Pleural Fluid Data Research Articles

Characteristics of pleural effusion due to paradoxical response in patients with pulmonary tuberculosis

BackgroundPatients with pulmonary tuberculosis may present with deterioration of pleural effusion during anti-tuberculosis therapy, referred to as a paradoxical response (PR), with some patients requiring additional intervention. However, PR may be confused with other differential diagnoses, and the predictive factors for recommending additional therapies are unknown. Therefore, this study aimed to reveal useful information for the diagnosis and intervention of PR. MethodsData from human immunodeficiency virus-negative patients with tuberculous pleurisy (n = 210), including 184 patients with pre-existing pleural effusion and 26 patients with PR at Fukujuji Hospital, were retrospectively collected from January 2012 to December 2022 and compared. Furthermore, patients with PR were divided into the intervention group (n = 9) and the no intervention group (n = 17) and were compared. ResultsPatients in the PR group had lower pleural lactate dehydrogenase (LDH) (median 177 IU/L vs. 383 IU/L, p < 0.001) and higher pleural glucose (median 122 mg/dL vs. 93 mg/dL, p < 0.001) levels than those in the preexisting pleural effusion group. Other pleural fluid data were not significantly different. Patients in the intervention group had a shorter duration from the initiation of anti-tuberculosis therapy to the development of PR than patients in the no intervention group (median 19.0 days [interquartile range (IQR): 18.0–22.0] vs. median 37.0 days [IQR: 28.0–58.0], p = 0.012). ConclusionThis study demonstrates that, apart from lower pleural LDH and elevated pleural glucose levels, PR presents with similar features to preexisting pleural effusion and that patients who develop PR faster tend to require intervention.

Predicting Survival for Patients with Malignant Pleural Effusion: Development of the CONCH Prognostic Model.

BackgroundMalignant pleural effusion (MPE) is a frequent complication of advanced malignancies that leads to a poor quality of life and limits treatment options.ObjectiveThe objective of this study was to identify biomarkers of survival in patients with MPE, which will greatly facilitate the clinical management of this complication.MethodsThis retrospective study recruited patients who had been pathologically diagnosed with MPE, regardless of the type of primary cancer, at Beijing Chao-Yang Hospital over 158 months. Demographic, clinical, hematological, and pleural fluid data were collected and analyzed as potential predictors of survival, and a new predictive model was developed based on Cox and logistic regression analyses.ResultsIn our alternative prognostic model (n = 281), four routinely detected variables, namely, carcinoembryonic antigen (CEA) level, monocyte count, N-terminal pro B-type natriuretic peptide (NT-pro-BNP) level, and pleural effusion chloride level on admission, were identified as predictors (the CONCH prognostic score). Patients were divided into three prognosis subgroups based on risk stratification, with median survival periods of 17, 11, and 5 months, respectively. In comparison with the low-risk group, patients in the medium- and high-risk groups showed significantly poorer survival (medium-risk group: hazard ratio [HR], 1.586; 95% confidence interval [CI], 1.047–2.402; P = 0.029; high-risk group: HR, 4.389; 95% CI, 2.432–7.921; P < 0.001).ConclusionFour routinely detected variables were used to develop the CONCH scoring system, which was confirmed to be an accurate prognostic score for patients with MPE. This system can guide the selection of interventions and management for MPE.

Differentiating tuberculous pleuritis from other exudative lymphocytic pleural effusions.

