Pleural Thickenings Research Articles

Primary pleural synovial sarcoma with diffuse pleural involvement: A case report

Synovial sarcoma (SS) is a mesenchymal tumor which generally affects the soft tissues of the extremities. Primary pleural synovial sarcoma (PPSS) is a very rare and aggressive subtype of SS. A 73-year-old male patient presented with chest-back pain and dyspnea. Hypermetabolic diffuse pleural lesions were detected in 18F-FDG PET/CT performed after pleural nodular thickenings were observed on CT. As the result of the molecular analysis performed in the excisional biopsy, SYT-SSX mutation was detected and the patient was diagnosed as SS. Pazopanib treatment was commenced. We are reporting a very rare case of PPSS with diffuse pleural involvement.

Pneumomediastinum As A New Rare Complicance Of Covid-19 Pneumonia: CT Findings

The Covid-19 Coronavirus infectious pandemic began since December 2019, mainly causing bilateral interstitial pneumonia in affected patients. The heterogeneity of the course and clinical frameworks of the pathology represents an important problem for health providers, who are faced with both the acute phase of the disease and the possible complications. An optimal management of patients was, initially, very hard. So, the use of computed tomography (CT) imaging in the diagnosis and follow-up had rapidly grown, and radiological patterns along the disease course were increasingly understood. Many typical imaging features of this disease were described: bilateral multilobar ground-glass opacity (GGO), with a prevalent peripheral or posterior distribution, mainly in the lower lobes; consolidative areas of the lungs; septal thickenings; bronchiectasis; pleural thickenings and subpleural involvements. Unenhanced chest CT is considered the first-line imaging tool for the diagnosis, the severity assessment, and monitoring of Covid-19 pneumonia [1]. Spontaneous pneumomediastinum (SPM) is a rare complication of Covid-19 pneumomia. The major risk factors for development of SPM are male gender, advanced age and preexisting lung disease. SPM was considered as a potential predictive factor for adverse outcome and probable cause of unexplained deterioration of clinical conditions in Covid-19 pneumonia [2,3] (Figure 1).

Lung ultrasonography in pulmonary tuberculosis: A pilot study on diagnostic accuracy in a high-risk population

ObjectivesThe validity of lung ultrasound (LUS) in the diagnosis of interstitial or focal lung pathologies is well documented, we assessed its accuracy in the diagnosis of pulmonary tuberculosis (PTB). MethodsSonographic signs suggestive of PTB and their diagnostic accuracy were evaluated in patients admitted with clinical suspicion of PTB. Consolidations, subpleural nodules, pleural thickenings or irregularities and pleural effusion were assessed. LUS signs significantly associated with PTB in the univariate analysis (p < .05) were entered in a multivariate logistic regression model. ResultsPTB was confirmed in 51 out of 102 patients. Multiple consolidations (OR 3.54, 95%CI 1.43–8.78), apical consolidations (OR 9.65, 95%CI 3.02–30.78), superior quadrant consolidations (OR 4.01, 95%CI 1.76–9.14), and subpleural nodules (OR 5.29, 95%CI 2.27–12.33) were significantly associated with PTB diagnosis. Apical consolidation (OR 9.67, 95%CI 2.81–33.25, p 0.003) and subpleural nodules (OR 5.30, 95%CI 2.08–13.52, p 0.005) retained a significant association in a multivariate model, with an overall accuracy of 0.799. ConclusionsOur data suggest a possible role of LUS in the diagnosis of PTB, a high burden pathological condition for which the delay in diagnosis still represents a critical point in the control of the disease.

New insights in the use of pleural ultrasonography for diagnosis and treatment of pleural disease.

The use of transthoracic ultrasound (US) has acquired a wide consensus among respiratory physicians during the last few years. The development of portable devices promotes patient's bedside evaluation providing rapid, real-time and low-cost diagnostic information. The different acoustic impedance between different tissues and organs produces artifacts known as A lines, B lines, sliding sign, lung point, etc. The identification of such artifacts is essential to discriminate normal pleural appearance from the presence of pleural effusion, pneumothorax, thickenings and tumors. Ultrasounds are also a valuable tool during interventional procedures, such as thoracentesis, chest tube insertion and transcutaneous biopsy. Its use is recommended before medical thoracoscopy in order to assess the best site of trocar insertion according to presence, quantity and characteristics of pleural effusion. The aim of this review is to provide practical tips on chest ultrasound in clinical and interventional respiratory practice.

