Transudative Effusion Research Articles

A novel interleukin 36 gamma for diagnosing and differentiating malignant from infectious pleural effusion

Background Pleural effusions can be caused by various diseases, making their diagnosis challenging. Light’s criteria are often used to distinguish transudative and exudative effusions. Exudative effusions have a more complex etiology, including parapneumonic, tuberculous, and malignant effusion. Objectives The main objective of this study was to evaluate the effectiveness and sensitivity of Interleukin 36 gamma (IL-36γ) as a diagnostic marker for differentiating between malignant and infectious pleural effusions. Methods The study involved 100 patients with pleural effusion. Patients were categorized into five groups based on their final diagnosis. An ELISA technique was used to quantitatively measure the levels of pleural fluid IL-36γ. Results The results showed that pleural IL-36γ levels were higher in tuberculous pleural effusion compared with malignant, transudative, and uncomplicated pleural effusion. In contrast, pleural IL-36γ levels were higher in complicated pleural effusion compared with tuberculous, malignant, transudative, and uncomplicated pleural effusion. Conclusion Based on the study’s findings, it was concluded that pleural IL-36γ is a novel biomarker that can be used to diagnose and differentiate malignant pleural effusion from infectious pleural effusion.

Constrictive pericarditis in a patient with fiberglass lung disease: a case report

BackgroundFiberglass has a larger aerodynamic diameter and is less likely to be inhaled into the lungs. Further, it will be cleared even if it is mechanically broken into smaller pieces and inhaled into the lungs. Fiberglass lung disease has been well documented if long term exposure but was thought reversible and would not cause severe diseases. The diagnosis of fiberglass lung disease depends on exposure history and histopathological findings. However, the exact occupational exposure history is often difficult to identify because mixed substance exposure often occurs and fiberglass disease is not as well-known as asbestosis.Case presentationA 66-year-old man had unexplained transudative pericardial effusion requiring pleural pericardial window operation twice at another medical center where asbestosis was told because of his self-reported long-term asbestosis exposure and the histopathological finding of a ferruginous body in his lung. Constrictive pericarditis developed two years later and resulted in congestive heart failure. Radical pericardiectomy combined with lung biopsy was performed following chest computed tomography imaging and the transudative nature of pericardial effusion not compatible with asbestosis. However, the histopathologic findings of his lung and pericardium at our hospital only showed chronic fibrosis without any asbestosis body. The patient’s lung was found to be extremely fragile during a lung biopsy; histopathologic specimens were reviewed, and various fragments of fiberglass were found in the lung and pericardium. The patient’s occupational exposure was carefully reevaluated, and he restated that he was only exposed to asbestosis for 1–2 years but was heavily exposed to fiberglass for more than 40 years. This misleading exposure history was mainly because he was only familiar with the dangers of asbestos. Since most fiberglass lung diseases are reversible and the symptoms of heart failure resolve soon after surgery, only observation was needed. Ten months after radical pericardiectomy, his symptoms, pleural effusion, and impaired pulmonary function eventually resolved.ConclusionFiberglass could cause inflammation of the pericardium, resulting in pericardial effusion and constrictive pericarditis, which could be severe and require radical pericardiectomy. Exact exposure history and histopathological examinations are the key to diagnosis.

ERS Statement on Benign Pleural Effusions in Adults.

The incidence of non-malignant pleural effusions (NMPE) far outweighs that of malignant pleural effusions (MPE) and is estimated to be at least 3-fold higher. These so called "benign" effusions do not follow a "benign course" in many cases, with mortality rates matching and sometimes exceeding that of MPEs. In addition to the impact on patients, healthcare systems are significantly affected, with recent US epidemiological data demonstrating that 75% of resource allocation for pleural effusion management is spent on NMPEs (excluding empyema). Despite this significant burden of disease, and by existing at the junction of multiple medical specialties, reflecting a heterogenous constellation of medical conditions, NMPEs are rarely the focus of research or the subject of management guidelines. With this ERS Taskforce, we assembled a multi-specialty collaborative across eleven countries and three continents to provide a Statement based on systematic searches of the medical literature to highlight evidence in the management of the following clinical areas: a diagnostic approach to transudative effusions, heart failure, hepatic hydrothorax, end stage renal failure, benign asbestos related pleural effusion, post-surgical effusion and non-specific pleuritis.

