Recurrent Exudative Pleural Effusions Research Articles

UNCOMMON CAUSES OF RECURRENT UNILATERAL PLEURAL EFFUSIONS

UNCOMMON CAUSES OF RECURRENT UNILATERAL PLEURAL EFFUSIONS

LEFT-SIDED PLEURAL EFFUSION, ASCITES AND LEIOMYOMATA: AN UNUSUAL CASE OF PSEUDO-MEIGS' SYNDROME

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meigs' Syndrome has been described as the development of ovarian fibroma or fibroma-like mass with pleural effusion and ascitic fluid. It is present in approximately 1% of all ovarian fibroma, thecoma and granulosa cell tumors. Pseudo-Meigs' Syndrome is secondary to benign etiologies and reported to be more uncommon. These syndromes should be considered in women with the clinical triad of pleural effusion, ascites and a pelvic mass and can mimic more serious malignant tumors [1]. A thorough evaluation including biopsy and peritoneal and pleural fluid analyses need to be performed. CASE PRESENTATION: A G0P0 29-year-old female presents with chills and fatigue since the start of her menstrual cycle. She was found to be tachycardic, tachypneic and hypoxemic to 85% with moderate abdominal distention. CT of the chest, abdomen and pelvis showed a large left-sided pleural effusion, multiple abdominal masses with compressive effect and large-volume abdominal ascites. CA-125 level was elevated at 295 U/ml. Biopsy showed small muscle proliferation with bland spindle cells and no malignant features. Thoracentesis was consistent with exudative effusion and negative cytology. Left-sided pleural effusion continued to reaccumulate requiring multiple thoracenteses. Patient underwent left pleuroscopy with pleural biopsies showing fibrotic pleura and reactive mesothelial proliferation, negative for malignancy. There was an active ascitic fluid leak into the left hemithorax through a small, thinned-out region in the dome of the left hemidiaphragm. She underwent abdominal myomectomy several months later with resolution of symptoms. Final pathology was consistent with leiomyomata. DISCUSSION: We describe a case of abdominal leiomyomatosis resulting in ascites and leak into the left hemithorax with recurrent exudative pleural effusions and resolution after surgical myomectomy, consistent with Pseudo-Meigs' Syndrome [2]. Right-sided pleural effusions are most common as pleural fluid collects due to fluid leakage from edematous tumor resulting in translocation via diaphragmatic pores into the right hemidiaphragm [3]. Effusions are exudative in nature, although in previous studies only 1.6% of patients underwent pleural fluid analysis [4]. CA-125 are typically found to be elevated, with normalization post-surgery [5]. CA-125 levels were not re-checked post-myomectomy in our case. Surgical tumor removal results in resolution of ascites and pleural effusion [5]. Therefore, in patients presenting with pleural effusion and ascites in the setting of abdominal leiomyomata, Pseudo-Meigs' Syndrome should be suspected, and pleural fluid analysis and cytology play an important role in aiding diagnosis and further management. CONCLUSIONS: The prompt evaluation of patients with leiomyomatosis presenting with ascites and large pleural effusion can be vital in guiding future interventional management. REFERENCE #1: 1. Cowan M, Crantz J, Welsh S, Nahhas W, Lindheim SR. A rare case of acute pseudo-Meigs' Syndrome presenting with pleural effusion and ascites and a ruptured leiomyoma and hemorrhagic shock. Obstet Gynecol Cases Rev. 2016. 3:070. REFERENCE #2: 2. Peparini N, Chirletti P. Ovarian malignancies with cytologically negative pleural and peritoneal effusions: demons' or meigs' pseudo-syndromes? Int J Surg Pathol. 2009 Oct; 15(5):396-7.3. Meyers MA. The spread and localization of acute intraperitoneal effusions. Radiology. 1970 Jun;95(3):547-54. REFERENCE #3: 4. Krenke R, Maskey-Warzechowska M, Korczynski P et al. Pleural effusion in Meig's syndrome - transudate or exudate? Systematic review of the literature. Medicine (Baltimore). 2015 Dec; 94(49): e2114.5. Nguyen P, Yazdanpanah O, Schumaker B. Meigs' versus Pseudo-Meigs' Syndrome: A case of pleural effusion, ascites, and ovarian mass. Cureus. 2020 Aug; 12(8): e9704. DISCLOSURES: No relevant relationships by Sally Askar, source=Web Response No relevant relationships by Patrick Bradley, source=Web Response No relevant relationships by Labib Debiane, source=Web Response No relevant relationships by Shaikh Husnain, source=Web Response