Radiological pleuroparenchymal fibroelastosis associated to limited cutaneous systemic sclerosis: a case report

BackgroundPleuroparenchymal fibroelastosis (PPFE) is a very rare interstitial lung disease (ILD) characterized by progressive fibrotic lesions of the visceral pleura and the sub-pleural parenchyma, affecting predominantly the upper lobes. PPFE may occur in different contextes like bone marrow or lung transplantations, but also in the context of telomeropathy with mutations of telomerase reverse transcriptase (TERT), telomerase RNA component (TERC) or regulator of telomere elongation helicase 1 (RTEL1) genes. PPFE-like lesions have recently been described in patients with connective tissue disease (CTD)-related ILD. We report here the first detailed case of PPFE associated to systemic sclerosis (SSc) in a woman free of telomeropathy mutations.Case presentationA caucasian 46 year old woman was followed for SSc in a limited form with anti-centromere Ab since 1998, and seen in 2008 for a routine visit. Her SSc was stable, and she had no respiratory signs. Pulmonary function tests showed an isolated decreased cTLCO at 55.9% (of predicted value). Cardiac ultrasonography was normal. Thoracic CT-scan showed upper lobes predominant mild and focal pleural and subpleural thickenings, suggestive of PPFE, with a slight worsening at 8 years of follow-up. She remained clinically stable. Biology only found a moderate and stable peripheral thrombocytopenia, and sequencing analysis did not find any mutations in TERT and TERC genes.ConclusionsILD is frequent in SSc but isolated PPFE has never been described so far. In our case, PPFE is not related to telomeropathy, has indolent outcome and seems to have good prognosis. PPFE might be an extremely rare form of SSc-related ILD, although a fortuitous association remains possible.

Chest ultrasonography in health surveillance of asbestos-related lung diseases.

Exposure to asbestos fibers can lead to different lung diseases, such as pleural thickening and effusion, asbestosis, mesothelioma, and lung cancer. These diseases are expected to peak in the next few years. The aim of the study was to validate ultrasonography (US) as a diagnostic tool in the management of lung diseases in subjects with a history of occupational exposure to asbestos. Fifty-nine retired male workers previously exposed to asbestos were enrolled in the study. Chest US was performed in all the subjects. The US operator was blinded to earlier performed computed tomography (CT) scan reports and images. The sonographic pathological findings were pleural thickening (with or without calcifications), peripheral lung consolidation, and focal sonographic interstitial syndrome and diffuse pneumogenic sonographic interstitial syndrome (pulmonary asbestosis). Significant US findings were recorded, stored, and subsequently compared with CT scans. With some patients falling into more than one category, on CT scan, pleural thickening was reported in 33 cases (56%, 26 with calcifications), focal interstitial peripheral alterations in 23 (39%), asbestosis in 6 (10%), and peripheral lung consolidation in 13 cases (22%). Comparing each pathological condition to CT scan reports, US findings had high levels of sensitivity, specificity, positive, and negative predictive values. US did not prove effective for the detection of central lung nodules or diaphragmatic pleural thickenings. Chest US was considered to be the best technique to detect minimal pleural effusions (six subjects, 10%). Chest US might be considered an additional tool to follow up subjects occupationally exposed to asbestos who have already undergone CT scan examination and whose pathology is detectable by US as well.

Two cases of asbestosis and one case of rounded atelectasis due to non-occupational asbestos exposure

Asbestos is a well-known cause of several neoplastic (malignant mesothelioma, lung cancer) and non-neoplastic (asbestosis, pleuropathies) occupational diseases. Lower-level exposure in the general environment may induce pleural plaques and thickenings, and is associated with an increased mesothelioma risk. We present two patients (a 68-year-old man and a 72-year-old woman) who developed asbestosis (in association with pleural plaques and calcifications), and a 78-year-old man who developed rounded atelectasis (with pleural plaques and benign effusion), after living for several decades in the proximity of large Italian asbestos-cement plant. None of them had been exposed to asbestos occupationally. Besides living in a contaminated area, the woman used to clean the work clothes of her brother, who was employed in the local asbestos factory. The three cases indicate that non-neoplastic, long-latency asbestos-related diseases which are usually observed as a consequence of occupational exposures, may rarely develop in subjects living in contaminated geographical sites and buildings. These unusual environmental diseases raise the diagnostic problem of differentiating them from other, more common respiratory illnesses, and impose the duties of patient notification, assessment and follow-up, to assess the possibility of progression of disease and increased neoplastic risk.

