Eosinophilic Pleural Effusion Research Articles

Acute Q fever revealed by an anti-phospholipid syndrome: A case report

IntroductionQ fever is a zoonosis caused by Coxiella burnetii. Acute infection is mainly asymptomatic. In other cases it mainly causes a flu-like illness, a pneumonia, or an hepatitis. We present an atypical case of an acute Q fever revealed by a massive pleural effusion. Case reportWe report the case of a 43-year-old man referred to our hospital for an acute respiratory distress. Further analyses showed an exudative eosinophilic pleural effusion, associated with a pulmonary embolism and a deep femoral vein thrombosis. Aetiologic explorations revealed an acute Q fever (IgM and IgG against C. burnetii phase II antigens) associated with anti-phospholipids. The outcome was favorable with vitamin K antagonists, doxycycline, and hydroxychloroquine, till the negativation of the anti-phospholipid antibodies. Discussion and conclusionDuring acute C. burnetii infections, anti-phospholipid antibodies are highly prevalent but thrombotic complications are rare. The 2023 ACR/EULAR APS criteria restricts the diagnosis of APS, as in our case of acute severe infection. In front of an atypical pneumonia and/or thrombotic events, screening of C. burnetii and anti-phospholipid antibodies could be useful. Given its low level of evidence, prolongated treatment by doxycycline, hydroxychloroquine ± anticoagulant for C. burnetii's associated anti-phospholipid syndrome is discussed, but succeeded in our case.

A Curious Case of Pulmonary Anisakiasis

Abstract Anisakiasis is a parasitic disease, caused by nematode species belonging to family Anisakidae. While gastrointestinal anisakiasis is common, pulmonary anisakiasis is rarely reported. To the best of our knowledge, there are no reported cases of anisakiasis from India. We are reporting a case of pulmonary anisakiasis presented with eosinophilic pleural effusion.

A curious case of idiopathic eosinophilic pleural effusion post swimming pool diving

Eosinophilic pleural effusion is defined as pleural effusion with >10% eosinophil count. Even though the mechanism underlying eosinophilic pleural effusion is poorly understood, it is considered to be caused by pleural fluid sequestration of bone marrow-derived eosinophils. Even though there is a wide spectrum of diseases recognized to be associated with eosinophilic pleural effusion, including pleural irritation, trauma (hemothorax, pneumothorax, thoracic surgery), malignancy, parasitic infection, drug/toxin-induced and pulmonary embolism; almost 25% of cases remain idiopathic. We herein report a curious case of eosinophilic pleural effusion, which has developed post blunt trauma to the chest, sustained after diving into a swimming pool. The patient was extensively evaluated for possible etiologies but was found negative for any underlying known pathology that could lead to eosinophilic pleural effusion.

Worm globalization

We report the first case of eosinophilic pleural effusion due to Anisakis spp. infection in a 39-years-old European subject hospitalized for worsening dyspnoea and abdominal and thoracic pain. Lung CT scan showed bilateral pleural effusion; thoracentesis revealed significant eosinophilia (45%), with normal eosinophils in the blood. Microbiological tests on pleural effusion were negative for bacteria, SARS-CoV-2, tuberculosis, fungi and parasites. The patient used to eat raw fish; Western blot was positive for Anisakis spp. in blood and pleural effusion. In the era of globalization, unusual parasitic infections should be considered also in nonendemic countries, especially in patients with unexplained eosinophilia.

