs’ syndrome and (2) to analyze the prevalence of transudative and exudative pleural effusion in relation to the applied definition of the syndrome.We performed a search through medical databases (MEDLINE, EMBASE, SCOPUS, and GOOGLE SCHOLAR) to identify papers on Meigs’ syndrome published between 1940 and 2013. Two authors independently reviewed each paper searching for prespecified data: (1) signs and symptoms, (2) tumor characteristics, (3) clinical and laboratory data on ascites, (4) clinical, radiological, and laboratory data on pleural fluid, (5) clinical course after tumor removal. All case reports were reclassified according to a new unequivocal classification of Meigs’ syndrome-related entities.A total of 653 papers were initially identified, and 454 articles reporting 541 patients were included in the final analysis. After reclassification according to our case definitions, there were 196, 113, and 108 patients defined as classic Meigs’ syndrome, nonclassic Meigs’ syndrome, and pseudo-Meigs’ syndrome, respectively. Significantly more patients presented with right-sided than left-sided and bilateral pleural effusions (P < 0.001). Median volume of withdrawn pleural fluid was 2950 (1500–6000) mL. The classification of pleural effusion with the use of Light's criteria was possible in only 7 patients. In 6 of these patients pleural effusion met the criteria for an exudate. When the protein concentration > 3.0 g/dL was applied as a criterion of pleural exudate, 88.8% (80/90) of effusions were classified as exudates. Increasing the cut-off level to 3.5 g/dL resulted in only a modest decrease in the percentage of exudative effusions (81%, 73/90).Surprisingly few reports on Meigs’ syndrome present data reliably defining the character of pleural effusion. The available data indicate, however, that the majority of pleural effusions in patients with this entity are exudates. This finding may be a prerequisite for the verification of some earlier presented concepts.

Clinical Research Abstracts of the British Equine Veterinary Association Congress 2015.

Pleural effusion (PE) is reported to occur most commonly secondary to bacterial pneumonia or lung abscesses, with neoplastic effusions contributing the minority of cases. The majority of these reports originate from America and Australia, where long distance transport of horses, a recognised risk factor, appears to occur more frequently. Anecdotally, neoplastic PE is more commonly diagnosed in the UK. To describe the causes of PE in horses resident in the UK, and to identify potential markers that can help differentiate between infectious and neoplastic causes of PE. Retrospective clinical study. Medical records from 4 referral hospitals in southern England were searched for horses diagnosed with PE. Information gathered from medical records included signalment, diagnosis (infectious vs. neoplastic), admission physical examination and biochemical findings, and characteristics of the effusion (volume, cell count, total protein [TP] concentration). Statistical comparisons were made between the neoplastic and infectious group using appropriate testing. Seventy horses were identified, of which 28 (40%) were neoplastic and 42 were infectious. Horses with infectious effusions were significantly younger (median 7 vs. 13 years; P = 0.002) and had significantly smaller volumes of pleural fluid drained at admission (9.8 vs. 32.3 l; P<0.001). Horses with infectious PE had a significantly higher rectal temperature (38.6 vs. 38.2°C; P = 0.03), fibrinogen concentration (7.8 vs. 5.7 g/l; P = 0.02) and serum amyloid A concentration (223 vs. 104 mg/l; P = 0.02). Pleural fluid characteristics identified a significantly greater cell count and TP concentration in horses with infectious PE (47 x 10(9)/l vs. 3.4 x 10(9)/l; P<0.001; 54 vs. 31 g/l; P = 0.001). These results suggest that in the UK neoplastic effusions account for a greater proportion of PE than previously reported. A large volume of PE in an older horse with a low cell count and TP concentration should increase the index of suspicion of neoplasia. Ethical animal research: This was a retrospective study of clinical cases. Explicit owner informed consent for inclusion of animals in this study was not stated. None. Competing interests: None declared.

