Differential Diagnosis Of Pleural Effusion Research Articles

Unlocking Diagnostic Precision: FATE Protocol Integration with BLUE and eFAST Protocols for Enhanced Pre-Hospital Differential Diagnosis of Pleural Effusion Manifested as Dyspnea in Adults-A Pilot Study.

Background: Dyspnea commonly stems from combined myocardial and pulmonary dysfunction, posing challenges for accurate pre-hospital diagnosis. Limited diagnostic capabilities hinder the differentiation of cardiac and pulmonary issues. This study assesses the efficacy of combined cardiac and pulmonary ultrasound using the BLUE, eFAST, and FATE protocols. Methods: Participants were consecutively enrolled from dyspnea-related emergency calls in Warsaw, Poland, from 4 April 2022, to 15 June 2023. Patients with pleural effusion were identified through pre-hospital and in-hospital radiological assessments. Pre-hospital thoracic ultrasonography followed the BLUE, eFAST, and FATE protocols, alongside comprehensive clinical assessments. The pre-hospital diagnoses were juxtaposed with the with hospital discharge diagnoses. Results: Sixteen patients (8 men, 8 women; median age: 76 years) were enrolled. Inter-rater agreement for the BLUE protocol was substantial (κ = 0.78), as was agreement for eFAST (κ = 0.75), with almost perfect agreement for combined protocol assessment (κ = 0.83). Left ventricle hypokinesis, identified via the FATE protocol, significantly correlated with hospital-diagnosed decompensated heart failure as the primary cause of dyspnea. Sensitivity and specificity were 1.0 (95%CI: 0.62-1.0) and 0.6 (95%CI: 0.15-0.95), respectively. Positive predictive value was 0.85 (95%CI: 0.55-0.98), and diagnostic accuracy was 0.86 (95%CI: 0.62-0.98). Conclusions: Integrating the FATE protocol into BLUE and eFAST enhances pre-hospital differential diagnosis accuracy of pleural effusion in adults. This synergistic approach streamlines diagnostic processes and facilitates informed clinical decision-making. Larger-scale validation studies are needed for broader applicability.

Differential Diagnosis of Pleural Effusion Using Machine Learning.

Rationale: Differential diagnosis of pleural effusion is challenging in clinical practice. Objectives: We aimed to develop a machine learning model to classify the five common causes of pleural effusions. Methods: This retrospective study collected 49 features from clinical information, blood, and pleural fluid of adult patients who underwent diagnostic thoracentesis between October 2013 and December 2018. Pleural effusions were classified into the following five categories: transudative, malignant, parapneumonic, tuberculous, and other. The performance of five different classifiers, including multinomial logistic regression, support vector machine, random forest, extreme gradient boosting, and light gradient boosting machine (LGB), was evaluated in terms of accuracy and area under the receiver operating characteristic curve through fivefold cross-validation. Hybrid feature selection was applied to determine the most relevant features for classifying pleural effusion. Results: We analyzed 2,253 patients (training set, n = 1,459; validation set, n = 365; extra-validation set, n = 429) and found that the LGB model achieved the best performance in both validation and extra-validation sets. After feature selection, the accuracy of the LGB model with the selected 18 features was equivalent to that with all 49 features (mean ± standard deviation): 0.818 ± 0.012 and 0.777 ± 0.007 in the validation and extra-validation sets, respectively. The model's mean area under the receiver operating characteristic curve was as high as 0.930 ± 0.042 and 0.916 ± 0.044 in the validation and extra-validation sets, respectively. In our model, pleural lactate dehydrogenase, protein, and adenosine deaminase levels were the most important factors for classifying pleural effusions. Conclusions: Our LGB model showed satisfactory performance for differential diagnosis of the common causes of pleural effusions. This model could provide clinicians with valuable information regarding the major differential diagnoses of pleural diseases.

LDH/ADA ratio in pleural fluid for the diagnosis of infectious pleurisy.

