Unilateral Pleural Effusion Research Articles

Pleural effusion caused by Trichinella spiralis infection: two case reports

BackgroundTrichinosis is a worldwide food-borne zoonotic parasitic disease, which is mainly obtained by ingesting undercooked meat containing infected larvae. The purpose of our article is to introduce and discuss two rare cases of pleural effusion caused by Trichinella spiralis.Case presentationHere we described two male patients who presented to the respiratory department of our hospital with a massive unilateral pleural effusion, their serum eosinophils were in the normal range, laboratory serological tests revealed that Trichinella spiralis IgG antibody was positive. After the oral administration of antiparasitic drugs, the pleural effusion of two patients was completely absorbed.ConclusionBoth patients were diagnosed with Trichinosis complicated with pleural effusion, which is very rare in the clinic and easy to be misdiagnosed because of normal eosinophils.

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.

IgG4-related eosinophilic pleural effusion: a case report

BackgroundThe diagnosis of unilateral eosinophilic pleural effusion (EPE) is difficult, especially for the elderly. IgG4-related disease (IgG4-RD) is a rare cause of EPE.Case presentationAn 81-year-old man was admitted to the hospital for dyspnea due to right pleural effusion. Laboratory examination shows elevated IgG4 and eosinophils in both serum and pleural fluid. The patient was diagnosed with IgG4-RD by video-assisted thoracoscopy and pleural biopsy. We found no evidence of other organ involvement except for the EPE and history of prurigo. He was treated with prednisolone 40 mg daily orally and pleural effusion decreased significantly.ConclusionIgG4-RD should be considered in the differential diagnosis of EPE in the elderly. High effusion IgG4 concentration may be an indication of IgG4-related pleural lesions.

Antiphospholipid Syndrome Complicated by Unilateral Pleural Effusion and Deep Vein Thrombosis: A Case Report

Antiphospholipid Antibodies (APLA) are autoantibodies directed against phospholipid-binding proteins. The development of thromboses in veins/arteries or the incidence of maternal morbidity, particularly miscarriages, in the presence of APLA constitutes Antiphospholipid Syndrome (APS). These Antiphospholipids (APLs) include antibodies against two glycoproteins, anticardiolipin antibodies, and Lupus Anticoagulant (LA). APLs are a diverse group of autoantibodies that have been linked to thrombus development, elevated maternal morbidity and mortality, and other symptoms that collectively constitute APS. Approximately half of APS cases are secondary disorders, while the remaining cases are autoimmune co-morbidities such as Systemic Lupus Erythematosus (SLE). This multisystem disorder mainly causes venous and arterial thrombosis and can also manifest as cutaneous, pulmonary, renal, and haematological involvement. APLA syndrome with pleural effusion is a rare complication. Patients with antiphospholipid syndrome can develop various types of pulmonary disease. The authors present the case of a 38-year-old male patient with a history of Deep Vein Thrombosis (DVT) and psoriasis, a known case of APLA syndrome, who presented with neck pain and breathlessness. Pulmonary embolism was ruled out, and the patient was discharged on oral anticoagulants. The present case highlights APLA as the culprit for the myriad presentations in the present case.

Unilateral pleural effusion after spontaneous migration of port a cath to the left hemithorax

Unilateral pleural effusion after spontaneous migration of port a cath to the left hemithorax

Clinico-epidemiological profile and short-term outcomes of patients with metastatic malignant pleural effusion in Baghdad, Iraq

Objectives: To describe the epidemiological profile of metastatic malignant pleural effusion (MPE) in patients admitted to the surgical wards at a tertiary hospital in Baghdad, Iraq. Methodology: The study was single-center, cross-sectional, and comprised 90 successive patients who were hospitalized with MPE. Results: Out of 90 patients, 60% were females and the age group 46-55 years formed the highest percentage (33.3%). We found that 97.8% had pre-existing malignancy, mainly breast cancer and 85.5% suffered non-specific generalized symptoms related to the primary malignancy. All the cases presented with shortness of breath, cough, and chest pain, and only 3.3% were asymptomatic. Pleurodesis was done in 84 patients and in the majority of them (86.7%) bleomycin was used. The majority of the pleural fluid aspirates were exudate according to Light criteria. 40% patients improved during hospitalization. Better improvement was observed among unilateral, and small MPE. Less than one-third of the cases had recurrent effusion, which was mostly in those with bilateral and secondary MPE. The survival rate was relatively good (82%). Around 6% cases were referred to oncologists. Conclusion: Although the therapeutic approaches of MPE were mostly palliative not curative, a substantial improvement in outcome after the management of MPE was noted. Parameters that predict favorable short-term outcomes are unilateral and small pleural effusions.

