Pleural Fluid Characteristics Research Articles

Pleural fluid characteristics of patients with COVID-19 infection.

Pleural effusions are known to occur in many cases of COVID-19. Data on typical characteristics of COVID-19-associated pleural effusions are limited. The goal of this project was to characterize the pleural fluid from patients with COVID-19. We retrospectively collected electronic medical record data from adults hospitalized at a large metropolitan hospital system with COVID-19 infection who had a pleural effusion and a thoracentesis performed. We assessed pleural fluid characteristics and applied Light's criteria. We identified 128 effusions from 106 unique patients; 45.4% of the effusions had fluid/serum protein ratio greater than 0.5, 33.9% had fluid/serum lactate dehydrogenase (LDH) greater than 0.6, and 56.2% had fluid LDHgreater than 2/3 of the serum upper limit of normal. Altogether, 68.5% of effusions met at least one of these three characteristicsand therefore were exudative by Light's criteria. The white blood cell (WBC) differential was predominantly lymphocytic (mean 42.8%) or neutrophilic (mean 28.7%); monocytes (mean 12.7%) and eosinophils (mean 2.5%) were less common. We demonstrate that 68.5% of pleural effusions in patients with COVID-19 infection were exudative and hypothesize that COVID-19-associated pleural effusions are likely to be exudative with WBC differential more likely to be predominantly lymphocytic.

Outcomes for Malignant Pleural Effusions Because of Melanoma Treated With Indwelling Pleural Catheters.

Indwelling pleural catheters (IPCs) reduce dyspnea and improve quality of life in patients with malignant pleural effusions (MPEs). Data on outcomes of MPEs secondary to metastatic melanoma managed with IPCs are scarce. We aimed to evaluate outcomes of patients receiving IPCs for MPEs secondary to melanoma compared with other malignancies. We identified patients from our prospectively collected database of all patients who had an IPC insertion for MPEs at our tertiary care center for melanoma between May 2006 and November 2018 and for nonmelanoma between May 2006 and June 2013. Chart reviews were conducted to obtain patient demographics, catheter complications, time of IPC removal or death, x-ray imaging, and pleural fluid characteristics. We identified 27 MPEs because of melanoma and 1114 because of nonmelanoma malignancies treated with IPC. The most frequent complication was pleural fluid loculation requiring fibrinolytics which was significantly higher in the melanoma (14.8%) compared with the nonmelanoma group (3.8%; P=0.02). Cumulative incidence functions for catheter removal (P=0.8) or death with catheter in situ (P=0.3) were not significant between melanoma and nonmelanoma groups in competing risk analysis. Baseline radiographic pleural effusion scores were similar, but became significantly higher (increased pleural opacity) in the melanoma group at time points following IPC insertion (P<0.05). MPEs because of melanoma had a higher rate of loculations requiring fibrinolytics and less radiographic improvement after IPC insertion suggesting this patient subgroup has a more complicated pleural space which may be less responsive to drainage.

Pleural Fluid Resolution Is Associated with Improved Survival in Patients with Malignant Pleural Effusion.

Malignant pleural effusion is associated with a poor prognosis and, while risk stratification models exist, prior studies have not evaluated pleural fluid resolution and its association with survival. We performed a retrospective review of patients diagnosed with malignant pleural effusion between 2013 and 2017, evaluating patient demographics, pleural fluid and serum composition, and procedural and treatment data using Cox regression analysis to evaluate associations with survival. In total, 123 patients were included in the study, with median survival from diagnosis being 4.8 months. Resolution of malignant pleural fluid was associated with a significant survival benefit, even when accounting for factors such as placement of an indwelling pleural catheter, anti-cancer therapy, pleural fluid cytology, cancer pheno/genotypes, and pleural fluid characteristics. Elevated fluid protein, placement of an indwelling pleural catheter, and treatment with targeted or hormone therapies were associated with pleural fluid resolution. We conclude that the resolution of pleural fluid accumulation in patients with malignant pleural effusion is associated with a survival benefit possibility representing a surrogate marker for treatment of the underlying metastatic cancer. These findings support the need to better understand the mechanism of fluid resolution in patients with malignant pleural effusion as well as the tumor-immune interplay occurring with the malignant pleural space.