Pleural effusion (PE) is a common medical concern, often requiring thoracentesis for a definitive diagnosis. An elevated pleural fluid adenosine deaminase (ADA) may indicate tuberculosis, but this is not always the case. This study aimed to evaluate the accuracy of biomarkers determined in pleural fluid and propose a new diagnostic strategy for PE in patients with high levels of ADA in pleural fluid. This retrospective analysis studied patients with PE who received thoracentesis for the first time with an ADA level of > 33 U/L in the pleural fluid analysis at two tertiary hospitals from March 2019 to March 2023. Demographic and clinical data, as well as pleural fluid biomarkers and their ratios, were studied and compared between different PE groups, and a decision tree was developed. During the study period, 259 patients were enrolled, with four different types of PE: parapneumonic (PPE) 155, tuberculosis (TPE) 41, malignant (MPE) 50, and miscellaneous 13. Biomarkers and their ratios performed well in the differential diagnosis of PE, with the LDH/ADA ratio distinguishing between PPE and non-PPE with sensitivity and specificity of 98.06% and 98.08%, respectively. The combination of LDH/ADA ratio, ADA, and mononuclear cell percentage was identified as important factors for creating a decision tree with an overall accuracy of 89.96%. The pleural fluid LDH/ADA ratio was a useful diagnostic for distinguishing PPE from non-PPE, and a decision tree with an accuracy of 89.96% was created to differentiate the four forms of PE in clinical situations.

DNA Methylation Analysis of the SHOX2 and RASSF1A Panel Using Cell-Free DNA in the Diagnosis of Malignant Pleural Effusion.

The differential diagnosis of pleural effusion (PE) is a common but major challenge in clinical practice. This study aimed to establish a strategy based on a PE-cell-free DNA (cfDNA) methylation detection system for the differential diagnosis of malignant pleural effusion (MPE) and benign pleural effusion (BPE). A total of 104 patients with PE were enrolled in this study, among which 50 patients had MPE, 9 malignant tumor patients had PE of indefinite causes, and the other 45 patients were classified as benign controls. The methylation status of short stature homeobox 2 (SHOX2) and RAS association domain family 1, isoform A (RASSF1A) was detected using PE-cfDNA specimens by real-time fluorescence quantitative PCR. Total methylation (TM) was defined as the combination of the methylation levels of SHOX2 and RASSF1A. The electrochemiluminescence immunoassay was applied to evaluate the levels of multiple serum tumor markers. The PE-cfDNA methylation status of either SHOX2 or RASSF1A was much higher in MPE samples than in benign controls. The combination of SHOX2 and RASSF1A methylation in PE yielded a diagnostic sensitivity of 96% and a specificity of 100%, respectively. When compared with the corresponding serum tumor marker detection results, TM showed the highest diagnostic efficiency (AUC = 0.985). Furthermore, the combination of the SHOX2 and RASSF1A methylation panels using PE-cfDNA could apparently improve the differential diagnostic efficacy of BPE and MPE and could help compensate for the deficiency of cytology. Our results indicated that SHOX2 and RASSF1A methylation panel detection could accurately classify BPE and MPE diseases and showed better diagnostic performance than traditional serum parameters. The SHOX2 and RASSF1A methylation detection of PE-cfDNA could be a potentially effective complementary tool for cytology in the process of differential diagnosis. In summary, PE-cfDNA could be used as a promising non-invasive analyte for the auxiliary diagnosis of MPE.

Isolated Pleural Effusion- An Interesting Case Report of Foreign Body Aspiration-A Case Report

Foreign body (FB) aspiration is a serious medical problem that can mimic other respiratory conditions. Isolated pleural effusion is a rare presentation of FB aspiration. We report herein a six years old boy presenting with fever and cough without history of choking and respiratory distress and X-ray chest suggestive of pleural effusion. Although, the child was initially misdiagnosed as pneumonia with sympneumonic effusion, the diagnosis was established only once he coughed out a piece of foreign body. The present case highlights that FB aspiration, even though rare, should be considered as one of the differential diagnosis of pleural effusion.