Unveiling Insights: A Comprehensive Review of the Role of Medical Thoracoscopy in Pleural Effusion Assessment.

Pleural effusion, characterized by abnormal fluid accumulation in the pleural cavity, poses diagnostic and therapeutic challenges across various medical conditions. This comprehensive review explores the role of medical thoracoscopy in assessing pleural effusions, providing insights into its historical context, procedural intricacies, diagnostic performance, safety considerations, and clinical applications. Medical thoracoscopy, a minimally invasive endoscopic procedure, offers advantages such as high diagnostic yield, therapeutic interventions, real-time assessment, and a minimally invasive nature. The review critically analyzes the procedure's advantages and disadvantages, including technical expertise, risk of complications, resource intensity, and patient selection criteria. Comparative analyses with alternative diagnostic modalities highlight the unique benefits of medical thoracoscopy in specific clinical scenarios. The diagnostic yield of medical thoracoscopy is examined, considering sensitivity and specificity in various contexts. Patient selection criteria, complications, and safety measures are discussed, emphasizing the importance of careful consideration in integrating thoracoscopy into clinical practice. The review further explores its clinical applications, including differentiating exudative and transudative effusions, identifying specific etiologies, and its role in treatment planning. In conclusion, medical thoracoscopy emerges as a valuable tool in the comprehensive management of pleural effusions, offering a nuanced approach to diagnosis and treatment. The evolving landscape of diagnostic modalities underscores the continued significance of medical thoracoscopy and potential advancements in the field.

Cardiac related pleural effusions: a narrative review.

Pleural effusions (PEs) are commonly seen in various pathologies and have a significant impact on patient health and quality of life. Unlike for malignant PEs, non-malignant PEs (NMPEs) do not have well-established guidelines. Much of the evidence base in this field is from a handful of randomised controlled trials (RCTs) and the majority are from retrospective cohort analyses and cases series. Cardiac related PEs fall within the entity of NMPEs and the aim of this narrative review is to gather the existing evidence in the field of congestive heart failure (CHF), pericarditis and post-cardiac injury syndrome (PCIS). This narrative review investigates the pathophysiology, diagnostic criteria and treatment options for the various cause of cardiac related PEs. This narrative review is based on a comprehensive literature search analysing RCTs, prospective and retrospective cohort analyses and published case series. CHF related PEs have a substantial mortality rate and carry a worse prognosis if the PEs are bilateral and transudative in nature. Light's criteria have often shown to misclassify transudative effusions in CHF (pseudo-exudates) and hence measuring serum-pleural albumin gradient is an invaluable tool to accurately identify transudates. Elevated serum and pleural N-terminal pro-B type natriuretic peptide (NT-proBNP) has shown increasing evidence of correctly identifying PEs secondary to CHF. However, they should be considered with the pre-test probability of CHF. Therapeutic thoracentesis and indwelling pleural catheter (IPC) placement may be necessary if medical management has failed. PEs can also occur secondary to pericarditis and are often small, bilateral and exudative. PCIS also results in PEs and are commonly seen in post-coronary artery bypass graft (CABG) surgery. Both entities need management of the underlying cause first, but in cases where PEs are refractory, individualised pleural interventions may be necessary. This comprehensive narrative review provides valuable insights into the aetiology, diagnosis and management of PEs secondary to CHF, pericarditis and PCIS. The aim is to enhance the clinicians' knowledge of this complex and controversial topic to improve patient care of cardiac-related PEs. Ongoing trials in this field will be able to provide valuable insights.

Hepatic hydrothorax.

Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.

Characterization of Markers in Blood Tests of Patients With Pleural Effusion and Their Correlation to Different Etiologies.

To investigate the etiology of pleural effusion, a variety of examinations are performed, including invasive ones: Thoracentesis is an invasive procedure to remove fluid or air from the pleural cavity for diagnostic or therapeutic purposes. Until now, there are no blood markers that can help us diagnose the type of pleural effusion without the need for pleural puncture or drainage. The aim of this study was to investigate the relationship and the utility of the new inflammatory markers taken from complete blood count (CBC) to differentiate between the various types of pleural effusion before the invasive procedure decision. This is an observational retrospective study. Data was collected from medical records of patients aged 18-90 admitted in Ziv Medical Center, Safed, Israel that were diagnosed with pleural effusion from 2013 to 2019. Of those patients, of whom inflammatory markers from blood counts and thoracentesis results were obtained, the outcomes were compared with the diagnosis type of pleural effusion. This study involved 391 patients, 256 suffered from exudate type effusion, their median age was 72 years, while 135 suffered from transudate effusion, their median age was 80 years. Those with exudate effusion had higher levels of CRP, platelets, neutrophils, and lymphocytes in blood, whereas those with transudate effusion had higher levels of MPV and RDW in blood. Other blood markers such as NLR and PLR were not statistically significant, but were also higher in the blood of patients with exudate effusion. An evaluation of simple and inexpensive measurements of blood count such as platelets, neutrophils, lymphocytes, MPV, RDW may provide insight into the etiology of pleural effusion.

A-111 There is More to Diluting Icterus Interference than Meets the Eye

Abstract Background Total protein is measured in serum and body fluids as part of routine evaluations of general nutritional status and differentiating exudative and transudative effusions. Spectral interference thresholds for bilirubin (e.g., icterus) is set by assay manufacturers to prevent inaccurate results from being reported. The Roche Cobas serum total protein assay package insert states no significant interference from bilirubin up to an icterus (I) index of 20. Body fluids tend to have lower total protein concentrations; therefore, thresholds were derived during prior validation studies and set to I = 10, a threshold that is exceeded routinely. Laboratories can mitigate some interferences by recollecting (e.g., hemolysis) or ultracentrifuging (e.g., lipemia) specimens. Serial dilutions are another option used; however, it is imperative that the laboratory understands the mechanism of interference and can demonstrate that it is mitigated by sample dilution. The aim of this study was to investigate whether bilirubin interference can be mitigated by sample dilution in pleural fluid, peritoneal fluid, and serum specimens. Methods Residual clinically ordered pleural fluid (n = 3), peritoneal fluid (n = 3), and serum (n = 3) samples submitted for protein testing were split into two equal volume aliquots with concentrations ranging 2.7 to 4.3 g/dL in pleural fluids, 3.9 to 5.4 g/dL in peritoneal fluids, and 3.8 to 11.0 g/dL in serum. One aliquot was spiked (<10% by volume) with a bilirubin conjugate solution (∼1000 mg/dL) to surpass the icterus index threshold (spiked). The second aliquot was spiked with an equal volume of 0.9% saline (control). Total protein was measured on the Roche Cobas c701 instrument in both samples to calculate difference (Spiked-Control). The mean(SD) difference was calculated for each sample type. Each spiked sample was serially diluted (2-fold, 4-fold and 8-fold) with 0.9% saline. Total protein was measured for each diluted sample. Mean(SD) difference was calculated (DilutedX-Control), where X = 2-fold, 4-fold, 8-fold. Linear regression analysis was performed by plotting the measured (x-axis) vs expected (y-axis) total protein concentration. Slope, y-intercept, and R2 were determined from serially diluted samples where the expected concentrations were derived using the spiked concentration to replicate the practice of diluting an icteric sample. Results Bilirubin spiking (average icterus index = 33.5) into pleural fluid, peritoneal fluid, and serum, respectively demonstrated mean(SD) bias (g/dL) = −1.0(0.2), −0.9(0.0), and −0.7(0.0). Subsequent 2-fold dilution demonstrated mean(SD) bias (g/dL) = −1.0(0.2), −1.0(0.0), and −0.8(0.1), 4-fold dilution with mean(SD) bias (g/dL) = −1.1(0.2), −1.0(0.0), and -1.0(0.1), and 8-fold dilution with mean(SD) bias (g/dL) = −1.3(0.2), −1.0(0.0), and −1.4(0.1). Diluting pleural, peritoneal, and serum samples, respectively spiked with bilirubin resulted in slope = 0.99, 1.00, and 0.99; y-intercept = 0.04, 0.01, and 0.07; R2 = 0.99, 0.99, 0.99. Conclusion The dilutions exhibited a linear dilution response, however the dilution results never returned to baseline (non-spiked) concentration. Laboratories should exercise caution when conducting serial dilutions to diminish bilirubin interference in samples when measuring total protein as the mechanism of interference does not appear to be reversible by dilution. This behavior was demonstrated in both body fluids and serum.