Characteristics of pleural effusion due to amyloidosis.

The characteristics of patients with pleural amyloidosis (PA) are poorly known. A systematic review was performed of studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of PA. Case descriptions and retrospective studies were included. The review included 95 studies with a total sample of 196 patients. The mean age was 63 years, male/female ratio was 1.6:1, and 91.9% of patients were >50 years. The most common symptom was dyspnea (88 patients). PF was generally serious (63%), predominantly lymphocytic, and with the biochemical characteristics of transudates (43.4%) or exudates (42.6%). Pleural effusion was generally bilateral (55%) and <1/3 of the hemithorax (50%), although in 21% pleural effusion (PE) exceeded 2/3. Pleural biopsy was performed in 67 patients (yield: 83.6%; 56/67) and was positive in 54% of exudates and 62.5% of unilateral effusions. Of the 251 treatments prescribed, only 31 were effective (12.4%). The combination of chemotherapy and corticosteroids was effective in 29.6% of cases, whereas talc pleurodesis was effective in 21.4% and indwelling pleural catheter in 75% of patients (only four patients). PA is more frequent in adults from 50 years of age. PF is usually bilateral, serous, and indistinctly a transudate or exudate. A pleural biopsy can aid in diagnosis if effusion is unilateral or an exudate. Treatments are rarely effective and there may be definitive therapeutic options for PE in these patients.

Pediatric empyema: Are ultrasound characteristics at the time of intervention predictive of reintervention?

Parapneumonic effusions and empyema are the most frequent complication of pediatric pneumonia. Interventions include chest drain and fibrinolytics (CDF) or thoracoscopic surgery. CDF is considered less invasive, and more cost-effective though with higher rates of reintervention. We hypothesized that sonographic pleural fluid characteristics could identify cases at increased risk of reintervention following primary CDF. A retrospective cohort of complicated pneumonia managed with primary CDF (2011-2018). Cases were reviewed using ultrasound criteria to describe pleural fluid. We analyzed the correlation between ultrasound findings and reintervention. We report 129 cases with a median age of 3.8 years and 44% female. A repeat intervention occurred for 24/129 (19%) cases. The interobserver reliability was moderate for the number of septations (κ0.72, 95% CI [confidence interval]: 0.62-0.81), weak for the size of the largest locule (κ0.55, 95% CI: 0.44-0.67),and minimal for the level of echogenicity (κ0.24, 95%CI: 0.11-0.37), pleural thickening (κ0.29, 95% CI: 0.17-0.42), maximum effusion depth (κ0.37, 95%CI: 0.22-0.51), and radiologist's risk for reintervention (κ0.34, 95% CI: 0.18-0.5). A repeat intervention was not associated with any objective sonographic variable. We report no association between ultrasound characteristics and repeat intervention for complicated pneumonia following primary CDF treatment. There was minimal interobserver agreement in reporting ultrasound characteristics despite more objective criteria. Clinicians rely on ultrasound findings to support decisions around intervention in pediatric empyema. This study does not support relying on ultrasound to estimate the likelihood of reintervention.

Hyporexia and cellular/biochemical characteristics of pleural fluid as predictive variables on a model for pleural tuberculosis diagnosis.

ABSTRACTObjectivesPleural tuberculosis (PlTB) diagnosis is a challenge due to its paucibacillary nature and to the need of invasive procedures. This study aimed to identify easily available variables and build a predictive model for PlTB diagnosis which may allow earlier and affordable alternative strategy to be used in basic health care units.MethodsAn observational cross-sectional study compared PlTB and non-TB patients followed at a tertiary Brazilian hospital between 2010 and 2018. Unconditional logistic regression analysis was performed and a Decision Tree Classifier (DTC) model was validated and applied in additional PlTB patients with empiric diagnosis. The accuracy (Acc), sensitivity (Se), specificity (Sp), positive and negative predictive values were calculated.ResultsFrom 1,135 TB patients, 160 were considered for analysis (111 confirmed PlTB and 49 unconfirmed PlTB). Indeed, 58 non-TB patients were enrolled as controls. Hyporexia [adjusted odds ratio (aOR) 27.39 (95% CI 6.26 – 119.89)] and cellular/biochemical characteristics on pleural fluid (PF) (polimorphonuclear in two categories: 3-14% aOR 26.22, 95% CI 7.11 – 96.68 and < 3% aOR 28.67, 95% CI 5.51 – 149.25; and protein ≥ 5g/dL aOR 7.24, 95% CI 3.07 – 17.11) were associated with higher risk for TB. The DTC constructed using these variables showed Acc=87.6%, Se=89.2%, Sp=84.5% for PlTB diagnosis and was successfully applied in unconfirmed PlTB patients.ConclusionThe DTC model showed an excellent performance for PlTB diagnosis and can be considered as an alternative diagnostic strategy by using clinical patterns in association with PF cellular/biochemical characteristics, which were affordable and easily performed in basic health care units.