Case report: Methimazole-induced eosinophilic pleural effusion in a patient recently diagnosed with Graves' disease

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

INTRAPLEURAL RUPTURED HYDATID CYST OF LIVER PRESENTED AS EOSINOPHILIC PLEURAL EFFUSION: CASE REPORT

Eosinophilic pleural effusions (EPE) are rare with an estimated incidence of 7.2% of all pleural effusions. EPE due to echinococcosis is exceptionally described in the literature. Pleural echinococcosis is almost always secondary to a ruptured primary lung cyst. Intrathoracic rupture of hepatic hydatid cyst (HC) is a rare clinical entity the rupture into the pleural cavity is less common than in the bronchial tree. We report a case of a 72 year old patient, presented with dyspnea, the chest X-ray showed a right-sided pleural effusion. The initial diagnostic process included two thoracentesis which yield eosinophilic pleural effusions. A transthoracic ultrasound showed cystic formations in the pleura, in addition to an abdominal collection with classic ultrasound images of water-lily sign and serpent sign. CT features suggested ruptured hepatic hydatid cyst in the pleura. Surgical intervention was indicated with postoperative chemotherapy.

IgG4-related eosinophilic pleural effusion: a case report

BackgroundThe diagnosis of unilateral eosinophilic pleural effusion (EPE) is difficult, especially for the elderly. IgG4-related disease (IgG4-RD) is a rare cause of EPE.Case presentationAn 81-year-old man was admitted to the hospital for dyspnea due to right pleural effusion. Laboratory examination shows elevated IgG4 and eosinophils in both serum and pleural fluid. The patient was diagnosed with IgG4-RD by video-assisted thoracoscopy and pleural biopsy. We found no evidence of other organ involvement except for the EPE and history of prurigo. He was treated with prednisolone 40 mg daily orally and pleural effusion decreased significantly.ConclusionIgG4-RD should be considered in the differential diagnosis of EPE in the elderly. High effusion IgG4 concentration may be an indication of IgG4-related pleural lesions.

Diagnostic Significance of Eosinophilic Pleural Effusion

A pleural effusion is defined as eosinophilic when eosinophils represent ≥ 10% of the total nucleated cell count, and accounts for approximately 10% of all pleural effusions. The diagnostic significance of eosinophilic pleural effusion has yet to be determined. Objective and Methods: A retrospective study was conducted on 65 patients with eosinophilic pleural effusion to evaluate the correlation between the percentage of eosinophils present in the pleural fluid and the benign or malignant nature of the effusion. An original aspect of current study was the evaluation of other variables in association with pleural eosinophilia, in particular pleural fluid lymphocytosis (≥ 50%), and the presence or absence of fever. Results: Data showed the trend towards a decrease in neoplastic incidence with increasing percentages of eosinophilic counts, although this correlation was not statistically significant. The presence of fever correlated with low incidence of neoplasms (10% of neoplastic effusions in patients with fever) and was the most significant variable (p=0.001), with a Negative Predictive Value of neoplastic disease of 90%, with sensitivity 92.6% and specificity 47.4%. When evaluated together with fever, eosinophils increased their discriminating sensitivity to the benign or malignant nature of the effusion but lost in specificity. When evaluated as absence or presence of lymphocytosis (≥50% lymphocytes), associated with eosinophilia, lymphocytes were significantly associated with the neoplastic nature of the effusion. Conclusions: the study showed that the finding of eosinophilic pleural effusion should not be considered an indicator of benignity of the effusion; the association of other parameters with eosinophilia, lymphocytosis of the pleural fluid and fever can provide more precise prognostic indications; a high percentage of eosinophils, the absence of lymphocytosis and the presence of fever would seem to be associated with a low probability of a neoplastic nature of the effusion.

A Case of Lung Typical Carcinoid in a Patient with Spontaneous Regression Who Showed Peripheral Eosinophilia and Eosinophilic Pleural Effusion

A Case of Lung Typical Carcinoid in a Patient with Spontaneous Regression Who Showed Peripheral Eosinophilia and Eosinophilic Pleural Effusion

Incidence, aetiology and clinical features of eosinophilic pleural effusion: a retrospective study