DIAGNOSTIC YIELD OF ADA IN TUBERCULAR PLEURAL EFFUSION

Objective: Tuberculosis (TB) is one of the most common causes of pleural effusion in developing countries like India encountered by medical professionals globally. The present study was carried out to evaluate the diagnostic yield of pleural fluid adenosine deaminase (ADA) in tubercular pleural effusion. Methods: This descriptive study was conducted in the Department of Medicine and Pulmonary Medicine, Saheed Laxman Naik Medical College and Hospital from January 1, 2019, to March 31, 2020. All patients >15 years of age with lymphocytic exudative pleural effusion and pleural effusion associated with smear/CBNAAT-positive pulmonary TB patients, who attended the department during the study period, were included in the study. A case was taken as tuberculous employing defined criteria. Patients with transudative effusions, post-traumatic effusions, pregnant and lactating women, and persons on drugs that affect ADA activity like interferon alpha, deoxycoformycin, ribavirin, and viramidine were excluded from the study. Results: The mean ADA value was 93.93±44.63 IU/L among the cases with tuberculous effusion and 56.36±62.81 IU/L in the non-tuberculous effusion group. At a cutoff value of 50.7 IU/L, pleural fluid ADA showed a sensitivity of 87% and a specificity of 74% in diagnosing TB etiology. Conclusion: The mean ADA values were significantly higher in tuberculous pleural effusions when compared to the non-tuberculous group. When this was combined with pleural fluid lymphocyte dominancy, the specificity increased to 96%. Pleural fluid ADA values have a strong association with age. ADA estimation is a simple, cost-efficient, and diagnostically helpful investigation with high reliability.

Clinical Significance of Pleural Lactate Measurement in Critically Ill Patients with Parapneumonic Pleural Effusion.

Pleural fluid pH measurement is recommended for tube thoracostomy decisions in complicated parapneumonic pleural effusions. However, pleural fluid pH may be affected by blood pH in critically ill patients with common systemic acid-base disorders. We aimed to investigate the use of pleural fluid lactate to distinguish culture-positive parapneumonic effusions from other pleural effusions. This prospective observational study included 121 eligible patients (51 female and 70 male). All patients with pleural effusion who underwent thoracentesis were assessed. Pleural fluid lactate was measured by a blood gas analyzer. Of the 121 patients, 30 (24.8%) were transudate and 91 (75.2%) were exudate. Of the 91 patients with exudative pleural effusion, 61 were diagnosed as culture-negative parapneumonic, 13 as culture-positive parapneumonic, 9 as malignant, and 8 as other exudative effusion. There was a strong positive linear association between serum pH and pleural fluid pH (R = 0.77, P < .001). The post hoc tests for pleural fluid lactate revealed there was a significant difference between culture-positive parapneumonic versus culture-negative parapneumonic groups (P = .004), culture-positive parapneumonic versus transudative effusion groups (P < .001), culture-negative parapneumonic versus transudative effusion groups (P = .008) and lastly; malignant effusion versus transudative effusion groups (P = .001). Receiver operating characteristics curve analysis for culture-positive parapneumonic indicated a cutoff of 4.55 mmol/L for pleural fluid lactate to have a sensitivity of 76.9% and a specificity of 84.3% (positive predictive value: 37%, negative predictive value: 96.8%). A cutoff of 4.55 mmol/L of pleural fluid lactate can be used as a useful tool to distinguish culture-positive parapneumonic effusions from other effusions in critically ill patients.