Elevated Nitrite/Nitrate Ratio as a Potential Biomarker for the Differential Diagnosis of Pleural Effusions.

Pleural effusions (PEs) are common in clinical practice and can be due to many different underlying diseases such as cancer, congestive heart failure, or pneumonia. An accurate differential diagnostic categorization is essential, as the treatment and prognosis of PEs largely depend on its cause. In this study, we tested the hypothesis that nitrite and nitrate concentrations in PEs are associated with the inflammation and infection conditions. We therefore measured the nitrite and nitrate levels in 143 PE samples using a sensitive liquid chromatography-tandem mass spectrometry method and investigated their diagnostic potential in differentiating PEs. The results showed that nitrite concentrations and nitrite/nitrate ratios were higher in exudates than in transudates (NO2−: 2.12 vs. 1.49 μM; NO2−/NO3−: 23.3 vs. 14.0). Both the nitrite concentrations and the nitrite/nitrate ratios were positively correlated with the three Light’s criteria. Moreover, the receiver operating characteristic curve analysis revealed that the nitrite/nitrate ratio with an area under the curve of 0.71 could be a potential diagnostic biomarker in separating infectious PEs (IPEs) from other types of PEs. Taken together, the nitrite/nitrate ratio not only reflected the statuses of inflammation, but also the nitrate reduction by pathogenic bacteria infection in the pleural cavity. The nitrite/nitrate ratio could be a better biomarker in the differential diagnosis of PEs than the nitrite concentration alone.

Diagnostic utility of measuring lactate dehydrogenase levels and its isoenzyme activities for the evaluation of malignancy in feline pleural effusion and ascitic fluid.

Lactate dehydrogenase (LDH) isoenzymes may be useful in the differential diagnosis of pleural effusion (PE) and ascitic fluid (AF) etiologies in cats since tissue damage induces their release, changing the pattern of their activity. This study aimed to determine the diagnostic utility of measuring LDH levels and isoenzyme activities in PE or AF in cats with malignancy. LDH levels and isoenzyme activities in the serum, PE, and AF were compared among cats in the malignant, infectious, and non-malignant, non-infectious groups. A receiver operating characteristic (ROC) analysis was performed to assess the accuracy in diagnosing feline malignancy. Significant differences in LDH level and LDH isoenzyme activities in the PE and AF were observed among the three groups. The combination of LDH level and LDH-1 activity in PE or AF had the highest area under the ROC (AUC) values for discriminating malignant effusion from non-malignant effusion. The AUC of the combination of LDH level and LDH-1 activity in PE or AF was 0.874. The sensitivity and specificity of using the combination of LDH level (cut-off: <2,269 U/l) and LDH-1 activity (cut-off: <4.8%) in PE or AF for predicting malignancy with the highest AUC value were 94.4% and 72.7%, respectively. Our results suggest that the combination of LDH level and LDH-1 activity in PE or AF is a potential factor for diagnosing malignancy. Considering that LDH isoenzymes can be measured inexpensively and easily, LDH tests can be readily accommodated in veterinary clinical practice.

Small Cell Lymphocytic Lymphoma: An Unexpected Etiology of Pleural Effusion

The differential diagnosis of pleural effusion is extensive. Pleural fluid characteristics are helpful in classifying, as transudate or exudate, being this determinant to achieve an accurate diagnosis. The authors present a clinical report of a 74-year-old man with reduced left ventricular ejection fraction heart failure, of ischemic etiology, and multiple cardiovascular risk factors, who develops a pleural effusion. In his medical history it is important to denote a recent diagnosis of colon adenocarcinoma, without evidence of metastatic disease, submitted to hemicolectomy. Four months after this diagnosis, he was admitted in the Emergency Department with dyspnea, type 1 respiratory failure and de novo pleural effusion. The most probable etiologies of pleural effusion were excluded, including heart failure and a metastatic disease. Ultimately, it was reported a difficult (or not so) and unexpected etiology for the pleural effusion, in a patient with multimorbidity and multiple confounders. It is crucial to see beyond the obvious. A real-life challenge for Internal Medicine.