BackgroundEosinophilic pleural effusion (EPE) is a distinct entity among pleural effusions, but its diagnostic and prognostic significance is still controversial. This study aimed to evaluate the incidence and aetiological distribution of EPE in our institution and to assess the relationship between EPE and malignancy and other underlying diseases and the relevance of the percentage of eosinophils and other laboratory parameters.MethodsA retrospective study was conducted by reviewing the medical records of 252 patients with PE from September 2017 to January 2021.ResultsEPE was found in 34 (13.49%) out of 252 patients. There were 20 (58.82%) males and 14 (41.18%) females in the EPE group. The mean percentage of eosinophils in EPE (21.7%, range (10.0–67.5%)) was significantly higher than the percentage of eosinophils in peripheral blood (5.65%, range (0–34.60%); p < 0.05). The most common cause of EPE was malignant disease (52.94%), followed by idiopathy (14.71%), parasites (8.82%), pneumonia (8.82%) and others (14.71%). Comparative analysis of patients with malignant versus nonmalignant EPE showed that patients with malignant EPE were significantly older, and had a lower white blood cell (WBC) count in the pleural fluid (1.8 vs 4.7 cells × 109/L, p < 0.05). However, the percentage of eosinophils in PE was not significantly different between malignant EPE and nonmalignant EPE (p = 0.66). There was no correlation between the percentage of eosinophils in PE and peripheral blood (r = 0.29; p = 0.09).ConclusionsMalignant disease ranks as the leading cause of EPE. The presence of EPE should not be considered as a predictive factor of benign conditions. Pleural parasitic infestation (PPI) should be emphasized in areas with a high incidence of parasitic disease.

Eosinophilic pleural effusion in an eleven-year-old boy

Pleural effusion fluid with ?10% eosinophils may be seen in 5-16% of exudative pleural effusions. Its association with helminthic infestation is reported in the literature. This patient with left-sided eosinophilic pleural effusion was a referred case from another hospital and treated initially as parapneumonic. With inadequate response to antibiotics and a markedly high IgE level praziquantel was started. This resulted in rapid disappearance of symptoms, decrease in the eosinophil count, and radiological improvement. After exclusion of parapneumonic, tuberculosis, autoimmune disease, and malignancy, a trial of antihelminthics should be considered an option. This may spare unnecessary investigations.

P8‐74: Eosinophilic pleural effusion due to lung cancer has a better prognosis than non‐eosinophilic malignant pleural effusion

P8‐74: Eosinophilic pleural effusion due to lung cancer has a better prognosis than non‐eosinophilic malignant pleural effusion

Fibrin glue-induced eosinophilic pleural effusion after pulmonary resection: A case report.

Introduction and importanceProlonged air leakage after pulmonary resection is a common complication, and fibrin glue is used as a sealant to reduce this. Fibrin glue-induced adverse events are generally rare. Herein, we describe a rare case of fibrin glue-induced eosinophilic pleural effusion (EPE).Case presentationA 77-year-old man underwent partial pulmonary resection for right lower lobe lung cancer, and the pulmonary staple stump was subsequently covered with fibrin glue. Antibacterial drugs were administered for the treatment of postoperative pneumonia. However, re-elevation of the inflammatory cell number was observed, and computed tomography revealed an increase in right pleural effusion. Although thoracoscopy was performed based on a possibility of empyema, no empyema was observed. The eosinophil count in the pleural effusion was 11%; thus, the patient was diagnosed with EPE, which was resolved after thoracic drainage, without corticosteroid administration. Fibrin glue was identified as the causative agent, using a drug-induced lymphocyte stimulation test.Clinical discussionEPE is defined as an eosinophil count of ≥10% in the pleural effusion. If pleural effusion on the surgical side, with fever or an elevated inflammatory cell number, is observed in the early postoperative period after pulmonary resection, empyema should be considered foremost. In this case, the administration of antibacterial drugs was ineffective, and the patient was eventually diagnosed with EPE.ConclusionEPE should be considered as a rare fibrin glue-induced adverse event after pulmonary resection. It is recommended that the leukocyte fraction be examined, if pleural effusion is collected for postoperative pleural effusion.