YELLOW NAIL SYNDROME PLEURAL ENTRAPMENT SUCCESSFULLY TREATED WITH INTRAPLEURAL CATHETER PLACEMENT FOLLOWED BY PLEURODESIS

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Yellow Nail Syndrome (YNS) is a rare cause of pleural effusions. The etiology of YNS remains unknown and treatment focuses on symptomatic management [1]. Therapies for YNS pleural effusions include thoracentesis, tunneled intrapleural catheters (IPC), pleurodesis, and pleurectomy [1,2,3]. Here we present a patient with YNS and bilateral pleural effusions successfully treated with staged IPC followed by video-assisted thoracoscopic surgery (VATS) pleurodesis. CASE PRESENTATION: A 79 year old woman who is a lifelong nonsmoker with a history of type one diabetes mellitus, hyperlipidemia, and hypothyroidism presented with chronic cough, bilateral lower extremity edema, and yellow nail discoloration. Chest computed tomography (CT) scan revealed bilateral lower lobe bronchiectasis and bilateral pleural effusions. A diagnosis of YNS was made recognizing the triad of yellow nails, lymphedema, and pulmonary disease. Thoracentesis revealed a clear-yellow, exudative pleural effusion with a lymphocytic predominance, normal triglyceride level, and negative cultures. Per patient preference, she underwent serial therapeutic thoracenteses. Over the following two years, her pleural effusions progressed requiring increased frequency of drainage, and she developed evidence of bilateral lung entrapment on manual pleural manometry with residual pleural fluid. She then opted to pursue VATS pleurodesis. Her right VATS pleurodesis was preceded by IPC placement, and her lung entrapment improved with serial IPC drainage over two months. She then underwent right VATS mechanical and doxycycline pleurodesis. This same staged procedure was performed on the left side. She has had successful resolution of her pleural effusions without evidence of recurrence at greater than 18 months of follow up. DISCUSSION: YNS is a rare diagnosis with less than 400 cases described and an estimated prevalence of <1:1,000,000 [1]. It is characterized by the triad of yellow discoloration of the nails, lymphedema, and respiratory system involvement [1]. The cause of YNS is unknown, but an anatomic or functional abnormality of lymphatic drainage is proposed as the cause of its clinical manifestations [1]. There are currently no guidelines for the management of YNS, and an individualized approach to the management of YNS pleural effusions should be taken [2,3]. As with other recurrent exudative pleural effusions, serial thoracenteses for YNS may be complicated by pleural entrapment and progression to trapped lung, limiting the efficacy of future pleurodesis. CONCLUSIONS: Our patient's case suggests a role for staged IPC placement followed by VATS pleurodesis in patients with YNS pleural effusions complicated by pleural entrapment. This may also suggest a role for IPC placement in patients who are not currently surgical candidates without sacrificing the potential for more definitive treatment in the future. REFERENCE #1: Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis. 02 2017;12(1):42. doi:10.1186/s13023-017-0594-4 REFERENCE #2: Kurin M, Wiesen J, Mehta AC. Yellow nail syndrome: a case report and review of treatment options. Clin Respir J. Jul 2017;11(4):405-410. doi:10.1111/crj.12354 REFERENCE #3: Valdés L, Huggins JT, Gude F, et al. Characteristics of patients with yellow nail syndrome and pleural effusion. Respirology. Oct 2014;19(7):985-92. doi:10.1111/resp.12357 DISCLOSURES: No relevant relationships by Peter Le, source=Web Response No relevant relationships by Eric Sumner, source=Web Response