Clinical value of CD97 and CD55 levels in the differential diagnosis of tuberculous and malignant pleural effusions.

This study evaluated the clinical levels of CD97 and CD55 for the differential diagnosis of pleural effusion.Pleural effusion samples were collected from 106 patients (55 tuberculous pleural effusions [TPE] and 51 malignant pleural effusions [MPE]). CD97 and CD55 levels in pleural effusions were measured by enzyme-linked immunosorbent assay.CD97 levels were significantly higher in the TPE group than in the MPE group (P < .001), while CD55 levels in the MPE group were significantly higher than the TPE group (P < .001). The sensitivity and specificity of CD97 testing for the differential diagnosis of TPE and MPE was 80.0% and 60.8%, respectively, while the sensitivity and specificity of CD55 testing for TPE and MPE was 88.2% and 85.5%, respectively. Furthermore, the sensitivity and specificity of combinatorial CD97 and CD55 testing for TPE and MPE was 90.0% and 87.5%, respectively. Moreover, CD97 and CD55 were negatively correlated in the MPE group (r = –0.383, P = .005), while no correlations were observed in the TPE group. CD97 or CD55 showed no correlations with other inflammatory cytokines (tumor necrosis factor α, interleukin 1β, erythrocyte sedimentation rate, and C-reactive protein) in both groups (P > .05).CD97 and CD55 may be used as biological markers for the differential diagnosis of pleural effusion in clinical settings.

Pleural Fluid GSDMD Is a Novel Biomarker for the Early Differential Diagnosis of Pleural Effusion.

ObjectiveGasdermin D (GSDMD), controlling pyroptosis in cells, has multiple physiological functions. The diagnostic role of GSDMD in pleural effusion (PE) remains unknown.MethodsSandwich ELISA kits that we developed were applied to measure the level of GSDMD for 335 patients with a definite cause of PE, including transudative PE, tuberculous pleural effusion (TPE), parapneumonic pleural effusion (PPE), and malignant pleural effusion (MPE). The diagnostic accuracy of Light’s criteria vs. the new marker GSDMD was performed. Clinical follow-up of 40 cases of PPE was conducted and divided into efficacy and non-efficacy groups according to the therapeutic outcome. Nucleated cells (NCs) in PE were isolated and further infected with bacteria to verify the cell source of GSDMD.ResultsThe diagnostic accuracy of GSDMD for the diagnosis of PE were 96% (sensitivity) and 94% (specificity). The receiver operating characteristic (ROC) curve indicated that GSDMD can be an efficient biomarker for the differential diagnosis of transudative PE and other groups (all AUC > 0.973). Noteworthily, the highest AUC belonged to tuberculosis diagnosis of 0.990, and the cut-off value was 18.40 ng/mL. Moreover, the same cut-off value of PPE and MPE was 9.35 ng/mL. The combination of GSDMD, adenosine deaminase (ADA), and lactate dehydrogenase (LDH) will further improve the diagnostic efficiency especially between TPE and PPE (AUC = 0.968). The AUC of GSDMD change at day 4, which could predict the therapeutic effect at an early stage, was 0.945 (P < 0.0001). Interestingly, bacterial infection experiments further confirm that the pleural fluid GSDMD was expressed and secreted mainly by the NCs.ConclusionGSDMD and its combination are candidates as a potentially novel biomarker not only to separate PEs early and effectively, but also monitor disease progression.

Efficacy of procalcitonin and pentraxin-3 as early biomarkers for differential diagnosis of pleural effusions.