Evaluation of pleural fluid cytology for the diagnosis of malignant pleural effusion: a retrospective cohort study.

BackgroundCytological examination of pleural fluid has good specificity, but imperfect sensitivity for the diagnosis of malignant pleural effusion (MPE). Published estimates of sensitivity vary and predictors of false negative cytology are not well established.AimsTo estimate pleural fluid cytology sensitivity and identify risk factors for false negative cytology.MethodsWe conducted a retrospective cohort study of patients who had cytology testing of pleural fluid at Christchurch Hospital, New Zealand, from July 2017 to October 2019. Data on clinical and pleural fluid characteristics were collected. MPE was defined by positive pleural fluid cytology, tissue histology or multidisciplinary meeting consensus. We estimated sensitivity of the first pleural cytology assessment. We performed multivariate logistic regression to ascertain patient groups at greatest risk of false negative results.ResultsInitial pleural fluid cytology was diagnostic in 117 of 156 patients, providing a sensitivity (95% confidence interval (CI)) of 75.0% (67.4–81.6%). The sensitivity was 79.0% (66.8–88.3%) for lung cancer, 91.3% (72.0–98.9%) for breast cancer and 33.3% (95% CI 11.8–61.6%) for mesothelioma. Cloudy appearance of pleural fluid (odds ratio (OR) 0.12; 95% CI 0.03–0.54) and yellow/gold pleural fluid (OR 0.24; 95% CI 0.06–0.96) reduced the odds of false negative pleural cytology. Pleural thickening on computed tomography scan (OR 3.3; 95% CI 1.2–9.4) was a risk factor for false negative cytology.ConclusionSensitivity of pleural fluid cytology was greatest in primary lung and breast cancer, and lowest in mesothelioma. Clinicians should be alert to false negative results when suspecting mesothelioma or if pleural thickening is present.

Lymphocyte predominant exudative pleural effusions: a narrative review

Background and Objective: An estimated 1.5 million people develop pleural effusion each year in the United States. Although substantial progress has been made in understanding pleural effusion, establishment of a definite diagnosis usually necessitates thoracentesis with pleural fluid analysis. Lymphocyte predominant pleural effusion is defined as an exudative effusion with lymphocytes over 50% of the total white cell count. The purpose of this review article is to elaborate on the different causes of lymphocyte predominant pleural effusion and the unique biochemical and cellular characteristics of pleural fluid in these conditions.

Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery.

ObjectivesPleural effusions appearing within the first 30 postoperative days following coronary artery bypass grafting (CABG) are classified as early and believed to be directly related to the surgery. The characteristics of such effusions are well-described. Orthotopic heart transplantation is also known to be complicated by pleural effusions; however, their characteristics have not been systematically reported. We assessed the features of early postoperative pleural effusions after heart transplantation and compared them to those of early effusions following CABG.MethodsWe retrospectively collected demographic, clinical, and laboratory data for patients who underwent either orthotopic heart transplantation (study group) or CABG (comparison group) at our institution and whose postoperative course within 30 days was complicated by new or worsening pleural effusion that prompted drainage. Patients subjected to analysis consisted only of those with sufficiently complete laboratory profiles to permit adequate characterization of the nature of their pleural fluid.ResultsOut of 251 orthotopic heart transplant recipients, seven (2.8%) were found to have sufficiently complete pleural fluid results to be included in the study group. Out of 1,506 patients who underwent CABG, 32 (2.1%) had sufficiently complete pleural fluid results and formed the comparison group. The radiological appearance of pleural effusions in both groups was similar: bilateral in at least half and exclusively moderate to large. Effusions complicating both surgeries were exudative in close to 90% of cases. For those with available leukocyte differential counts, the pleural fluid of the post-orthotopic heart transplantation group was more often neutrophilic (3/5, 60%), whereas the fluid of the post-coronary artery bypass grafting group was more often lymphocytic (22/32, 69%) and tended to be hemorrhagic (median RBC count 33,000 cells/µL vs. 10,000 cells/µL). None of the comparisons of pleural fluid characteristics between the two groups reached statistical significance.ConclusionsThis small, descriptive study is the first to systematically report the fluid characteristics of pleural effusions complicating orthotopic heart transplantation within the first 30 postoperative days and to compare this group to those who developed effusions after CABG. Our findings revealed both similarities and differences in the pleural fluid characteristics between these two types of patients.