A Novel Method for Early Diagnosis of Malignant Pleural Mesothelioma from Human Serum Samples: ATR-FTIR Spectroscopy

Malignant pleural mesothelioma (MPM) is an aggressive and rare form of cancer which arises from environmental fibrous minerals (tremolite asbestos or erionite) exposures. Since it is difficult to differentiate the benign pleural thickenings from carcinomas, MPM can only be diagnosed in the advanced stage. Therefore, it is important to develop a new method with high specificity and sensitivity for the early diagnosis of MPM. Fourier Transform Infrared (FTIR) spectroscopy is a novel and non-invasive method that provides high specificity and sensitivity in the diagnosis of cancer. Moreover, FTIR with its attenuated total reflectance (ATR) tool is eminent technique because of its rapidity and ease to put into clinical practice. Hence, we used ATR-FTIR spectroscopy coupled with chemometric analysis methods to characterize the molecular alterations as well as to differentiate the experimental groups from each other. FTIR spectra of the samples collected from patients diagnosed with malignant pleural mesothelioma (MPM), lung cancer (MLC), benign, and healthy control (C) were recorded in the 4000-650 cm-1spectral region.. Recording the spectra and analysis of the spectral data were obtained with Perkin Elmer Spectrum One Program. Spectral analysis indicated a significant decrease in the lipid, protein, carbohydrates, and nucleic acid contents in MLC and MPM with respect to the healthy samples. Hierarchical Cluster Analysis (HCA) and Principal Component Analysis (PCA) were performed to differentiate the studied groups based on the spectral differences. HCA of the samples demonstrated that all studied groups successfully differentiated from the control. Moreover, successful clustering of the all groups (control, MLC, MOC, MPM) was obtained in the protein region (1900-1485 cm-1 and 3500-3010 cm-1) by PCA of serum samples.

Genes involved in innate immunity associated with asbestos-related fibrotic changes

ObjectivesTo determine whether genetic polymorphisms in several candidate genes related to innate immunity and protease–antiprotease balance modify individual susceptibility to develop asbestos-related fibrotic pleuropulmonary changes.MethodsSixteen polymorphisms from nine genes (NLRP3,...

Our double valve replacement strategy in a case with pectus carinatum deformity

Background Pectus carinatum is a deformity of the chest characterized by a protrusion of the sternum and ribs. It develops as a result of an overgrowth of cartilage causing the sternum to protrude forward. It is detected most commonly during pubertal growth spurt. Methods Our case was a 63-year-old male. An elective umbilical hernia repair was being planned. During the investigations due to shortness of breath, transthoracic echocardiography (TTE) revealed severe aortic and mitral regurgitation. Left ventricular end-diastolic and end-systolic diameters were measured as 72 and 48 mm, respectively. Left and right atrial diameters were measured as 56 and 55 mm, respectively. Pulmonary arterial pressure was calculated as 35 mm Hg and left ventricular ejection fraction was identified as 60%. Coronary angiography detected no significant stenoses and confirmed aortic and mitral regurgitation with an ejection fraction of 50%. Our case was consulted with Department of Pulmonary Diseases due to dyspnea and moderate pectus carinatum. Fibrotic lesions and pleural thickenings in the upper zones of both hemithoraces were interpreted as sequelae of tuberculosis. Pulmonary function tests were normal. Elective open heart surgery was planned. Results After standard median sternotomy, aortic valve was replaced with 23 mm St. Jude mechanical valve and mitral valve was replaced with 31 mm St. Jude mechanical valve. Left atrial appendix was sutured internally due to atrial fibrillation to avoid embolization and posterior leaflet of the mitral valve was preserved. Postoperative period was event-free. Conclusions Most cases with pectus carinatum are asymptomatic as in our case. Psychological and cosmetic disturbances may be observed as well as respiratory tract infections and exertional dyspnea. We think that technically challenging correction surgery should be avoided if patients are asymptomatic, particularly after completion of calcification process of the bony structures.