CHEST WALL MASS IN A PATIENT WITH RECURRENT PLEURAL EFFUSION

SESSION TITLE: Chest Infections 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Recurrent exudative pleural effusion often presents a diagnostic challenge. Undetected malignancy and indolent infections should be considered in the differential. We present one such case. CASE PRESENTATION: A 62 year old Caucasian male with severe COPD (FEV1 1.54 L or 49% predicted) presents for evaluation of dyspnea and productive cough. Further history is notable for 44 pack year smoking, cats at home, poor dental hygiene, and occupation as a truck driver.CXR is positive for left pleural effusion, with CT demonstrating moderate non-loculated pleural effusion. Thoracentesis reveals exudative fluid, negative cytology, stains, and culture including AFB/ fungal.At eight months follow up, he presents with a palpable, firm, left posterior chest wall mass. MRI demonstrates the palpable mass to be a lipoma. MRI also reveals an invasive 9x7x3 cm pleural based tissue mass in the left costophrenic sulcus infiltrating through the pleural space into the posterior chest wall. Chest CT done next day confirms large left sided pleural effusion with lingular and left lower lobe atelectasis. An irregular mass showing some central low density attenuation in the left paraspinous area measuring 33 x 40 mm was detected. PET/CT reveals large lobulated intense uptake abnormality in the same area with SUV of 8.7. Differential diagnoses included mesothelioma, pleural metastasis, and soft tissue sarcoma.Additional workup included CT guided needle aspiration and core biopsy of the lesion. Aspirate reveals acute and prominent histiocytic inflammation. Core biopsy demonstrates conspicuous sulfur granules displaying prominent Splendore-Hoeppli phenomenon. Tissue gram stain reveals numerous thin beaded, branching filamentous bacteria within these sulfur granules.He underwent thoracotomy with decortication and left pleurectomy. Loculated fluid collection demonstrated benign cytology with colonies of Gram positive and GMS positive filamentous bacteria morphologically consistent with Actinomycosis. No readily identifiable communication tract was found between the chest and the chest wall abscess.He was treated with penicillin for protracted period with CT chest showing complete resolution of pleural effusion 16 months later. DISCUSSION: This case highlights the fact that in cases of recurrent exudative pleural effusion in a setting of poor dental hygiene and COPD, Actinomycosis should be in the differential diagnosis. Penicillins remain the mainstay for treatment with protracted course needed for complete resolution. CONCLUSIONS: Indolent infections should be considered in the differential diagnosis of recurrent pleural effusion. Cutaneous masses/lump in the chest wall in association with pleural effusion should raise suspicion of Actinomycosis/Empyema necessitans. Reference #1: Choi H, Lee H, Jeong SH, Um S-W, Kown OJ, Kim H. Pulmonary actinomycosis mimicking lung cancer on positron emission tomography. Annals of Thoracic Medicine. 2017;12(2):121-124. https://doi.org/10.4103/1817-1737.203752. DISCLOSURES: No relevant relationships by Riju Dasgupta, source=Web Response No relevant relationships by Asok Dasgupta, source=Web Response No relevant relationships by Paresh Timbadia, source=Web Response No relevant relationships by James Uhlenbrock, source=Web Response

Retrospective study to evaluate the results of medical thoracoscopy in diagnosis of exudative pleural effusion at chest department El-Hussein university hospital in the period from July 2013 to July 2018