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.

Withdrawal: Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery.

Anant Jain (2021) Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery, (https://doi.org/10.4081/monaldi.2021.1740). The above article from the Monaldi Archives for Chest Disease published online on 24 November 2021, has been withdrawn by agreement between the journal's Editors-in-Chief, the Authors and PAGEPress Scientific Publications. This action has been agreed upon due to an administrative error by the publisher which caused the article to be published as an Accepted Article. The author is not responsible for this error. The publisher regrets any confusion this error may have caused.

Urinotórax, una causa infrecuente de derrame pleural

Urinotórax se refiere a la acumulación de orina en la cavidad pleural, es una causa infrecuente de derrame pleural y existen pocos reportes sobre esta patología a nivel mundial. La etiología puede ser obstructiva o traumática, pero en algunos casos no se puede determinar la causa. Las características clínicas y del líquido pleural suelen ser variables y para su diagnóstico se requiere de un radio de la creatinina del líquido pleural/sérica &gt; 1. En la mayoría de casos el pronóstico es favorable. Presentamos el caso de una mujer de 66 años con diagnóstico de urinotórax.

PLEURAL EFFUSIONS DUE TO SARS-COV-2 INFECTION

SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The radiological changes in the lungs of patients infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) have not been fully characterized, but different radiological patterns have been observed at different times throughout the disease course. Pleural effusions range between 5% and 9.7% of the patients with confirmed COVID-19 pneumonia. In this study we aimed to calculate the prevalence of pleural effusions in COVID-19 hospitalized patients and to objectively describe the pleural fluid characteristics in this subgroup of patients. METHODS: Retrospective medical records review of patients diagnosed with pleural effusions and SARS-CoV-2 between January 1, 2020 and May 20, 2020 at Beth Israel Deaconess Medical Center, Boston, MA. Patients were identified from our institutional database. Demographics, baseline comorbidities, mortality, intensive care unit (ICU) stay, interventions and pleural fluid analysis (PFA) were recorded. RESULTS: A total of 587 patients were admitted with SARS-CoV-2 infection (Age 65.29 years [SD 16.9]; 49.9% males). Nineteen (3.2%) developed pleural effusions during hospitalization course. There was no statistical difference between the baseline characteristics of both groups. Patients who developed pleural effusions had a prolonged ICU stay (7 vs 2 days, p=0.01). There was no statistically significant increased mortality rate in the pleural effusions group. Six (31.6%) of patients with pleural effusions required fluid drainage with tube thoracostomy. All PFA of the six patients were non complicated neutrophilic exudates. CONCLUSIONS: Pleural effusions are an infrequent finding in patients with COVID-19. Most effusions are small and don’t require drainage. Pleural effusions may not be associated with an increased mortality in COVID-19 patients, but further prospective large cohort studies are needed. CLINICAL IMPLICATIONS: Characterization of pleural effusions in COVID-19. DISCLOSURES: No relevant relationships by Ramsy Abdelghani, source=Web Response No relevant relationships by Alvaro Ayala, source=Web Response No relevant relationships by Alex Chee, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Rachel Martinez, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Priya Patel, source=Web Response No relevant relationships by Alichia Paton, source=Web Response No relevant relationships by Juan Pablo Uribe, source=Web Response