1746 – A case of isoniazid-induced delirium

To report a case of isoniazid-induced delirium. A 56-year-old man affected by alcoholism and hepatic cirrhosis was admitted to hospital for a suspected pneumonia with pleural effusion and thickenings. A Mantoux skin test was positive. A core biopsy of the pleural nodules revealed a tubercular granulomatous pleuritis. An isoniazid, ethambutol and rifampicin therapy was then started. Subsequently the patient developed a state of delirium. A diagnostic work-up was carried out considering different hypothesis: hepatic encephalopathy was ruled out because of lack of response to appropriate treatment; negative encephalic CT scan, liquor examination and EEG excluded a tubercular involvement of the central nervous system or other neurologic etiologies. Haloperidol and delorazepam were administered under the suspicion of Wernicke-Korsakoff syndrome, without any benefit. Finally a toxic etiology was considered. Among isoniazid side effects psychosis is described, though rare. Isoniazid therapy was then stopped and substituted by moxifloxacin, with progressive improvement of the state of consciousness. Cases of isoniazid-related psychiatric disorders reported include psychosis, obsessive-compulsive disorder and mood alterations. Two mechanisms are generally considered as responsible: pyridoxin deficiency and isoniazid toxicity, a molecule chemically near to iproniazid, a powerful monoamineoxidase inhibitors. This is the first report of a case of isoniazidinduced pure delirium, with all clinical features according to DSM-IV criteria. We also confirmed successful resolutions of symptoms only by discontinuation of therapy. In the work-up of a state of delirium, when investigating the toxic hypothesis, clinicians should consider neuropsychiatric side effects of isoniazid.

Analysis of “dry” mesothelioma with ultrasound guided biopsies

BackgroundImage-guided sampling of the thickened pleura is a sensitive approach in patients with malignant pleural mesothelioma with pleural effusion. Malignant pleural mesothelioma presenting without effusion however is more of a diagnostic challenge. In this study we report the diagnostic yield and complications of ultrasound-guided cutting needle biopsies in this particular category of patients. MethodsA retrospective database analysis from September 2007 until January 2012 was performed in 56 patients with malignant pleural mesothelioma. Clinical characteristics and results of diagnostic evaluations were analysed. ResultsOf the 56 patients with malignant pleural mesothelioma, 20 patients presented without pleural effusion of with locular effusion. Ultrasound-guided cutting needle biopsy was performed in 14/20 patients with a diagnostic accuracy of 80%. Only 1 patient had mild haemoptysis immediately following biopsies. ConclusionDiagnosing patients with pleural thickenings suspect for malignant mesothelioma without pleural effusion or with loculated pleural effusion is effective and safe with ultrasound-guided cutting needle biopsies.

Focal dependent pleural thickening at MDCT: Pleural lesion or functional abnormality?

To describe the characteristics of reversible focal pleural thickenings (PTs) mimicking real plaques, that firstly suggest asbestos exposure or pleural metastasis; to propose an imaging strategy and propose an explanation for their mechanism of formation. Retrospective review of data from 19 patients with PTs fitting the description of pleural plaques at chest computed tomography (CT) and presenting modifications (clearance or appearance) of at least one PT at an additional chest examination in prone position. A total of 152 PTs were recorded on the first chest CT examinations with a range of two to 19 pleural opacities per patient. All PTs had a posterior distribution in the lower lobes. On the additional acquisitions, 144 PTs disappeared. Seventeen patients presented complete regression of PTs and two patients presented persistence of eight PTs. Additional low dose acquisition in prone position should be performed in all patients presenting with focal PT in a dependent and basal location. This may allow to exclude a pleural plaque in case of asbestos exposure but also a pleural metastasis in oncologic patients. These reversible dependent PTs could be related to physiological focal accumulation of lymphatic fluid in subpleural area.

3D Surface-based Detection of Pleural Thickenings

Pleuramesothelioma is a malignant tumor of the pleura. It evolves from pleural thickenings which are a typical long-term effect of asbestos exposure. A diagnosis is performed by examining CT scans acquired from the patient’s lung. The analysis of the image data is a very time-consuming task and is subject to strong inter- and intra-reader variances. To objectivize the analysis and to speed-up the diagnosis a full automatic system is developed. An essential step in this process is to identify potential thickenings. In this paper we describe the complete system in brief, and then take a closer look on thickening detection. A CT slice based approach is presented here. It is extended by using 3D knowledge of thelung surface which could scarcely have been acquired visually.