Background: Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space and intrathoracic structures. It enables taking pleural biopsies under direct vision, therapeutic drainage of effusions, and pleurodesis in one sitting. Persistent and recurrent exudative pleural effusions become common and thoracocentesis and blind pleural biopsy procedures do not give a definitive diagnosis in many patients. Therefore, thoracoscopy today remains the gold standard for these cases. In tuberculous pleuritis, the combined yield of histology and culture for rigid thoracoscopy was nearly 100%. Objective: This study was carried out to analyze our five years experience of medical thoracoscopy in the management of undiagnosed exudative pleural effusion at chest department El-Hussein University Hospital. Materials and Methods: All patients with undiagnosed exudative pleural effusion who underwent thoracoscopy during the period between July 2013 to July 2018 at Al Hussein University Hospital were included in the study. All patients were subjected to thorough history taking, clinical examination, routine laboratory investigations, pleural fluid analysis and medical thoracoscopy with multiple pleural biopsies. All patients data, thoracoscopy results and complications were recorded. Results: Thoracoscopy was successful for giving final diagnosis in 122 patients (84.13%) from total 145 patients. Malignancies reported in 113 patients (77.9%) of patients and TB reported in 6.2% of patients. Mesothelioma was the most common diagnosis in 67 patients(46.2%) Minor complications occurred only in 14 out of 145 patients (9.65%), 4 patients (2.8%) developed cellulitis, 8 patients (5.5%) developed surgical emphysema, and 2 patient (1.4%) developed bleeding. Conclusion: Medical thoracoscopy is an easy, safe procedure with high diagnostic sensitivity for pleural effusion of uncertain etiology.

Retrospective study to evaluate the results of medical thoracoscopy in diagnosis of exudative pleural effusion at chest department El-Hussein university hospital in the period from July 2013 to July 2018

Background: Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space and intrathoracic structures. It enables taking pleural biopsies under direct vision, therapeutic drainage of effusions, and pleurodesis in one sitting. Persistent and recurrent exudative pleural effusions become common and thoracocentesis and blind pleural biopsy procedures do not give a definitive diagnosis in many patients. Therefore, thoracoscopy today remains the gold standard for these cases. In tuberculous pleuritis, the combined yield of histology and culture for rigid thoracoscopy was nearly 100%. Objective: This study was carried out to analyze our five years experience of medical thoracoscopy in the management of undiagnosed exudative pleural effusion at chest department El-Hussein University Hospital. Materials and Methods: All patients with undiagnosed exudative pleural effusion who underwent thoracoscopy during the period between July 2013 to July 2018 at Al Hussein University Hospital were included in the study. All patients were subjected to thorough history taking, clinical examination, routine laboratory investigations, pleural fluid analysis and medical thoracoscopy with multiple pleural biopsies. All patients data, thoracoscopy results and complications were recorded. Results: Thoracoscopy was successful for giving final diagnosis in 122 patients (84.13%) from total 145 patients. Malignancies reported in 113 patients (77.9%) of patients and TB reported in 6.2% of patients. Mesothelioma was the most common diagnosis in 67 patients(46.2%) Minor complications occurred only in 14 out of 145 patients (9.65%), 4 patients (2.8%) developed cellulitis, 8 patients (5.5%) developed surgical emphysema, and 2 patient (1.4%) developed bleeding. Conclusion: Medical thoracoscopy is an easy, safe procedure with high diagnostic sensitivity for pleural effusion of uncertain etiology.

Current practice in management of exudative pleural effusions-a survey of American Association of Bronchology and Interventional Pulmonology (AABIP).