Comparison of the Efficacy of Light's Criteria With Serum-Effusion Albumin Gradient and Pleural Effusion Glucose.

Introduction While Light's criteria exhibit high sensitivity (98%) in detecting exudative pleural effusions, the capacity to rule out transudates is relatively limited. A previous study showed thatapproximately one-fifth of patients with congestive cardiac failure on diuretics also met the criteria for exudate. This study compares the diagnostic value of Light's criteria, the serum-effusion albumin gradient (SEAG) method, and pleural effusion glucose levels for accurately categorizing pleural effusion as transudate or exudate. Methodology We conducted this cross-sectional observational study in a tertiary care hospital in Ahmedabad, India. Two hundred patients with pleural effusion undergoing thoracentesis were included. Laboratory parameters measured in pleural fluid analysis included pleural fluid protein, pleural fluid lactate dehydrogenase (LDH), pleural fluid albumin, and pleural fluid glucose. Serum protein, serum LDH, and serum albumin were also collected. Mean values and standard deviations (SDs) were calculated for analysis. Results A significant difference was observed in the mean value of exudative and transudative effusions for each parameter (pleural fluid protein/serum fluid protein ratio, pleural fluid LDH/serum fluid LDH ratio, pleural fluid LDH, SEAG, and pleural fluid glucose) (P < 0.001). Light's criteria demonstrated the highest efficacy in diagnosing exudates (accuracy = 97.50%), while SEAG demonstrated the highest efficacy in diagnosing transudates (accuracy = 97.50%). Conclusion SEAG is an effective alternative diagnostic tool for identifying transudates misclassified by Light's criteria. Its use can contribute to prompt diagnosis and timely treatment of patients with pleural effusion, improving patient outcomes.

Lymphoscintigraphy findings in patients with chylothorax: influence of biochemical parameters

BackgroundChylothorax is a condition that can be challenging to diagnose due to its nonspecific clinical presentation. Several biochemical parameters of chylous pleural effusion have been identified as important indicators for the diagnosis of chylothorax. Lymphoscintigraphy is utilized to assess chylothorax and determine the location of chyle leakage. The present study aimed to evaluate the correlation between the biochemical parameters of chylous pleural effusion and 99mTc-dextran (99mTc-DX) lymphoscintigraphy in diagnosing chylothorax.Material and methodsA total of 120 patients were enrolled in the study, 83 of the patients with unilateral chylothorax, and 37 with bilateral chylothorax. All patients underwent both 99mTc-DX lymphoscintigraphy and pleural effusion laboratory analysis. The 99mTc-DX lymphoscintigraphy images were categorized as positive or negative groups based on the presence or absence of abnormal radioactive tracer accumulation in the thorax, respectively. The biochemical parameters of the two groups were subsequently compared.ResultsAmong these patients, 101 (84.17%) had exudative effusions, while 19 (15.83%) had transudative effusions, as determined by the levels of pleural effusion protein, lactate dehydrogenase and cholesterol. Abnormal tracer accumulation in thorax was observed in 82 patients (68.33%). Our findings indicated that lymphoscintigraphy results were not associated with exudative and transudative chylothorax (P = 0.597). The lymphoscintigraphy positive group displayed significantly higher levels of pleural effusion triglyceride and pleural effusion triglyceride/serum triglyceride ratio in all biochemical parameters, compared to the negative group (P = 0.000 and P = 0.005). We identified cutoff values of 2.870 mmol/L for pleural effusion triglycerides and 4.625 for pleural effusion triglyceride/serum triglyceride ratio, respectively, which can facilitate differentiating the positive and negative cases on lymphoscintigraphy.ConclusionLymphoscintigraphy technique is a dependable diagnostic tool for the qualitative assessment of chylous pleural effusion. Higher pleural effusion triglyceride level and pleural effusion triglyceride/serum triglyceride ratio indicate a positive result in patients with chylothorax on lymphoscintigraphy, with the cutoff values of 2.870 mmol/L and 4.625 aiding in the diagnosis.