CHYLOTHORAX AS A RARE MANIFESTATION OF METASTATIC GASTRIC ADENOCARCINOMA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Chylothorax is a pleural effusion characterized by a chyle containing intestinal lymphatic fluid in the pleural space. It usually occurs secondary to disruption of flow within the lymphatic system or thoracic duct. A triglyceride count of >200 mg/dL or a cell count and differential >70% lymphocytes on fluid analysis aids with diagnosis, however, the presence of chylomicrons is the gold standard. Metastatic malignancy accounts for only 2.4% of cases. CASE PRESENTATION: A 51-year-old female presented with complaints of abdominal pain and shortness of breath. Physical examination revealed a non-distended abdomen, tender to palpation in bilateral lower quadrants. Lungs were clear to auscultation bilaterally with reduced air entry in the left lung base. Chest x-ray was remarkable for a left sided pleural effusion with left basilar atelectasis. Computed Tomography (CT) chest showed a left sided pleural effusion. CT abdomen and pelvis revealed gastric wall thickening with upper abdominal and retroperitoneal adenopathy, as well as retrocrural nodes extending into the chest. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scan revealed gastric wall thickening, diffuse lymphadenopathy and bilateral pleural based nodules. Left sided thoracentesis was performed and 1100 cc of milky-white fluid was obtained. The effusion contained 300 mg/dL of triglycerides, 104 mg/dL Cholesterol, and 696/mcL white blood cells with 47% lymphocytes. Medical cytology of the pleural fluid was significant for poorly differentiated adenocarcinoma. Patient opted for hospice care and chose not to undergo chemotherapy. DISCUSSION: Chylothorax as a manifestation of gastric adenocarcinoma is rare. Approximately 50% of chylothorax are as a result of malignancy, however only 2.4% are secondary to metastasis. Signs and symptoms of chylothorax are nonspecific, often presenting like an upper respiratory infection. In most cases, respiratory symptoms precede the diagnosis of gastric cancer. Lymphedema is a common concomitant finding. Chylothorax secondary to malignancy usually presents as a result of direct invasion of the thoracic duct, metastasis into the lymphatic capillaries, or external compression of the thoracic duct. In chylothorax of unknown origin where carcinoma is highly suspected, FDG-PET/CT as a form of imaging can be used as an adjunct to help with diagnosis. Management of chylothorax usually involves treating the underlying cause. Methods may be operative or non-operative. Chemotherapy, irradiation and surgery may be employed to treat the underlying gastric adenocarcinoma, however, unless a high level of suspicion is employed and the gastric carcinoma is recognized early, prognosis is generally poor. CONCLUSIONS: Underlying gastric cancer should be considered as a differential, in those with chylothorax of unknown origin, allowing for early diagnosis and better outcomes. Reference #1: Doerr, C., Allen, M., Nichols, F., Ryu, J. Etiology of Chylothorax in 203 Patients, Mayo Clinic Proceedings 2005; 80(7): 867-870 Reference #2: Maldonado, F., Hawkins, F., Daniels, C., Doerr, C., Decker, P., Ryu, J. Pleural Fluid Characteristics of Chylothorax, Mayo Clinic Proceedings 2009; 84(2): 129 Reference #3: Majoor, C., Aliredjo, P., Dekhuijzen, P., Bulten, J., van der Heijden, H. A Rare Cause of Chylothorax and Lymph Edema, Journal of Thoracic Oncology 2007; 2(3): 247-248 DISCLOSURES: No relevant relationships by Akwe Nyabera, source=Web Response

Differential diagnosis between lymphoma-associated malignant pleural effusion and tuberculous pleural effusion.