Recently, the combination of clinical and pleural fluid data can be used to calculate a score which helps facilitate differential diagnosis between tuberculous pleuritis (TBP) and No-TBP effusions. However, a reliable determination of adenosine deaminase (ADA) remains difficult to obtain in Thailand. Therefore, the aim of our study was set out to develop a scoring which makes use of clinical and pleural fluid data. A retrospective study involved 15 patients with TBP and 41 patients with no-TBP. The clinical and pleural fluid data of all patients from January 1, 2011, 32 to December 31, 2014, were collected. The diagnostic sensitivity, specificity, positive and negative predictive value were calculated. The parameters were superior in detecting TBP, including the ADA ≥17.5 U/L, In scoring I [ADA ≥40 U/L, age The high pleural fluid ADA, high scores model 1, high scores model 2, lower RBC, and no previous history of cancer may help to categorize patients into probable TBP for further clinical decisionmaking.35 years, temperature ≥37.8 ℃, and RBC The high pleural fluid ADA, high scores model 1, high scores model 2, lower RBC, and no previous history of cancer may help to categorize patients into probable TBP for further clinical decisionmaking.5×109 /L] as ≥1.5 points, and scoring II [no previous history of cancer, age The high pleural fluid ADA, high scores model 1, high scores model 2, lower RBC, and no previous history of cancer may help to categorize patients into probable TBP for further clinical decisionmaking.35 years, temperature ≥37.8 ℃ RBC The high pleural fluid ADA, high scores model 1, high scores model 2, lower RBC, and no previous history of cancer may help to categorize patients into probable TBP for further clinical decisionmaking.5×109 /L, pleural protein ≥50 g/L, and LDH ratio ≥2.2] as ≥4.5 points, since the area under curve (AUC) 74.0%, 74.0%, and 81.0%, sensitivity 73.3%, 73.3%, and 71.4%, and specificity 68.7%, 62.5%, and 71.1%, respectively). Moreover, no previous history of cancer and lower RBC The high pleural fluid ADA, high scores model 1, high scores model 2, lower RBC, and no previous history of cancer may help to categorize patients into probable TBP for further clinical decisionmaking.5×109 /L indicated sensitivity (90.6% and 65.5%), and specificity (70.0% and 44.4%), respectively. Summated scores of ≥5 points in model 1 and ≥6 points in model 2 yielded measures of sensitivity (46.7% and 57.1%), and specificity (84.4% and 80.5%), respectively. The high pleural fluid ADA, high scores model 1, high scores model 2, lower RBC, and no previous history of cancer may help to categorize patients into probable TBP for further clinical decisionmaking.

Characteristics and survival impact of polymorphonuclear leucocyte-predominant malignant pleural effusions secondary to lung cancer.

In comparison with mononuclear leucocyte (MNL)-predominant malignant pleural effusions (MPEs), polymorphonuclear leucocyte (PMNL)-predominant MPEs have rarely been investigated and may be associated with a poorer prognosis. To investigate the characteristics and survival impact of PMNL-predominant MPEs secondary to lung cancer. This retrospective study included patients with MPE secondary to lung cancer, which were classified into the PMNL- and MNL-predominant groups according to cellular predominance in the pleural fluid. Clinical, hematological, radiological, and pleural fluid data were compared between the groups, and the survival impact of PMNL predominance in MPE was evaluated. Of the 193 MPEs included, 37 (19%) were characterised by PMNL predominance. Compared to the MNL-predominant group, the PMNL-predominant group showed significantly poorer patient performances (P=.001), higher white blood cell counts (P=.009), higher neutrophil counts, higher blood neutrophil-to-lymphocyte ratio (P=.046), higher serum C-reactive protein (P=.003), lower serum albumin (P<.001), lower pleural fluid pH (P=.002) and higher pleural fluid lactate dehydrogenase (P=.029) levels. In contrast, most clinical and radiological findings, including the duration of symptoms, showed no significant intergroup differences. A shift towards MNL predominance was observed in only 38% of the PMNL-predominant patients who underwent repeat thoracentesis. Overall survival of the PMNL-predominant group was significantly shorter than the MNL-predominant group (P=.003). PMNL predominance in MPEs secondary to lung cancer may be observed in variable phases with respect to the duration of symptoms and the time of thoracentesis. Overall, PMNL-predominant MPEs were associated with more advanced stages and poorer survival outcomes, compared to MNL-predominant MPEs.

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.