Could pleural fluid lactate level have an added diagnostic value in para pneumonic effusion?

Abstract Background Pleural effusion is the accumulation of fluid in the pleural space, can be classified into transudative and exudative effusion. A parapneumonic effusion is a pleural effusion that forms adjacent to pneumonia. Para pneumonic effusion can be sub-typed into uncomplicated and complicated effusion. The aim of our work was to identify accuracy of pleural fluid lactate level to discriminate transudative from exudative effusion and uncomplicated from complicated parapneumonic effusion. Methods Thoracocentesis was done with subsequent evaluation of pleural fluid PH, protein, LDH, glucose and lactate.Also, gram stain, microbiological cultures, cytological examination was performed. Medical thoracoscopy was done whenever indicated. Results Our study included 52 males and 38 females with mean age 57.14 ± 11.69 years. Transudative effusions were detected in 22 patients (24.4%). Parapneumonic effusions accounted for 39 cases (43.3%), of these 23 cases were uncomplicated and 16 cases were complicated. The median pleural fluid lactate level in exudative effusion was significantly higher than transudative effusion (P value&lt;0.001), in complicated parapneumonic effusion was significantly higher than uncomplicated parapneumonic effusion (P value&lt;0.001). Pleural fluid lactate cut-off value of 2.68 mmol/l or more yielded 97% sensitivity, 90.9% specificity for detection of exudative effusion (Auc 0.968). A cut of value of 6.22 mmol/l had 87.5% sensitivity, 91.3% specificity for detection of complicated parapneumonic effusion. (Auc 0.971). Conclusion The pleural fluid lactate level has a high accuracy to discriminate transudative from exudative pleural effusion and uncomplicated from complicated parapneumonic effusion.

ROLE OF COMBINED PLEURAL FLUID CHOLESTEROL AND TOTAL PROTEIN FOR DIFFERENTIATING EXUDATIVE FROM TRANSUDATIVE PLEURAL EFFUSION IN A TERTIARY CARE CENTRE-AN OBSERVATIONAL STUDY

Introduction:Identifying whether the pleural effusion is exudative or transudative is the first step in making a diagnosis.Lights criteria, have been accepted more widely than any other criteria for discriminating between transudative and exudative effusions.But incorrectly labels 15–20% of transudative effusions as exudates. We investigate if comparable results may be obtained using pleural fluid cholesterol and pleural fluid total protein. Objectives:To compare combined pleural fluid cholesterol and pleural fluid total protein with Light’s criteria in differentiating exudative and transudative effusion and find its significance. Methods:This is a hospital based cross sectional study conducted in the Department of Respiratory medicine, GMC, Kannur over a period of one year on 120 patients who presented with pleural effusion,and fulfilling the inclusion and exclusion criteria. The pleural fluid sample obtained from each patient was taken for analysis,and nature of effusion by using Light’s criteria and combined pleural fluid cholesterol+total protein was noted. The final diagnosis based on clinical diagnosis along with HPR and/or culture was set as the gold standard. Mc Nemar’s Chi-square test was applied to compare Light’s criteria and Pleural fluid cholesterol+total protein with gold standard.The diagnostic parameters like sensitivity, specificity, PVP, PVN and accuracy of Light’s criteria and pleural fluid cholesterol+ total protein to predict exudates were estimated. Results: We found out that there is significant difference in the classification of transudate and exudate by Light’s criteria with respect to gold standard (p-value 0.001). Kappa value 0.722 shows a significant substantial agreement between Light’s criteria and gold standard test (p-value &lt;0.001). The sensitivity ,specificity, PVP,PVN and accuracy of Light’s criteria to predict exudate was 100.00%,63.33%, 89.11%,100.00%, and 90.83% respectively. Also, there is significant difference in the classification of transudate and exudate by Pleural fluid cholesterol+total protein with respect to gold standard (p-value 0.031). Kappa value 0.875 shows a significantly almost perfect agreement between pleural fluid Cholesterol+Total protein and gold standard test (p-value &lt;0.001).The sensitivity, specificity, PVP,PVN and accuracy of Pleural fluid Cholesterol+Total protein to predict exudate was 93.33%, 100.00%, 100.00%,83.33%, and 95.00% respectively. Conclusion: As compared to Light’s criteria, Pleural fluid cholesterol+total protein shows a high agreement with gold standard to distinguish exudative and transudative effusion and can be used as an alternative to Light’s criteria.