With increased availability of techniques to address pleural effusions including medical thoracoscopy (MT) and tunneled pleural catheter (TPC), we anticipate there has been an evolution in the practice pattern. We sought to evaluate the current practice patterns in the management of exudative pleural effusion in the interventional pulmonary (IP) community. A questionnaire was developed and was disseminated to all listed American Association of Bronchology and Interventional Pulmonology (AABIP) members. Survey addressed the approach to the management of recurrent exudative pleural effusions with emphasis on the roles of Semi-rigid and rigid thoracoscopy. Of 388 members who opened the survey, 165 (43%) completed it. The majority were interventional pulmonologists representing academic and private practice in the United States (US), with approximately one third of respondents from other countries. Almost two thirds (61%) of them perform thoracoscopy. For those who do perform thoracoscopy, 93% would perform thoracoscopy for recurrent undiagnosed exudate. Equal numbers perform rigid and semi-rigid thoracoscopy and 31 (44%) perform both procedures, there was no statistically significant difference. There was a slight preference for Semi-rigid thoracoscopy although opinion was skewed slightly in favor of rigid thoracoscopy when asked about diagnostic yield. TPCs play a large role in management patterns, sometimes without and sometimes after thoracoscopy, 59% of the respondents chose a TPC alone for the management of known malignant effusion, while a 16% would combine it with MT (P value <0.0001). Thoracoscopy is accepted as the diagnostic procedure of choice for undiagnosed exudative effusion. TPCs play a dominant role in management even when thoracoscopy is performed.

The role of medical thoracoscopy in the diagnosis of exudative pleural effusion at the Chest Department of Zagazig University Hospitals

Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space and intrathoracic structures. It enables taking pleural biopsies under direct vision, therapeutic drainage of effusions, and pleurodesis in one sitting. Persistent and recurrent exudative pleural effusions become common and thoracocentesis and blind pleural biopsy procedures do not give a definitive diagnosis in many patients. Therefore, thoracoscopy today remains the gold standard for these cases. In tuberculous pleuritis, the combined yield of histology and culture for rigid thoracoscopy was nearly 100%. The aim of the present study was to examine the diagnostic yield of medical thoracoscopy in patients with undiagnosed exudative pleural effusion. This study was carried out at the chest department of Zagazig University Hospitals in the period from October 2014 to October 2015. It included 36 patients with undiagnosed pleural effusion. All participants signed a written informed consent. The included patients were subjected to full history taking, clinical examination, plain chest radiograph, ultrasonography, computed tomography of the chest, and tuberculosis assessment. Diagnostic aspiration of pleural fluid was performed by using chemical, cytological, and bacteriological analyses. Closed pleural biopsy was carried out in patients with unhelpful pleural fluid analysis. Lastly, if the etiology remained unknown, thoracoscopy was carried out. The present study included 18 men and 18 women patients, with a mean age of 54.4±16.1 years. Dyspnea was the most common presenting symptom among the studied patients. Sixteen (72.2%) patients had moderate right-sided pleural effusion. The diagnostic yield of medical thoracoscopy among the studied patients was 80.6%. The histopathological yield of thoracoscopic pleural biopsies was as follows: 25 (69.4%) malignant cases, two (5.6%) patients with tuberculous pleuritis, one (2.8%) patient diagnosed with empyema, and another one (2.8%) with collagenic disease. There were seven (19.4%) patients who were not diagnosed. The post-thoracoscopic complications in this study occurred only in nine (25%) patients, which were minor complications in the form of surgical emphysema and prolonged air leak, wound infection, dislodged drain, trapped lung, and pain during the procedure. Medical thoracoscopy is a good diagnostic procedure for pulmonologists to evaluate undiagnosed pleural effusions.

Comparative study between the use of image guided pleural biopsy using abram’s needle and medical thoracoscope in diagnosis of exudative pleural effusion