Clinical value of pleural biopsy in the etiological diagnosis of children with pleurisy

To investigate the clinical value of pleural biopsy in the etiological diagnosis of pleurisy in children. Totally 213 cases with pleurisy, who underwent pleural biopsy and hospitalized in Children's Hospital of Chongqing Medical University from January 2007 to April 2014 were enrolled into this study. Clinical symptoms, imaging manifestations, pleural fluid characteristics, the results of pleural biopsy and postoperative complications were retrospectively analyzed to evaluate the clinical value and security of pleural biopsy in making the etiological diagnosis of pleurisy. (1) Of the 213 cases, 144 were boys and 69 were girls, their mean age was (6. 5 ± 4. 1) years. (2) Two hundred and thirteen patients had a surgical pleural biopsy under general anesthesia, the cause of 97 cases (45. 5%) were made clear by histopathological examination, including 35 purulent pleurisy, 55 tuberculous pleurisy and 7 paragonimus infection. For the remaining 83 (41. 3%) cases a final diagnosis was made based on the full analysis of clinical data, including 63 cases of purulent pleurisy, 3 cases of tuberculous pleurisy and 17 cases of paragonimiasis pleurisy but for 33 patients no exact cause was found at the end. (3) The mean operating time of the biopsy was (1. 4 ± 0. 6) hours. Seventy one (33. 3%) patients required blood transfusion during or after the operation. Thirty one (14. 6%) cases used the ventilator after surgery, and the ventilator supporting time was (6. 6 ± 5. 8) hours on average. The wound healing reached grade A in 200 cases (93. 9%), grade B in 13 cases (14. 6%). Postoperative complications included pneumothorax in 92 cases (43. 2%), subcutaneous emphysema in 18 cases (8. 5%), bronchopleural fistula in 3 cases(1. 4%). The average days of hospitalization was (17. 7 ± 7. 1) d. Pleural biopsy is of great diagnostic value in the etiological diagnosis and differential diagnosis of pleurisy in children, and it is considered reasonable to be used in the clinical practice when appropriate.

Pleural fluid characteristics of pleuropulmonary paragonimiasis masquerading as pleural tuberculosis.

Background/AimsPleuropulmonary paragonimiasis produces no specific symptoms or radiologic findings, allowing for the possibility of misdiagnosis. We evaluated the specific clinical and pleural fluid features of pleuropulmonary paragonimiasis masquerading as pleural tuberculosis.MethodsWe retrospectively analyzed the clinical and radiologic characteristics of 20 patients diagnosed with pleuropulmonary paragonimiasis between 2001 and 2011.ResultsIn total, 17 patients presented with respiratory symptoms, including dyspnea (30%), hemoptysis (20%), cough (20%), and pleuritic chest pain (15%). Chest radiographs revealed intrapulmonary parenchymal lesions, including air-space consolidation (30%), nodular opacities (20%), cystic lesions (15%), ground-glass opacities (10%), and pneumothorax (5%). A pleural f luid examination revealed eosinophilia, low glucose levels, and high lactate dehydrogenase (LDH) levels in 87%, 76%, and 88% of the patients, respectively. These traits helped to distinguish pleuropulmonary paragonimiasis from other pleural diseases such as parapneumonic effusion, malignancy, and pleural tuberculosis.ConclusionsPleuropulmonary paragonimiasis is often initially misdiagnosed as other pleural diseases. Therefore, it is important to establish the correct diagnosis. In patients with unexplained pleural effusion living in paragonimiasis-endemic areas, pleural fluid obtained by thoracentesis should be examined to distinguish pleuropulmonary paragonimiasis. When marked eosinophilia, high LDH levels, and low glucose levels are identified in pleural fluid, physicians could consider a diagnosis of pleuropulmonary paragonimiasis.

Clinical value of pleural biopsy in the diagnosis of children with tuberculous pleurisy