Clinical Predictors of Successful and Earlier Removal of Indwelling Pleural Catheters in Benign Pleural Effusions

Background: Indwelling pleural catheters (IPCs) are an emerging therapy for persistent benign pleural effusions. IPCs may achieve pleurodesis and be removed. Objectives: We aimed to identify factors associated with higher pleurodesis rates and earlier IPC removal in benign pleural effusions. Methods: We reviewed a database of IPCs inserted for nonmalignant pleural effusions in the period August 2007 to June 2017 in patients who underwent medical thoracoscopy (MT). Clinical, radiologic, and pleural fluid data were recorded. Logistic regression and Cox proportional hazards were used to assess the rate of and time to pleurodesis. Results: 304 IPCs were reviewed. 52 were excluded from the pleurodesis analysis due to removal for another reason, or because of an eventual diagnosis of malignant disease. The overall pleurodesis rate was 74%, and median time to pleurodesis was 42 (IQR 18–93) days. Variables with increased pleurodesis rates in multivariate analysis include Eastern Cooperative Oncology Group performance status score of ≤2 (odds ratio [OR] 4.22, 95% confidence interval [CI] 1.75–10.16) and MT (OR 5.27, 95% CI 2.74–10.11). No variables were associated with reduced pleurodesis rates in multivariate analysis. Variables that predicted earlier removal in multivariate analysis included secondary pleural infection (hazard ratio [HR] 14.19, 95% CI 4.11–48.91), % eosinophils (HR 1.03, 95% CI 1.01–1.05), and connective tissue disease (HR 2.59, 95% CI 1.20–5.57). Variables that predicted delayed removal include pleural effusion above the hilum (HR 0.54, 95% CI 0.34–0.85), liver failure (HR 0.31, 95% CI 0.16–0.60), and heart failure (HR 0.32, 95% CI 0.20–0.52). Conclusions: IPCs are safe in benign effusions. Clinicians should consider numerous factors when predicting the rate of and time to pleurodesis.

Laboratory Discrimination Between Neutrophilic Malignant and Parapneumonic Pleural Effusions

BackgroundMalignant pleural effusion (MPE) occasionally demonstrates neutrophilic predominance, commonly found in parapneumonic pleural effusion (PPE). In comparison with lymphocytic MPE, neutrophilic MPE may have different characteristics associated with a more intense inflammatory response and poor prognosis. These characteristics of neutrophilic MPE may lead to inappropriate management and delayed diagnosis. Moreover, the limited diagnostic yield of microbiologic and cytologic tests makes early differential diagnosis between neutrophilic MPE and PPE more challenging. This study investigated objective laboratory findings to help distinguish neutrophilic MPE from PPE. Materials and MethodsA retrospective study was conducted on patients with neutrophilic MPE and PPE. Routine blood and pleural fluid data of the 2 groups were compared, and the diagnostic performances of predictors for neutrophilic MPE were assessed using receiver-operating characteristic curves. ResultsForty-one and 140 patients with neutrophilic MPE and PPE, respectively, were included. In final analysis, serum C-reactive protein, pleural fluid neutrophil-to-lymphocyte ratio, and pleural fluid carcinoembryonic antigen were significantly different between the 2 groups. With cut-off values of C-reactive protein <6.0 mg/dL, neutrophil-to-lymphocyte ratio <3.0 and carcinoembryonic antigen >8.0 ng/mL, the presence of any 2 or more parameters provided an area under the curve of 0.928 (95% CI, 0.851-0.999), yielding a sensitivity of 88%, specificity of 98%, positive predictive value of 92% and negative predictive value of 96% for identifying MPE. ConclusionsMPE should be considered even in patients with neutrophilic exudative effusion, especially if at least 1 predictor for neutrophilic MPE is present. Our results may help guide differentiation of neutrophilic MPE from PPE.

Clinical predictors of successful and earlier pleurodesis with a tunnelled pleural catheter in malignant pleural effusion: a cohort study.