ObjectivesPleural effusion, defined as an abnormal accumulation of fluid in pleural space, can be of two types: transudative and exudative. The primary aim of the study was to assess the predictive accuracy of procalcitonin (PCT) and pentraxin-3 (PTX-3) in comparison to other biochemical markers such as C-reactive protein (CRP), and adenosine deaminase (ADA) in the differential diagnosis of pleural effusions.MethodsA cross-sectional analytical study was conducted on patients with pleural effusion. Multiple comparisons and receiver-operating characteristics (ROC) analyses were made to evaluate the diagnostic significance of biochemical markers.ResultsSixty-six patients with exudative pleural effusion classified as malignant, tuberculous, and parapneumonic effusions (malignant pleural effusion [MPE], tuberculous [TPE], and parapneumonic [PPE]) were included. Significant differences in pleural fluid levels in both PCT (p-value: 0.001) and PTX-3(p-value: 0.001), as well as serum levels of PCT (p-value: 0.001), were observed between the three groups. ROC analysis showed both PTX-3 and PCT having favorable discrimination ability with high sensitivity (≥90%) and specificity to predict PPE from TPE and MPE.ConclusionsEvaluation of serum and pleural fluid PCT and levels of PTX-3 in the pleural fluid may be used as an early biomarker to differentiate the etiology of pleural effusion.

CAMPO Precision128 Max ENERGY Spectrum CT Combined with Multiple Parameters to Evaluate the Benign and Malignant Pleural Effusion.

The emergence of energy spectrum CT provides greater diagnostic value for clinical practice. Its advantage is that it can provide more functional imaging parameters and accurate image information for clinical practice, which represents a mainstream direction of CT technology development at present. This paper mainly studies the clinical trial of CAMPO Precision128 Max ENERGY spectrum CT combined with multiple parameters to evaluate the benign and malignant pleural effusion. This paper analyzes the principle and key performance parameters of energy spectrum CT imaging, the etiology of pleural effusion, and its conventional diagnostic methods and uses energy spectrum CT to detect the benign and malignant pleural effusion. In this paper, two groups of patients with different types of pleural effusions were scanned by line spectrum chest CT scans, and energy spectrum analysis software was used to measure and calculate the CT values of conventional mixed energy values of ROI of patients with pleural effusions. For the CT value and energy curve slope measurement value of different single energy keV, independent sample t-test was used to analyze and compare the two sets of data, and finally it has been found out that the two sets of data were similar. According to the experimental results, the curves of energy spectrum of the two groups of data are similar in the descending curve of bow-back. The slope of energy spectrum curve in the leakage group was lower than that in the exudate group, showing statistical significance (P < 0.05). The slope of energy spectrum curve K in the malignant pleural effusion group was significantly higher than that in the benign pleural effusion group, and the difference was statistically significant (P < 0.05). The trend of energy spectrum curves of the two is roughly the same, while at the high energy level, part of the energy spectrum curves of the two are overlapped. The above conclusion indicates that energy spectrum CT plays a certain role in the differential diagnosis of pleural effusion. At the same time, energy spectrum CT also provides a noninvasive and rapid examination method for clinical differentiation of pleural effusion, which has certain clinical application value and prospect.

Can computerized tomography Hounsfield unit values be useful in the differential diagnosis of pleural effusion?

Introduction: We aimed to investigate the efficacy of Hounsfield unit (HU) attenuation measured on computed tomography (CT) as a non-invasive method for pleural effusion characterization. Methods: Patients with pleural effusion who underwent thoracic CT imaging and thoracentesis within a maximum of three days were included in this retrospective study (15 transudate and 36 exudate). By drawing a circular region of interest (ROI) on the section with the thickest pleural effusion in terms of anteroposterior diameter in the upper-medial-lower zone on axial images, a total of three HU values, one from each level, were averaged. An independent t-test was applied to the CT attenuation (HU) values for the transudate-exudate differentiation. A receiver operating characteristic (ROC) analysis was then made. Results: The mean attenuation±standard deviation (minimum-maximum) value for the patients with transudate was 2.17±3.76 ((-7.5)-7.5) HU, whereas the mean HU value for the patients with exudate was 8.38±6.2 ((-6)-22). The independent t test made for the transudate-exudate differentiation revealed a statistically significant difference (P=0.001). In the ROC analysis carried out to determine the cut-off value of the attenuation value of pleural effusion in the transudate-exudate differentiation, the area under the curve was found to be 82.8%. When the cut-off value was taken as 2.75HU for the area under the curve, sensitivity was found to be 84%, and specificity was 60%. Conclusion: Although CT-HU values are statistically significant in the differential diagnosis of transudate-exudate, there is still a need to establish a correlation with other tomographic findings and clinical laboratory findings.