Genetic susceptibility to asbestos-related fibrotic pleuropulmonary changes

The objective of this study was to determine whether genetic polymorphisms in enzymes that metabolise oxidative agents modify the individual susceptibility to developing asbestos and smoking-related pleuropulmonary changes. Nine polymorphisms of six genes (EPHX1, GSTM1, GSTM3, GSTP1, GSTT1 and NAT2) were genotyped from 1,008 Finnish asbestos-exposed workers. The genotype data were compared to signs of lung fibrosis and pleural thickenings, as well as with total lung capacity, single-breath diffusing capacity of the lung for carbon monoxide (D(L,CO)) and specific diffusing capacity (expressed as D(L,CO) per unit of alveolar volume (V(A))). The GSTT1 deletion polymorphism was associated with fibrotic changes (p=0.003), and decreased D(L,CO) (p=0.02) and D(L,CO)/V(A) (p=0.002), and the GSTM1 deletion polymorphism was associated with the greatest thickness of pleural plaques (p=0.009). On further analysis, the GSTT1 null genotype was found to pose over a three-fold risk for severe fibrotic changes (OR 3.12, 95% CI 1.51-6.43), and around two-fold risks for decreased D(L,CO) (OR 1.77, 95% CI 1.06-2.95) and D(L,CO)/V(A) (OR 2.37, 95% CI 1.33-4.23). In addition, the GSTM1 null genotype showed an elevated risk (OR 1.36, 95% CI 1.03-1.80) for thicker pleural plaques. Our data suggest that inherited detoxification capacity may affect the development and severity of asbestos and smoking-related nonmalignant pulmonary changes.

Association of findings in flow‐volume spirometry with high‐resolution computed tomography signs in asbestos‐exposed male workers

Disorders of pulmonary tissue and pleura are visualized by findings in high-resolution computed tomography (HRCT), and the impairment caused by these findings is assessed by pulmonary function tests. Our aim was to determine how some commonly used spirometric variables are related to certain HRCT signs, in order to find out which HRCT signs are associated with restrictive and which with obstructive ventilatory impairment. Altogether 590 asbestos-exposed workers, 95% of whom were smokers or ex-smokers, were studied with HRCT; 19 pathological signs were scored. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flow at 50% of FVC (MEF50) and total lung capacity (TLC) were measured, and their relationship with HRCT signs was examined with bivariate correlations and multiple regression analysis. FVC and TLC were negatively correlated with fibrosis score, parenchymal bands, extent of pleural thickenings and positively with widened retrosternal space. FEV1/FVC ratio was negatively correlated with emphysema types and widened retrosternal space and positively with parenchymal bands and subpleural nodules. Thickened bronchial walls did not separate between restrictive and obstructive ventilatory function. HRCT signs showed distinctive patterns in restrictive and obstructive ventilatory impairment. These results can be used to help to analyse the lung function of patients simultaneously exposed to asbestos and smoking, when this relationship requires elucidation. In addition, the results may be helpful in explaining some radiological findings.

Computer-assisted Diagnosis for Early Stage Pleural Mesothelioma

Pleural thickenings as biomarker of exposure to asbestos may evolve into malignant pleural mesothelioma. For its early stage, pleurectomy with perioperative treatment can reduce morbidity and mortality. The diagnosis is based on a visual investigation of CT images, which is a time-consuming and subjective procedure. Our aim is to develop an automatic image processing approach to detect and quantitatively assess pleural thickenings. We first segment the lung areas, and identify the pleural contours. A convexity model is then used together with a Hounsfield unit threshold to detect pleural thickenings. The assessment of the detected pleural thickenings is based on a spline-based model of the healthy pleura. Tests were carried out on 14 data sets from three patients. In all cases, pleural contours were reliably identified, and pleural thickenings detected. PC-based Computation times were 85 min for a data set of 716 slices, 35 min for 401 slices, and 4 min for 75 slices, resulting in an average computation time of about 5.2 s per slice. Visualizations of pleurae and detected thickenings were provided. Results obtained so far indicate that our approach is able to assist physicians in the tedious task of finding and quantifying pleural thickenings in CT data. In the next step, our system will undergo an evaluation in a clinical test setting using routine CT data to quantify its performance.