Tunnelled pleural catheters used to treat malignant pleural effusions may achieve pleurodesis. We aimed to identify factors associated with higher pleurodesis rates and earlier catheter removal. We retrospectively reviewed a prospective database of tunnelled pleural catheters inserted consecutively between May 2006 and June 2013 for confirmed malignant pleural effusion. The cohort included patients who underwent medical thoracoscopy. Clinical, radiologic and pleural fluid data were recorded. We used logistic regression and Cox regression to assess rates of and days to pleurodesis, respectively. We analyzed data for 1071 tunnelled pleural catheters in 956 patients. Increased rates of pleurodesis were associated with lymphoma (odds ratio [OR] 3.49, 95% confidence interval [CI] 1.93-6.33), ovarian cancer (OR 2.93, 95% CI 1.68-5.11), Eastern Cooperative Oncology Group Scale of Performance Status grade 2 or less (OR 2.79, 95% CI 1.79-4.34), medical thoracoscopy (OR 2.21, 95% CI 1.28-3.85), protein level (OR 1.03, 95% CI 1.01-1.06), albumin level (OR 1.07, 95% CI 1.03-1.12) and percent eosinophils (OR 1.04, 95% CI 1.00-1.07). Reduced rates of pleurodesis were associated with gastrointestinal cancers (OR 0.41, 95% CI 0.19-0.87), hydropneumothorax on the postdrainage chest radiograph (OR 0.62, 95% CI 0.41-0.94) and percent other cells on cell count (OR 0.98, 95% CI 0.97-0.99). Earlier pleurodesis was associated with ovarian cancer (hazard ratio [HR] 1.48, 95% CI 1.06-2.08), medical thoracoscopy (HR 1.45, 95% CI 1.10-1.92), protein level (HR 1.03, 95% CI 1.01-1.04) and percent eosinophils (HR 1.02, 95% CI 1.00-1.04). Delayed pleurodesis was associated with breast cancer (HR 0.61, 95% CI 0.46-0.81), hydropneumothorax with 80% or less lung expansion (HR 0.55, 95% CI 0.38-0.80) and percent other cells (HR 0.99, 95% CI 0.98-1.00). Clinicians should consider numerous factors to predict the probability of and timing to pleurodesis with tunnelled pleural catheters.

Clinical relevance and characteristics of pleural effusion in patients with Mycoplasma pneumoniae pneumonia

Data regarding parapneumonic pleural effusion in Mycoplasma pneumoniae pneumonia (MP) patients are limited. In this study MP patients with pleural effusion tended to be younger and had longer hospital stays and more common use of systemic steroids compared to those without pleural effusion. In 5 of the 6 patients for whom pleural fluid data were available, the pleural effusion was lymphocyte-predominant rather than polymorphonuclear leukocyte-predominant; these patients also had elevated adenosine deaminase levels. Taken together, these results indicate that MP patients with pleural effusion may have a more severe form compared to those without pleural effusion. M. pneumoniae should be considered an aetiological agent of lymphocyte-predominant pleural effusion.

Prognostic significance of pleural fluid data in patients with malignant effusion

Background To determine the effects of the biochemical and cytological properties of the pleural fluid (PF) on the survival of patients with malignant pleural effusion (MPE). Methods A retrospective study of 284 patients with MPE was performed, which measured overall survival, survival of patients with different types of primary tumors, and survival as a function of PF biochemical variables transformed into quartiles. Results Median overall survival of MPE patients was 5.4 months following diagnosis. Survival varied significantly depending on the type of the primary tumor: 17.4 months for mesothelioma, 13.2 months for breast cancer, 7 months for lymphoma and 2.6 months for lung cancer. A multivariate analysis of PF biochemical parameters showed that survival was lower as the concentration of lactate dehydrogenase (LDH) increased (11.3 months if LDH was between 140 U/L and 358 U/L vs 2.8 months if LDH was between 1027 U/L and 10,110 U/L) or the concentration of pleural proteins decreased (9.4 months if proteins were between 4.92 g/dL and 7.94 g/dL vs 2.2 months if proteins were between 0.97 g/dL and 3.85 g/dL). We also found that when mesotheliomas were excluded from the analysis, survival was lower in patients with a PF pH lower than 7.3 (2.4 months vs 6.8 months, p = 0.03). Conclusions Tumor type as well as some biochemical features of the pleural fluid, such as pH and concentrations of proteins and LDH, influence survival in patients with MPE.