Determining The Etiological Factors in Pleural Fluid by Crp, Albumin And Procalcitonin Levels

Abstract &#x0D; Aim: The Light criteria with a specificity of 72% and a sensitivity of 100% have led to further research into the detection of more specific diagnostic methods for transudate exudate separation. In this study, we aimed to evaluate whether pleural fluid and serum CRP, procalcitonin, on the other hand CRP / Albumin and Procalcitonin / Albumin ratios may be suggested as an alternative to Light criteria in the differential diagnosis of pleural effusions.&#x0D; &#x0D; Material and Method: In this study, the pleural effusions of 121 patients who were aged ≥18 years were evaluated. The study was planned as a prospective cohort type study.&#x0D; &#x0D; Results: Effusions were divided into two sub-groups as transudate (n:37) and exudate (n:84); and malignant (n:30) and non-malignant (n:91). Serum procalcitonin level of 0.035 was having a sensitivity of 0.726 and specificity of 0.964; on the other hand, pleural fluid procalcitonin level of 0.035 was having a sensitivity of 0.690 and specificity of 0.919. For serum procalcitonin /albumin ratio, 0.0104 value was having a sensitivity of 0.774 and specificity of 0.757 while for pleural fluid procalcitonin /albumin ratio of 0.019 value was having a sensitivity of 0.667 and specificity of 0.649.&#x0D; &#x0D; Conclusion: Serum and pleural fluid procalcitonin levels and procalcitonin/ albumin ratio were having a significant role in differentiating transudate and exudate. However, procalcitonin, CRP or any other ratios obtained from these parameters were not useful in diagnosis of malignant effusions.&#x0D;

Вопросы дифференциальной диагностики плевральных выпотов

Вопросы дифференциальной диагностики плевральных выпотов

URINOTHORAX SECONDARY TO UNILATERAL URINOMA CAUSED BY URETERAL STRICTURE

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Urinothorax is a rare and atypical cause of pleural effusion and it usually involves patient with obstructive uropathy, iatrogenic genitourinary procedure complications or abdominal trauma. CASE PRESENTATION: A 67-year-old male with PMHx of colon cancer s/p right hemicolectomy with entero-colonic anastomosis presented with right flank pain radiating to umbilical/pelvic region for 5 days. He was hemodynamically stable. His P/E showed decrease air entry with decreased percussion in the right mid lung and tenderness in the right flank area. His CXR which was significant for right pleural effusion and CT abdomen showed severe right kidney perinephric fluid, stranding with dilation of the pelvicalyceal system and focal rupture of the superior right renal pelvis and proximal-mid ureter stricture without any present of renal or ureteral calculus. This large perinephric collection is consistent with Urinoma. Patient underwent thoracocentesis yellow color fluid was removed. The analysis showed pH of 7.34, glucose 102, WBC 27 (Lymph: 87), RBC 26, LDH of 53 and protein of 2. Serum chemistry showed protein of 8.1 and LDH of 108.The pleural fluid was transudative which is suggestive of urinothorax. The patient successfully received a right ureteral stent, relieving his obstruction, and was subsequently discharged home. Follow up CXR and CT abdomen after discharge showed resolved pleural effusion and patent ureteral stent. DISCUSSION: In our patient, the cause of the pleural effusion is due to unilateral obstructive uropathy leading to rupture pelvis and accumulation of urine in the retroperitoneal space (Urinoma) that leaked into the pleural space. The most plausible theory that would explain our case is that the urinoma drained into the pleural space via the communication between the retroperitoneal and pleural lymphatic systems due to increased retroperitoneal or intraperitoneal pressure. Urinothorax is mostly a transudative process where the pleural fluid is typically a yellow color with very low total urine protein, pH <7.4 and low cell count as well which correlated with the finding of the pleural fluid analysis in our patient. The diagnosis of urinothorax and its underlying cause can be identified with an ultrasound or CT scan of the abdomen. The management of the urinothorax may require a thoracentesis for diagnostic and symptomatic relief purposes. In our case, the underlying cause was ureteral stricture most likely risen from the complication of his right hemicolectomy. The ureteral stricture was relieved with a ureteral stent resulting in the rapid resolution of the urinothorax. CONCLUSIONS: Unilateral urinothorax is rare entity caused due to genitourinary obstruction, surgical complications and abdominal trauma, which can be resolved once the underlying cause is treated. We highlight this case to show that “zebras” should always remain in the differential diagnosis of pleural effusion. Reference #1: Casallas A, Castañeda-Cardona C, Roselli D. Urinothorax: case report and systematic review of the literature. Urol Ann 2016;8:91-4. 10.4103/0974-7796.164851 Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systematic review. Journal of Thoracic Disease. 2017;9(5):1209-1218. https://doi.org/10.21037/jtd.2017.04.22 Reference #3: Garcia-Pachon E, Padilla-Navas I. Urinothorax: case report and review of the literature with emphasis on biochemical diagnosis. Respiration. 2004;71(5):533-36. DISCLOSURES: No relevant relationships by Waheed Abdul, source=Web Response