To explore the value of pleural biopsy in the diagnosis of tuberculous pleurisy in children. Fifty-one cases with tuberculous pleurisy, whose diagnosis was established according to the clinical diagnostic criteria of the child pulmonary tuberculosis formulated by the Chinese Medical Association (CMA) in 2006, after pleural biopsy hospitalized in Children's Hospital of Chongqing Medical University from Jan. 1, 2007 to Jan. 1, 2013 were enrolled into this study. Clinical symptoms, history traits, laboratory examination, imaging tests, pleural fluid characteristics and the results of pleural biopsy were retrospectively analyzed. Medical records of the cases who were diagnosed with tuberculous pleurisy by histological examination were reviewed to assess tuberculosis detection rate of pleural biopsy and to get the percentage of cases with a preoperative diagnosis inconsistent with the final diagnosis. There were 35 boys and 16 girls, and the mean age was (9.7 ± 3.5) years. The common symptoms included fever (82%), cough (71%) , chest pain (23%), weakness (10%) and shortness of breath (10%); 27% (14/51) children had shown tuberculosis toxic symptoms; 76% (39/51) patients had BCG vaccination history; 12% (6/51) cases had a history of contact with tuberculosis patients. The positive rates of the tuberculin skin test, serum tuberculosis antibody detection, detection of Mycobacterium tuberculosis DNA by polymerase chain reaction, acid-fast bacillus test of sputum (or gastric juice) smear, acid-fast bacilli (AFB) smear and culture of pleural effusion were respectively 61% (20/33), 6% (3/46), 0 (0/12), 4% (1/27), 22% (7/32). Pleural effusion was found by using imaging tests in 50 cases, among whom 28 cases (55%) with encapsulated effusion, and the multilocular cysts separated by fibrous tissue in 12 patients (23%) . Other features included pleural thickening (53%) , hilar and mediastinal lymph-nodes enlargement (14%) and white nodules of calcification (10%) . Thoracocentesis was performed in 31 cases, and pleural effusion obtained from which were exudative. The cell count, mainly mononuclear cells, increased in 28 patients (90%) . Among the 51 children investigated, 47 (92%) were histologically diagnosed to be tuberculous pleurisy. The typical pathologic changes of tuberculosis (caseous necrosis, granulomas, Langhans' giant cells and inflammatory cell infiltration) were observed in 40 cases, granulomatous inflammation without caseous necrosis were the main manifestations in 7 other patients. The pathological changes of the remaining 4 cases were not consistent with the pathological characteristics of tuberculosis. All 47 cases were given a preoperative diagnosis of tuberculous pleurisy (32%), purulent pleurisy (51%) and pleural effusion of unknown origin (17%) respectively before pleural biopsy. Therefore, the tuberculosis detection rate of pleural biopsy was 92%, and the preoperative misdiagnosis rate was 68%. Pleural biopsy was of great diagnostic value for children with tuberculous pleurisy.

Factors affecting pleural fluid adenosine deaminase level and the implication on the diagnosis of tuberculous pleural effusion: a retrospective cohort study

BackgroundAdenosine deaminase (ADA) is useful in the diagnosis of tuberculous pleural effusion (TPE). This study aims to determine the factors affecting pleural fluid ADA levels and to establish the optimal ADA levels for diagnosis of TPE for different age groups.MethodsThis was a retrospective study from January 2007 to October 2011. One hundred and sixty patients who had pleural fluid ADA performed for investigation of pleural effusion were analyzed. Variables examined included demographics, pleural fluid characteristics and peripheral blood counts. The ADA cut-offs according to age were selected using the receiver operating characteristic (ROC) curve.ResultsThe mean pleural fluid ADA was significantly higher in the TPE group (100 ± 35 IU/L) compared to non TPE patients (30 ± 37 IU/L). There was significant correlation between pleural fluid ADA and age, pleural fluid protein, LDH, and fluid absolute lymphocyte count. The strongest correlation was seen with age (r = −0.621). For patients ≤ 55 years old the ROC for ADA had area under curve (AUC) of 0.887. A pleural fluid ADA of 72 IU/L had sensitivity of 95.1%, specificity of 87.5%, positive predictive value (PPV) of 95.1% and negative predictive value (NPV) of 87.5% for the diagnosis of TPE. For patients > 55 years old the AUC is 0.959. ADA of 26 IU/L had a sensitivity of 94.7%, specificity of 80.4%, PPV of 62% and NPV of 97.8%.ConclusionsThere is a significant negative correlation between pleural fluid ADA and age. For older patients, a lower ADA cut-off should be used to exclude TPE.