IntroductionWhen cytology for pleural fluid is nondiagnostic, thoracoscopy or cutting-needle pleural biopsy or closed percutaneous needle biopsy using Abrams needle (ANPB) can be used to obtain tissue samples. Ultrasound guidance for biopsies performed with an Abrams needle can be used to increase the diagnostic yield of this traditional method. Aim of the studyThis study aimed to compare the diagnostic validity of ANPB under ultrasound guidance (US-ANPB) with that of medical thoracoscopy in patients with pleural effusion. Methods30 patients with recurrent exudative pleural effusion of undetermined etiology that have undergone cytologic analysis and could not be diagnosed were included in the study and divided into 2 groups, Group I who underwent medical thoracoscopy for diagnosis (n=15) and Group II who underwent ultrasound-guided Abrams needle biopsy for diagnosis (n=15). Comparison between the two groups was drawn in terms of diagnostic sensitivity and complications associated with the methods used. ResultsThe sensitivity and specificity of diagnostic thoracoscopy in group I was 100% & 100% respectively. The sensitivity and specificity of ultrasound-guided Abrams needle in group II was 100% & 100% respectively. No difference was identified between the sensitivities of the two methods. Complications of both groups were of low rate and tolerable. ConclusionIf US guidance can be used for biopsies performed with an Abrams needle, the yield of this traditional method can be increased. The use of US-guided Abram’s needle pleural biopsy is simple, safe and well tolerated.

Recurrent Exudative Pleural Effusion After Chest Trauma: A Case Series

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: It is estimated that up to 15% of patients with a pleural effusion do not have a diagnosis despite a complete evaluation. A high percentage of these idiopathic effusions turn out to be malignant if followed up. This has led to a more aggressive approach with medical thoracoscopy and pleural biopsies. There are only a few case reports in the literature of patients with persistent pleural effusion after mechanical trauma and thus their optimal management has not yet been defined. METHODS: We retrospectively collected information on adult patients at our institution, including 5 cases that had chronic non-specific pleuritis after a mechanical fall. All of these patients were initially treated as inpatients and were subsequently followed in the outpatient clinic until resolution of their pleural effusion. We collected data on their comorbidities, initial and subsequent pleural fluid analysis, number of thoracentesis, the treatment underwent as well as outcome. RESULTS: A total of 5 patients between 61 and 88 years old (median 72 years) had recurrent pleural effusion after chest trauma. There was no evidence of malignancy or infection in any of these patients defined as negative cultures, negative cytology for malignant cells and a negative flow cytometry. All effusions were considered to be exudates according to Light’s modified criteria. Three of our patients underwent tunneled pleural catheter placement (median length of time in place 30 days). Three of our patients underwent medical thoracoscopy and pleural biopsy. All three biopsies showed no evidence of malignancy or infection as well. Two of our patients underwent pleurodesis with talc pouldrage, only one of these being successful. All 5 patients had resolution of their pleural effusion. CONCLUSIONS: Patients that present with a recurrent exudative pleural effusion after chest trauma without evidence of malignancy or infection tend to resolve spontaneously over time. The extent of diagnostic and therapeutic procdures done in these patients has not been defined yet. CLINICAL IMPLICATIONS: In these patients, conservative management with close follow-up might be a better option than medical thoracoscopy and pleurodesis. However, the best treatment and other factors that predict which patients benefit the most from an aggressive approach are yet to be determined. DISCLOSURE: The following authors have nothing to disclose: Alejandro Folch, Adnan Majid, Daniel Alape, Jose Cardenas-Garcia, Christopher Manley, George Cheng, Erik Folch No Product/Research Disclosure Information

A case of recurrent pleural effusion: Can we think beyond tuberculosis and malignancy?

Pleural effusion can occur due to a variety of causes such as infectious, neoplastic, inflammatory, autoimmune, traumatic, etc. Recurrent pleural effusions have always been a diagnostic challenge. Here, we present a case of recurrent exudative pleural effusion in a male patient, which was the first clinical manifestation of rheumatoid arthritis. Of note was the absence of articular involvement at the onset of the disease. The low glucose concentration, low pH and low C4 level in the pleural fluid were the most valuable findings to distinguish it from tuberculous and malignant pleural effusions. Pleural biopsy also helped in making such a distinction. Thus, in a patient with recurrent pleural effusion, rheumatoid etiology should also be kept in mind as a differential diagnosis.