Eosinophilic pleural effusion due to lung cancer has a better prognosis than non-eosinophilic malignant pleural effusion

ObjectiveTumor-related eosinophilia may have extended survival benefits for some cancer patients. However, there has been no report on the prognosis difference between eosinophilic pleural effusion (EPE) and non-EPE in lung cancer patients. Our study aimed to investigate the prognosis difference between EPE and non-EPE due to lung cancer.Patients and methodsWe retrospectively reviewed patients diagnosed with lung cancer who presented with malignant pleural effusion (MPE) between May 2007 and September 2020 at the National Hospital Organization Kochi Hospital. EPE is defined as pleural fluid with a nucleated cell count containing 10% or more eosinophils.ResultsA total of 152 patients were included: 89 were male (59%). The median age was 74.4 years (range 37–101), and all patients were pathologically shown to have MPE. Most patients (140; 92%) had an Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) of 0/1. Twenty patients had EPE. The median overall survival (OS) of all 152 lung cancer patients with MPE was 298 days. The median OS of the patients with EPE was 766 days, and the median OS of the patients with non-EPE was 252 days. Kaplan–Meier univariate analysis showed that lung cancer patients with EPE had a significantly better prognosis than patients with non-EPE (P < 0.05). Cox proportional regression analysis showed that EPE, ECOG PS, sex, and the neutrophil-to-lymphocyte ratio in the serum (sNLR) may be independent prognostic factors affecting survival in patients with MPE.ConclusionLung cancer patients with EPE have a better prognosis than those with non-EPE.

Histiocytic pleural effusion: the strong clue to malignancy

BackgroundThere have been many studies on the clinical characteristics of neutrophilic, lymphocytic, and/or eosinophilic pleural effusion. While caring for patients with pleural effusion, we found that histiocytic pleural effusion (HisPE) was not uncommon. However, few studies have explored HisPE. The purpose of the present study was to determine the clinical characteristics and etiologies of HisPE.MethodsIn this retrospective study, HisPE was defined as pleural fluid white blood cells comprised of ≥ 50% histiocytes. Using a clinical data warehouse, patients with HisPE among all patients aged >18 years who underwent thoracentesis and pleural fluid analysis between January 2010 and December 2019 at Ulsan University Hospital were enrolled. A total of 295 (9.0%) of 3279 patients who underwent thoracentesis were identified as HisPE patients. Among them, 201 with exudative HisPE were included. Clinical characteristics and etiologies were extracted from medical records and analyzed.ResultsAmong the 201 patients with exudative HisPE, the major causes were malignant pleural effusion (n = 102 [50.7%]), parapneumonic effusion (n = 9 [4.5%]), and tuberculous pleurisy (n = 9 [4.5%]). In the 102 patients with malignant pleural effusion, the main types of cancer were lung (n = 42 [41.2%]), breast (n = 16 [15.7%]), and stomach cancer (n = 11 [10.8%]). Among lung cancers, adenocarcinoma (n = 34 [81.0%]) was the most common histology.ConclusionsThe leading cause of exudative HisPE was malignancy, particularly lung cancer. Physicians should consider the possibility of malignant disease if histiocytes are predominantly present in pleural effusion.

A narrative review of malignant eosinophilic pleural effusion: incidence, etiology and prognostic significance.

Eosinophilic pleural effusion (EPE) is defined as a pleural fluid with an eosinophilic count exceeding 10% and currently considered to be mainly caused by malignancy. However, the incidence, etiology and prognostic significance of malignant eosinophilic pleural effusion (MEPE) have not been studied extensively yet. Thus, the objective of this review was to summarize medical studies regarding MEPE to 2020 throughout an extensive search of PubMed. Overall, MEPE was a disease associated with multiplecytokines-mediated immunity and varied from 4% to 92% of patients who had EPE. The discrepancy of the MEPE prevalence among studies could be explained by the development of diagnostic technology, disparity of study population, or various disease spectrum over time. Data summarized in this review demonstrated that the incidence of malignancy was lower in EPEs than in non-EPEs (29.7% vs. 32.9%). Additionally, MEPE could be a manifestation of a great variety of tumor subtypes, among which lung cancer was the most common cause and accounted for more than 34% of cases. The second common causes were non-Hodgkin lymphoma and metastatic cancers with unknown primary site which were observed in around 5% of cases, respectively. The presence of eosinophils in the pleural effusion may be associated with a positive prognosis of MEPE. Besides, the prognosis of MEPE may be related to the percentage of eosinophils in the pleural fluid. More extensive studies, however, are warranted to validate these findings.