The laboratory investigation of pleural fluids: An update based on the available evidence.

Selecting appropriate laboratory tests based on available evidence is central to improve clinical effectiveness and impacting on patient outcome. Although long studied, there is no mutual agreement upon pleural fluid (PF) management in the laboratory context. Given the experienced confusion about the real contribution of laboratory investigations to guide clinical interpretation, in this update, we tried to identify useful tests for the PF analysis, aiming to unravel critical points and to define a common line in requesting modalities and practical management. We performed a careful literature review and a deepened study on available guidelines to finalize an evidence-based test selection, intended for clinicians' use to streamline PF management. The following tests depicted the basic PF profile routinely needed: (1) abbreviated Light's criteria (PF/serum total protein ratio and PF/serum lactate dehydrogenase ratio) and (2) cell count with differential analysis of haematological cells. This profile fulfils the primary goal to determine the PF nature and discriminate between exudative and transudative effusions. In specific circumstances, clinicians may consider additional tests as follows: the albumin serum to PF gradient, which reduces exudate misclassification rate by Light's criteria in patients with cardiac failure assuming diuretics; PF triglycerides, in differentiating chylothorax from pseudochylothorax; PF glucose, for identification of parapneumonic effusions and other causes of effusion, such as rheumatoid arthritis and malignancy; PF pH, in suspected infectious pleuritis and to give indications for pleural drainage; and PF adenosine deaminase, for a rapid detection of tuberculous effusion.

Commentary on A Patient with Third-Space Fluid Loss.

This is an interesting clinical case highlighting the value of body fluid testing to assist in diagnosing a complex patient presenting with multiple effusions. The clinical presentation of unilateral pleural effusion is usually more suggestive of exudative causes, although bilateral effusion with right-side predominance is observed in transudative effusions. Bilateral leg swelling is observed more often with transudates, such as those caused by heart or liver failure (1). Severe hypoalbuminemia is frequently caused by renal failure associated nephrotic syndrome and/or end stage liver failure associated with reduced synthetic output. Renal and liver impairment were inconsistent with clinical findings until the globin predominance prompted protein electrophoresis, which returned a diagnosis of myeloma as an explanation for severe hypoalbuminemia. It is possible that severe hypoalbuminemia may have contributed to the transudative pleural effusion as well as ascites. The successful chemotherapeutic treatment for myeloma resolved the ascites and presumably the pleural effusion as serum albumin normalized. Lack of measurement of serum or plasma NT-ProBNP makes heart failure a questionable contributor to the transudative effusion, and follow-up may be warranted posttreatment to definitively rule out cardiac disease.

What is your diagnosis? Perineal swelling in a dog.

What is your diagnosis? Perineal swelling in a dog.