Pleural Fluid Analysis and Clinical Characteristics of Spontaneous Bacterial Pleuritis in Patients with Liver Cirrhosis

Purpose: There are limited published data defining complete pleural fluid analysis in patients with liver cirrhosis and spontaneous bacterial pleuritis. Herein, we sought to examine the laboratory factors associated with this disease, as well as the clinical characteristics of patients who presented with it. Methods: We reviewed the pleural fluid analyses of all patients with liver cirrhosis and hepatic hydrothorax referred for thoracentesis at a single tertiary care center between 2011 and 2013. Spontaneous bacterial pleuritis was defined as pleural fluid absolute neutrocytic cell count (ANC) > 500 cell/mm3 or a positive pleural fluid culture with ANC > 250 cell/mm3 in the absence of a surgically-treatable intrathoracic source of infection. Results: The pleural fluid characteristics in eight patients with spontaneous bacterial pleuritis are listed in the table below. All patients with pleuritis (100%) had exudative pleural effusions by Light's criteria, compared with only two out of 11 (18%) of those without this condition (p<0.001). This yielded a sensitivity of 100% and specificity of 82% as a screening modality. Pleural fluid cultures were positive in only two cases. Only one patient had a prior history of spontaneous bacterial peritonitis (SBP), and none had concurrent SBP. Five patients were on a prophylactic antibiotic prior to presentation. Five patients underwent liver transplantation within six months of diagnosis, and all of them were alive and well to date. Of the three patients who did not undergo transplantation, two died within one year of the diagnosis and the remaining patient was lost to follow-up. Conclusion: Our findings suggest that the diagnosis of exudative pleural effusion using Light's criteria is very sensitive and specific in screening for spontaneous bacterial pleuritis. This is especially useful as our study also found that cultures are frequently negative in this condition. Following infection clearance, liver transplantation provides a favorable outcome.Table

Preoperative Predictors of Successful Surgical Treatment in the Management of Parapneumonic Empyema

Video-assisted thoracoscopic surgery (VATS) and thoracotomy are the main surgical options for treating parapneumonic empyema. The choice of either operation depends on many preoperative features, including the patient's condition, clinical and radiologic findings, and pleural fluid characteristics. The identification of the combination of those preoperative findings that will allow surgeons to select the appropriate approach for a successful operation (VATS or thoracotomy) could be of great interest in clinical settings. We retrospectively reviewed a series of 97 patients who had undergone successful VATS or thoracotomy for parapneumonic empyema; in all cases, the operation had begun through VATS and was changed to a thoracotomy if a complete decortication was needed. Preoperative clinical, radiologic, and laboratory features were compared between the two groups to search for differences that might serve as predictive factors for either operation. Perioperative findings were also analyzed. The operation was accomplished by VATS in 40 patients (41%), and conversion to thoracotomy was necessary in 57 (59%). Significant predictive factors for conversion were a prolonged delay from diagnosis to operation, the presence of fever and of pleural thickness on computed tomography (CT) images. The 25 patients who presented with these three features were cured by thoracotomy. The operative time and postoperative complication rate were significantly higher for the thoracotomy patients. Some preoperative features can help the surgeon to better select patients for the appropriate operation. Delayed operation, fever, and pleural thickness can be used to predict the likelihood of conversion to thoracotomy.

Management of malignant pleural effusions

Malignant pleural effusion (MPE) is common. However, regardless of the differences between patients, their underlying cancer type, and pleural fluid characteristics, management options are often limited. These have not advanced significantly over the last 80 years since pleurodesis was first described. Correspondingly, patient-related outcome measures have been neglected. The evidence (or lack of) behind the current treatment recommendations is reviewed and key research questions are described. Talc continues to be the most effective sclerosant available for pleurodesis in MPE. A recent randomized controlled trial comparing talc pleurodesis and indwelling pleural catheter insertion as first-line therapy suggests these approaches are equally effective, and utilized a patient-based symptom score as the primary outcome. The need to acknowledge the advances in translational medicine and oncological therapies to measure patient-related trial outcomes and to target pleural fluid formation in MPE is discussed. Pulmonologists should be aware of the staggering lack of progress in the evidence that supports the current 'recommended' management of MPE. The need for a re-think about MPE management with a focus on alternative therapeutic targets and treatment objectives should be appreciated, in order to optimize future patient care.