Lymphoma-associated malignant pleural effusions (L-MPE) can mimic tuberculous pleural effusion (TPE) characterized by lymphocytic exudate with high adenosine deaminase (ADA) levels. Furthermore, the low cytological yield of L-MPE makes differentiation between L-MPE and TPE more challenging. However, there are few data regarding differential diagnosis of L-MPE and TPE. All consecutive patients diagnosed with L-MPE or TPE between January 2011 and December 2016 were retrospectively recruited using the Electronic Medical Record database. Clinical symptoms and laboratory and pleural fluid data [including serum lactate dehydrogenase (LDH), C-reactive protein, and pleural fluid ADA levels] were compared between L-MPE and TPE. Useful variables in the differential diagnosis of L-MPE and TPE were evaluated by multivariate logistic regression analysis. Seventeen patients with L-MPE and 216 patients with TPE were included in this study. In the multivariate analysis, fever was negatively associated with L-MPE [odds ratio (OR): 0.175, 95% confidence interval (CI): 0.033-0.941, P=0.042], while serum LDH levels were positively associated with L-MPE (OR: 1.005, 95% CI: 1.003-1.007, P<0.001). Serum LDH >460 U/L provided a sensitivity of 76% and a specificity of 81% to distinguish L-MPE and TPE. In contrast, serum C-reactive protein and pleural fluid ADA levels were not significantly different between the groups. Patients with L-MPE and TPE present very similar clinical, laboratory, and pleural fluid characteristics. Fever and serum LDH levels may be helpful in guiding the differential diagnosis of L-MPE and TPE. Lymphoma should be kept in mind in the differential diagnosis in patients with lymphocytic pleural effusion and high ADA levels.

Distinguishing tuberculosis pleural effusion from parasitic pleural effusion using pleural fluid characteristics: A case control study.

Tuberculosis pleural effusion (TPE) and parasitic pleural effusion (PPE) present with similar clinical manifestations. We evaluated the pleural fluid features of TPE and PPE.A total of 76 patients with pleuritis, including 25 patients with TPE and 51 patients with PPE were retrospectively studied. Pleural fluid was sent for analyses of protein, cytology, cell count, acid fast bacilli (AFB) staining, Gram stain, culture, sensitivity, and adenosine dehydrogenase (ADA).The proportion of eosinophilia present in the PPE group was significantly higher than that in the TPE group (P < .001). However, the proportion of lymphocytes found in the TPE group was significantly higher than that in the PPE group (P < .001). The mean level (SD) of ADA was 46.99 ± 22.09 U/L in the TPE group and 39.08 ± 23.03 U/L in the PPE group. No difference was detected between the study groups in terms of the ADA level of the pleural fluid (P > .05).When the results of pleural fluid testing reveal marked eosinophilia and a low proportion of lymphocytes, physicians should consider a diagnosis of PPE, especially for patients who live in or have traveled to endemic areas.

Pleural effusion in acute pulmonary embolism in Bahrain: Radiological and pleural fluid characteristics.

Background and Objectives:Pleural effusion is seen in around half of the cases of pulmonary embolism (PE). There are no data on the incidence of pleural effusion in cases of PE in the Kingdom of Bahrain. This study was done to determine the frequency and radiological features of pleural effusion in cases of acute PE and also to characterize the pleural fluid biochemistry and cell type in patients subjected to diagnostic thoracentesis.Methods:This was a retrospective, observational single-center study. All the data of patients subjected to computed tomography pulmonary angiography (CTPA) in suspected cases of acute PE over a 4-year period were analyzed.Results:A total of 1756 patients were subjected to CTPA from January 2013 to December 2016. A diagnosis of acute PE was made in 200 patients (11.4%). Pleural effusion was identified in 70 cases (35%). Majority of the effusions were small to moderate in size, bilateral, and associated with peripheral emboli. Consolidation, atelectasis, and ground glass attenuation were common associated findings on CTPA in these patients. Consolidation was more common in patients of PE associated with pleural effusion as compared to those with PE alone (62.85% and 33.8%, respectively, odds rato: 3.279 and 95% confidence interval: 1.798–6.091, P < 0.001). Diagnostic thoracentesis was done in 6 (8.6%) of the cases. All the patients had an exudative effusion with normal glucose values and neutrophil predominance.Conclusion:PE was associated with pleural effusion in around one-third of the patients in Bahrain. The effusions were mainly small and bilateral. The emboli in cases associated with pleural effusion were mostly peripheral. Consolidation was the parenchymal abnormality detected on CTPA which was significantly associated with the presence of pleural effusion. Most of the pleural effusions were not suitable for thoracentesis. In patients subjected to fluid analysis, the effusions were exudative, neutrophilic predominant, and associated with normal glucose levels.

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.