ANTISYNTHETASE SYNDROME AND PLEURAL EFFUSION: A CASE REPORT

ANTISYNTHETASE SYNDROME AND PLEURAL EFFUSION: A CASE REPORT

S2234 Pulmonary Manifestations of Crohn’s Disease

INTRODUCTION: Pulmonary complications of inflammatory bowel disease (IBD) are rare; these include pneumonitis, interstitial lung disease, and pleural effusions. We present a case of eosinophilic pleural effusion and pulmonary hypertension as the presenting extra intestinal manifestations (EIM) in a patient with Crohn’s disease (CD). CASE DESCRIPTION/METHODS: A 63-year-old African American man with recent diagnosis of inflammatory ileocolonic CD treated with a single course of budesonide presented to his pulmonologist with shortness of breath. His CD diagnosis was made on routine screening exam and he was otherwise asymptomatic. CT imaging showed a new right-sided pleural effusion, entrapped lung, and enlarged mediastinal lymph nodes. Echocardiogram revealed pulmonary hypertension (PT). The patient underwent thoracentesis that showed eosinophilic infiltrate without evidence of infection or malignancy. After ten days the patient had recurrence of his pleural effusion, and required repeat thoracentesis. V/Q scan was consistent with chronic thromboembolic pulmonary hypertension (CTEPH). Colonoscopy showed inflammatory CD of the ascending colon and cecum. Lab evaluation showed peripheral eosinophilia, and a positive S. stercoralis serum IgG. He was treated with a course of Ivermectin and started on infliximab infusions with resolution of his effusion and shortness of breath. DISCUSSION: EIM of IBD affect half of all patients. Pulmonary EIM are rare, especially as presenting symptoms for disease. Per our review, this is the first documented case of PH and pleural effusion as the presenting symptoms of CD. We believe the hypercoagulable state induced by CD led to the development of CTEPH. It is unclear what role the S. stercoralis played in this patient’s disease, however, we suspect given distribution and histology the patient had CD and previous S. stercoralis exposure. As his symptoms, effusions, and lymphadenopathy all improved with infliximab, this suggests that the pulmonary manifestations were related to his inflammatory condition. We provide this case as the first description of CTEPH and pleural effusion as an EIM for CD.