Diagnostic Accuracy of CYFRA21-1 in the Differential Diagnosis of Pleural Effusions.

Approximately 20% of pleural effusions are associated with cancer; about 50% require invasive procedures to perform diagnosis. Determination of the concentration of soluble cytokeratin 19-fragments (CYFRA21-1) may help identify patients with malignant effusions. However, pathologies other than cancer can increase its concentration. The identification of these possible false positives with routine tests CRP, ADA, % polymorphonuclear cells (PN) may improve diagnostic accuracy. This study aimed to determine the diagnostic accuracy of CYFRA21-1 in the detection of malignant pleural effusions and the possible false positives. Analysis of CYFRA21-1, adenosine deaminase (ADA), C-reactive protein (CRP), and the percentage of polymorphonuclear leukocytes (PN%) in the fluid from 643 consecutive undiagnosed pleural effusions was performed. CYFRA21-1 showed 38.7% sensitivity and 97.3% specificity at 175 ng/ml cut-off. Effusions not suspicious of a false-positive showed 39.0% sensitivity and 98.2% specificity, while effusions suspicious of false positive showed lower sensitivity (36.4%) and specificity (95.0%). The diagnostic accuracy of CYFRA21-1 in pleural effusions can be improved by classification according to the possibility of false positives.

Ultrasound elastography: a novel tool for the differential diagnosis of pleural effusion.

Traditional thoracic ultrasound (TUS) is often the initial tool used to help diagnose malignant pleural effusion (MPE). Ultrasound elastography, a relatively new technique, has been used to differentiate malignant disease from benign disease by evaluating tissue "stiffness". However, no studies evaluating the efficacy of ultrasound elastography for diagnosing MPE are available. We assessed the value of ultrasound elsatography for diagnosing MPE prospectively. All 244 enrolled patients were divided into a development set and a validation set in chronological order. The cut-off elasticity index was established using a receiver operating characteristic curve constructed from the continuous data of the patients in the development set. The diagnostic performance of ultrasound elastography was compared with that of TUS in the validation set. In the development set, the mean elasticity index (47.25 kPa) was the optimal cut-off. In the validation set, pleural ultrasound elastography had a sensitivity of 83.64%, a specificity of 90.67%, a positive predictive value of 86.79%, a negative predictive value of 88.31%, a positive likelihood ratio of 8.96 and a negative likelihood ratio of 0.18 for diagnosing MPE. The sensitivity of ultrasound elastography was significantly higher (p=0.006) than that of TUS (60%). Pleural ultrasound elastography is a better technique than TUS for differentiating MPE from benign pleural disease.