Bayesian analysis using continuous likelihood ratios for identifying pleural exudates

To ascertain if equations that calculate continuous likelihood ratios (CLRs) for pleural exudates improve pleural fluid categorization, especially when false positive or false negative test results are obtained by using Light's criteria. Retrospective review of the clinical and pleural fluid data from a consecutive series of patients with pleural effusion who underwent thoracentesis at the University Hospital Arnau de Vilanova (Lleida, Spain) over an 11-year period. A total of 1490 patients with pleural effusion (298 transudates and 1192 exudates) were recruited into the study. The presence of a transudate or exudate was established by clinical judgment. We examined the comparative diagnostic accuracy of 4 tests (i.e. pleural fluid protein and lactate dehydrogenase (LDH), and pleural fluid to serum protein and LDH ratios) for discriminating between transudates and exudates. Decision thresholds were determined by receiver operating characteristics (ROC) analysis. Equations for calculating CLRs derived from a logistic regression analysis based on a previously described method. Individual pleural fluid tests did not differ in their diagnostic accuracies according to ROC analysis. We calculated CLRs for the elements of Light's criteria and pleural fluid protein, and also illustrated the sequential use of CLRs for determining posttest probabilities. Overall, CLR formulas had marginal performance for the correct categorization of pleural fluid. CLRs provide a probabilistic statement as to the likelihood an effusion is a transudate or exudate. However, clinical judgment is little changed by the application of CLRs, and in doubtful cases a great amount of uncertainty remains. This Bayesian approach is likely to have no major impact on the clinical practice.

Thoracocentesis: Clinical Value, Complications, Technical Problems, and Patient Experience

A prospective study of 129 consecutive thoracocentesis in 86 patients at a university medical center evaluated the clinical value, complications, and patient experience with thoracocentesis. Pleural fluid analysis in conjunction with the clinical presentation placed 78 pleural fluids into diagnostic categories: definitive 14 (18 percent), presumptive 44 (56 percent), and nondiagnostic 20 (26 percent). Fourteen of 78 (18 percent) of the nondiagnostic fluids were useful, while only six (8 percent) were not useful clinically; therefore, 92 percent of thoracocentesis provided clinically useful information. Using sequential data analysis, initial diagnostic categorizations of eight of 78 patients were upgraded from presumptive or nondiagnostic to definitive based on data available 24 hours following thoracocentesis. Thus, 70 patients were categorized based on the pleural fluid data obtained within the first 24 hours of thoracocentesis. Thirty-four objective complications occurred in 26 of 129 (20 percent) thoracocentesis. The most common complications were pneumothorax, 15 of 129 (12 percent), and cough, 12 of 129 (9 percent). Sixty-five subjective complications occurred in 56 of 123 (46 percent) thoracocentesis. Anxiety, 26 of 123 (21 percent), and site pain, 24 of 123 (20 percent), were the most common subjective complications noted. Thirty technical problems occurred in 129 (23 percent) thoracocentesis with blood contamination, 14 of 129 (11 percent), and dry tap, nine of 129 (7 percent), being the most common. We conclude that diagnostic thoracocentesis is a clinically valuable procedure if used in conjunction with the patient presentation with an understanding of its limitations for providing a specific etiologic diagnosis. When performed by physicians in training, the number of complications are substantial and the operator often underestimates the degree of patient discomfort. Awareness of the clinical value and complications of thoracocentesis should lead to improved use and safety of this procedure.

Pleural fluid data: 2. Interpretation in pulmonary embolism and malignancy.

Pleural fluid data: 2. Interpretation in pulmonary embolism and malignancy.