LARGE, RECURRENT PLEURAL EFFUSION FROM IATROGENIC METHIMAZOLE-INDUCED HYPOTHYROIDISM

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pleural effusion is a recognized but uncommon manifestation of hypothyroidism. We describe a large, recurrent unilateral effusion attributed to iatrogenic hypothyroidism from methimazole. The effusion resolved with methimazole discontinuation and without the need for hormone replacement therapy. CASE PRESENTATION: An 84 year-old female with remote history of hyperthyroidism treated with methimazole and partial thyroidectomy presented with three days of dyspnea. Evaluation revealed a large unilateral pleural effusion. Diagnostic and therapeutic thoracentesis removed a 1.4L collection that was borderline exudative by Light’s criteria. Her dyspnea transiently resolved but recurred within 5 days. Repeat thoracentesis removed an additional 1.2 liters of exudative fluid. Cytologic and microbiologic studies were unremarkable. However, serum TSH and free T4 were noted to be 56.9 and 0.6, respectively, consistent with hypothyroidism. It was discovered that her primary provider had started methimazole 3 months prior, after misinterpreting routine results as recurrence of her hyperthyroidism when they were actually indicative of subclinical hypothyroidism (TSH/FT4 4.25/0.9, respectively). Methimazole was discontinued upon this discovery. In follow up visits, her thyroid function tests normalized without the need for hormone replacement therapy, and the pleural effusion never recurred. DISCUSSION: Hypothyroidism is rare but recognized cause of pleural effusions (1). Case studies have documented pleural effusions directly related to hypothyroidism, including some attributable to methimazole, which in turn has been theorized to be mediated by a drug-induced ANCA-vasculitis mechanism (2). Our patient developed a large, recurrent, unilateral pleural effusion when methimazole was erroneously prescribed for subclinical hypothyroidism. Her subsequent hospitalization with dyspnea that led to the recognition of iatrogenic hypothyroidism. After repeated diagnostic and therapeutic thoracenteses, her clinical course finally improved after discontinuation of the offending agent and without the need for hormone replacement therapy. Our case reinforced the connection between hypothyroidism and pleural effusions, including those from methimazole-induced hypothyroidism. It also re-emphasizes the importance of appropriate outpatient monitoring and interpretation of thyroid function labs (3). CONCLUSIONS: Pleural effusions can arise due to hypothyroidism, including iatrogenic hypothyroidism secondary to methimazole. The fluid collection may be massive and lead to significant symptoms, but the clinical course appears to be self-limited once the offending agent is removed. Thyroid function tests should be appropriately monitored after the initiation of anti-thyroid drugs like methimazole to avoid complications. Reference #1: Gottehrer A, Roa J, Standford GG, Chernow B, Sahn SA. Hypothyroidism and Pleural Effusions. Chest. 1999;98(5):1130-1132. Reference #2: Gaspar-da-Costa P, Duarte Silva F, Henriques J, do Vale S, Braz S, Meneses J, et al. Methimazole associated eosinophilic pleural effusion: a case report. BMC Pharmacol Toxicol. 2017 Mar 21;18(16). Reference #3: Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid. 2014 Dec 1;24(12):1670-1751. DISCLOSURES: No relevant relationships by Tydus Thai, source=Web Response No relevant relationships by Kenneth Wei, source=Web Response

Diagnostic procedure for idiopathic eosinophilic pleural effusion: a single-center experience

BackgroundEosinophilic pleural effusion (EPE) is attributed to several well-recognised causes. However, some patients remain idiopathic, even after thorough clinical work-up. The present study aimed to better characterize idiopathic EPE (IEPE) and to outline the diagnostic procedure for this disease.MethodsComplete clinical data of 11 consecutive patients with IEPE were prospectively collected and analysed. Preliminary diagnostic procedure of IEPE in our hospital was performed.ResultsAll the 11 patients had respiratory symptoms and unilateral pleural effusion (PE) occurred in 4 patients. The mean percentage of eosinophils in PE was 22.4% (range, 12.4–50.5%). Lactate dehydrogenase, adenosine deaminase, proteins and carcinoembryonic antigen in PE were 246.0 U/L (range, 89.8–421.9 U/L), 13.8 U/L (range, 1.8–24.0 U/L), 42.6 g/dl (range, 32.8–52.6 g/dl) and 2.17 mg/mL (range, 0.46–4.31 mg/mL), respectively. Parasite-specific IgG antibody in blood and parasite eggs in stool were both negative. No evidence of tuberculosis or malignancy was observed in pleural biopsy. Symptoms and abnormal pulmonary imaging were eliminated after glucocorticoid use.ConclusionsIEPE is a diagnosis of exclusion. Patients with EPE without a clear cause should be asked to provided complete medical, surgical and drug-related histories. A thorough work-up is essential. Moreover, we recommend follow-up after the use of glucocorticoid until effusion resolves.Trial registrationGYFYY. Registration No: GYFYY20150901221. Registered time: 1 September 2015. Date of enrolment of the first participant to the trial: 22 January 2016.