Detection of carcinoembryonic antigen levels in pleural effusion and serum and their ratio for differential diagnosis of pleural effusion resulting from tuberculosis and lung cancer

To study the clinical value of detecting carcinoembryonic antigen levels in pleural effusion (PCEA) and serum (SCEA) and their ratio (P/S) in the differential diagnosis of pleural effusions resulting from tuberculosis and lung cancer. This retrospectively study was conducted among 82 patients with pleural effusion caused by pulmonary tuberculous (TB; control group) and 120 patients with pleural effusion resulting from lung cancer in our hospital between April, 2016 and March, 2018. PCEA, SCEA and P/S were compared between the two groups and among the subgroups of lung cancer patients with squamous cell carcinoma (SqCa), adenocarcinoma (ACA), small cell carcinoma (SCLC). The receiveroperating characteristic curve (ROC) analysis was used to confirm the optimal critical value to evaluate the diagnostic efficiency of different combinations of PCEA, SCEA and P/S. PCEA, SCEA and P/S were significantly higher in the overall cancer patients and in all the 3 subgroups of cancer patients than in the patients with TB (P &lt; 0.05). The areas under the ROC curve of PCEA, SCEA and P/S were 0.925, 0.866 and 0.796, respectively; PCEA had the highest diagnostic value, whose diagnostic sensitivity, specificity, accurate rate, and diagnostic threshold were 83.33%, 96.34, 88.61%, and 3.26 ng/ml, respectively; SCEA had the lowest diagnostic performance; the diagnostic performance of P/S was between that of SCEA and PCEA, but its combination with SCEA greatly improved the diagnostic performance and reduced the rates of misdiagnosis and missed diagnosis. Parallel tests showed that the 3 indexes combined had significantly higher diagnostic sensitivity than each or any two of the single indexes (P &lt; 0.05), but the diagnostic specificity did not differ significantly. The area under the ROC curve of combined detections of the 3 indexes was 0.941 for diagnosis of lung cancer-related pleural effusion, higher than those of any other combinations of the indexes. The combined detection of PCEA, SCEA and P/S has a high sensitivity for diagnosis of lung cancer-related pleural effusion and provides important information for rapid and accurate diagnosis of suspected cases.

The diagnostic role of pentraxin-3 in the differential diagnosis of pleural effusions

Discrimination of pleural effusion etiology is not always easy in clinical practice. Pentraxin-3 (PTX-3) is a new acute- phase protein. The aim of this study was to investigate the role of PTX-3 in the differential diagnosis of pleural effusions. This prospective study enrolled all consecutive patients from two tertiary hospitals who underwent diagnostic or therapeutic thoracentesis. In a cohort of 149 subjects with pleural effusion, including transudates and malignant (MPE), tuberculous (TPE), and parapneumonic effusion (PPE), serum and pleural effusion PTX-3 concentration measurements were performed using ELISA. Serum and pleural effusion protein, lactate dehydrogenase, C-reactive protein (CRP), and adenosine deaminase levels were also assessed. Of these patients, 34 had transudates, 29 had PPE, 63 had MPE, and 23 had TPE. There was a weak correlation between pleural effusion PTX-3 level and serum CRP (P < 0.01). There was a significant difference in pleural PTX-3 levels between the exudative effusion groups (P < 0.01). The median pleural effusion PTX-3 was significantly higher in patients with PPE (11.2 ng/mL, 2–17.8) than MPE (4.7 ng/mL, 1.8–13.9) and TPE (3.1 ng/mL, 2.0–4.1). At a cut-off point of 5.89 ng/mL, PTX-3 had the best discriminatory power for PPE versus other exudative effusions (sensitivity: 86.2%, specificity: 87.7%). The exudative effusion group had a significantly different pleural effusion/serum PTX-3 ratio (P = 0.03). PTX-3 concentration in pleural effusion was elevated without a significant correlation with serum PTX-3 in PPE. These results may suggest that PTX-3 is a local acute-phase reactant and may allow discrimination of PPE from other exudative effusions.