Bilateral Aspiration of Pleural Fluid in a Case of Contarini Syndrome

Contarini syndrome refers to the presence of bilateral pleural effusions with different characteristics resulting from distinct aetiologies on each side. The syndrome was named after Francesco Contarini, the 95th Doge of Venice, who had right-sided transudative effusion possibly due to heart failure, and left-sided exudative effusion due to parapneumonic effusion. While bilateral pleural effusions typically exhibit similar characteristics and are secondary to the same underlying cause, such as heart failure or malignancy, there have been rare reports of bilateral effusions with different characteristics. In this case report, we present the case of a 53-year-old female with known breast carcinoma who presented with right-sided exudative pleural effusion and left-sided transudative pleural effusion, each with distinct aetiologies, thus establishing Contarini syndrome. This report highlights the importance of considering the possibility of two separate aetiologies for bilateral pleural effusions, which should not be overlooked in clinical practice

Chylothorax in the Setting of Lung Malignancy.

Chylothorax refers to chyle within the pleural space, which frequently arises from an interruption in the thoracic duct or because of reduced lymphatic drainage. Pleural fluid that is white/milky in appearance, with a triglyceride concentration of greater than 110 mg/dL, strongly supports the diagnosis of chylothorax. Chylothorax is nearly always exudative. Transudative chylothorax is extremely rare and typically presents due to a secondary cause, such as liver cirrhosis, nephrotic syndrome, or congestive heart failure. We present a case of chylothorax that occurs in the setting of lung adenocarcinoma. A 65-year-old African American man with a past medical history of metastatic right lung adenocarcinoma presented with dyspnea and palpitations. He denied fever, orthopnea, and paroxysmal nocturnal dyspnea. Therapeutic drainage of the left pleural effusion resulted in 650 mL of milky-white fluid. Pleural fluid analysis demonstrated a triglyceride concentration of 520 mg/dL, a pleural/serum protein ratio of 0.41, a pleural/serum lactate dehydrogenase (LDH) ratio of 0.26, a total pleural LDH of 127 IU/L, and a cholesterol level of 58 mg/dL. This effusion can be classified as transudative as per Light's criteria and exudative as per Heffner's and pleural cholesterol criteria. A subsequent pleural fluid cytology found malignant cells consistent with lung adenocarcinoma. Malignancy is the most common cause of nontraumatic, exudative chylothorax. Light's criteria misinterpret about 25% of transudative effusions as exudative. Therefore, to minimize this error, a combination of the 3-criterial consideration is ideal.

Diagnostic role of different biochemical parameters in pleural effusion

A pleural effusion, an excessive accumulation of fluid in the pleural space, indicates an imbalance between pleural fluid formation and removal. For diagnosing and treatment plan, pleural effusions have to be classified into transudate and exudate. The aim of present study was to analyze various biochemical parameters (LDH, pH, Glucose, Triglycerides, Cholesterol, Creatinine, Amylase and ADA) in pleural fluid and to correlate these Biochemical parameters with diagnosis of the patients. The study was a hospital based descriptive study. The study was conducted over a period of one year on 100 samples. Total 100 samples were enrolled in the study. Both serum and pleural fluid samples were collected and quantitatively analyzed using semi-automated analyzer. The results of the present study shows thatThe Mean±SD of concentration of glucose in pleural fluid was 65.69±14.13 mg/dl, total protein 3.53±1.53g/dl, albumin 1.64±0.85g/dl, cholesterol 58.9±13.05mg/dl, triglycerides 68.7±10.47mg/dl, creatinine 1.73±0.96mg/dl, amylase 49.56±17.78IU/L, LDH 299.82±65.46 U/L and ADA was 49.56±17.78U/L.It was concluded that Biochemical parameters play important role in diagnosing Pleural effusions. These markers when used collectively their diagnostic efficacy is greatly increased. The SEAG is superior to Light's criteria in identifying the transudative effusions. It is also observed that Light's criteria identified exudative effusions better than SEAG.