Impairment of lung function in asbestos-exposed workers in relation to high-resolution computed tomography

The aim of the study was to determine the causes of impairment of ventilatory function and diffusing capacity in smoking asbestos-exposed workers (N=590) showing radiological pleural thickenings or pulmonary fibrosis. High-resolution computed tomography (HRCT) and spirometry were performed, and diffusing capacity was measured. The workers were divided into five groups based on the HRCT scoring: pleural disease (N=190), pulmonary fibrosis (N=68), emphysema (N=148), combined fibrosis and emphysema (N=74), and marked adhesions (N=110). The graded lung function impairment was compared between the groups. Moderate impairment of forced expiratory volume in 1 second [odds ratio (OR) 2.72, 95% confidence interval (95% CI) 1.31-5.57] and forced vital capacity (OR 2.81, 95% CI 1.05-6.89) was associated with the persons with combined fibrosis and emphysema. Marked impairment of diffusing capacity was associated with the combined fibrosis and emphysema (OR 4.94, 95% CI 2.48-9.77) but not with pleural disease (OR 0.21, 95% CI 0.09-0.45) or pulmonary fibrosis (OR 0.36, 95% CI 0.08-1.05). For the persons with combined fibrosis and emphysema, the mean fibrosis score did not differ between normal, slightly reduced, or markedly reduced diffusing capacity, but the emphysema score was significantly higher for the patients with marked impairment than for those with normal diffusing capacity (P < 0.01). Different profiles of asbestos- and smoking-induced pulmonary or pleural disease were found. The results indicate that the most important factor determining the degree of functional impairment in smoking asbestos-exposed workers is the presence of pulmonary emphysema.

Acute and chronic pleural complications in lung transplantation

Background Lung transplant recipients may have pleural complications. However, the influence of these complications on the prognosis is not well known. Methods We analyzed pleural complications and clinical and radiologic data from 100 patients who underwent lung transplantation in a general hospital in a 9-year period. Pre-operative evaluation, surgical protocol, immunosuppressive regimen, and follow-up were carried out systematically. Chest computerized tomography (CT) was performed at 3 and 12 months after transplantation. Results All patients had early post-operative pleural effusion ipsilateral to the graft, which required drainage for a mean of 19.3 days (range, 5–52 days). Thirty-four patients had 43 acute pleural complications: 15 hemothoraxes, 10 persistent air leaks, 8 pneumothoraxes, 7 transient air leaks, and 3 empyemas. Multivariate analysis showed hemothorax and persistent air leak were associated with increased post-operative mortality ( p = 0.024, p = 0.011, respectively). Post-operative mortality was not associated with any pre-transplant variable. Chest CT findings at 3 months revealed ≥1 pleural alteration in 58 of 70 patients (83%): 34 post-operative residual ipsilateral pleural effusions; 36 pleural thickenings; and 3 residual pneumothoraxes, 1 with a coexisting bronchial dehiscence. Chest CT at 12 months showed pleural alterations in 50 of 58 patients (86%): pleural thickening in 48, calcification in 4, and residual pleural effusion in 4. Conclusions Pleural complications are common in lung transplant recipients. Hemothorax and persistent air leak are associated with increased post-operative mortality. Chest CT showed pleural alterations in most patients 12 months after transplantation.

Effects of Intracavitary Urokinase Instillation in Complicated Pleural Effusion

Background : Complicated exudative pleural fluid collections have traditionally been treated by either closed tube thoracostomy drainage or by open surgical drainage. Complete drainage is important in order to control pleural sepsis, restore pulmonary function, and entrapment. Recently intracavitary fibrinolytic therapy has been advocated as a method to facillitate drainage of complicated exudative pleural effusion and to allow enzymatic debridemant of the restrictive fibrinous sheets covering the pleural surface. The purpose of this study is to prospectively evaluate the effects of image-guided catheter drainage with high dose urokinase(UK) instillation in the treatment of complicated pleural effusions. Patients : Twenty complicated pleural effusion patients that poorly respond to image-guided drainage were allocated to receive UK. There were 8 pneumonia and 12 tuberculosis. Methods : Drugs were diluted in 250 mL normal saline and were infused intrapleurally through the chest tube or pig-tail catheter in a daily dose of 250,000 IU of UK. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasound and/or computed tomography. Results : The mean UK instillation time was . The mean volume drained UK instillation was , and post-UK was . The follow up duration after UK therapy was mean days. We had successful results in 19 cases (95.0%). There were 12 pleural thickenings (60.0%), 2 markedly decreased effusions (10.0%) and 5 cases of no thickening or effusion. There was recurrence after treatment in only one patient(5%) with complicated pleural effusiondue to tuberculosis. Conclusions : Image-guided drainage with high dose UK instillation (250,000 U/day) in complicated pleural effusion is a safe and more effective method than closed thoracostomy drainage. And this management, in turn, can obviate surgery in most cases.