Clinical Worsening in an Adolescent With Pleural Tuberculosis

A 17-year-old previously healthy female presented with unilateral chest pain and dyspnea. Chest radiographs demonstrated a unilateral pleural effusion and pneumonia. Pleural fluid bacterial cultures were negative; acid-fast cultures grew Mycobacterium tuberculosis. Two months after starting appropriate therapy, she had a recrudescence of symptoms and reaccumulation of the pleural fluid. Her tuberculosis antibiotic regimen was expanded, the effusion drained, and systemic corticosteroids initiated, resulting in rapid clinical improvement. Cultures of the second pleural fluid collection were negative. Her clinical deterioration was due to immune reconstitution inflammatory syndrome (IRIS). IRIS can be seen within the first several months of starting tuberculosis therapy and can result in paradoxical worsening of symptoms or radiographic findings in adolescents who are on the appropriate therapy. IRIS is a diagnosis of exclusion after drug resistance and medication malabsorption, intolerance, and nonadherence are excluded. Therapy includes nonsteroidal anti-inflammatory agents for milder reactions and systemic corticosteroids for more severe IRIS cases.

897: VV ECMO AFTER COMPLICATED ABDOMINAL SURGERY IN AN OBESE PATIENT: IS EARLIER BETTER?

Introduction: Aspiration pneumonia and respiratory failure following abdominal surgery are well-known complications in patients with a body mass index (BMI) over 30 kg/m2. The use of venous-venous extracorporeal membrane oxygenation (VV-ECMO) as rescue therapy has been explored in patients who develop acute respiratory failure postoperatively. This case strives to highlight the importance of early initiation of VV-ECMO to improve outcomes in obese patients. Description: A 59-year-old woman with past medical history of hypertension and morbid obesity status post laparoscopic Roux-en-y gastric bypass presented with new onset nausea, emesis, and abdominal pain. Patient was febrile, tachycardic, hypoxic, and hypotensive upon evaluation. Physical exam was significant for bibasilar coarse breath sounds, abdominal distention, and hypoactive bowel sounds. Abdominal radiography showed evidence of small bowel obstruction and chest radiography revealed massive aspiration with unilateral pleural effusion. Patient ultimately required exploratory laparotomy after failure of conservative management for unresolved bowel obstruction. The post-operative course was complicated by acute respiratory failure, which did not improve despite multiple measures. VV-ECMO was then initiated, which led to significant recovery of hemodynamics and respiratory status in three days. Discussion: Anesthetic-induced decrease in functional residual capacity, disruption of thoracoabdominal musculature during abdominal surgery, and pre-existing lung disease predispose obese patients to respiratory failure. Non-invasive approaches are limited and invasive mechanical ventilation becomes the appropriate next step to achieve improved oxygenation in this sub-set of patients. Studies show that obesity is an independent factor in improving 90-day survival when transitioned to VV-ECMO early in the clinical course. Further clinical studies are required to determine the optimal time between initiation of mechanical ventilation and transition to VV-ECMO, as well as the effect on ICU and hospital length of stay.

Symptomatic Unilateral Pleural Effusion Secondary due to Ovarian Hyperstimulation Syndrome

Isolated pleural effusion is a rare presentation of ovarian hyperstimulation syndrome following ovulation induction therapy. We hereby report the case of a 24-year-old female who presented with unilateral moderate pleural effusion following ovulation induction therapy. Therapeutic thoracentesis was performed to relieve the breathlessness in this case.

Role of Prosaposin and Extracellular Sulfatase Sulf-1 Detection in Pleural Effusions as Diagnostic Biomarkers of Malignant Mesothelioma.

Malignant pleural mesothelioma is an aggressive malignancy with poor prognosis. Unilateral pleural effusion is frequently the initial clinical sign requiring therapeutic thoracentesis, which also offers a diagnostic opportunity. Detection of soluble biomarkers can support diagnosis, but few show good diagnostic accuracy. Here, we studied the expression levels and discriminative power of two putative biomarkers, prosaposin and extracellular sulfatase SULF-1, identified by proteomic and transcriptomic analysis, respectively. Pleural effusions from a total of 44 patients (23 with mesothelioma, 8 with lung cancer, and 13 with non-malignant disease) were analyzed for prosaposin and SULF-1 by enzyme-linked immunosorbent assay. Pleural effusions from mesothelioma patients had significantly higher levels of prosaposin and SULF-1 than those from non-malignant disease patients. Receiver-operating characteristic (ROC) analysis showed that both biomarkers have good discriminating power as pointed out by an AUC value of 0.853 (p = 0.0005) and 0.898 (p < 0.0001) for prosaposin and SULF-1, respectively. Combining data ensued a model predicting improvement of the diagnostic performance (AUC = 0.916, p < 0.0001). In contrast, prosaposin couldn't discriminate mesothelioma patients from lung cancer patients while ROC analysis of SULF-1 data produced an AUC value of 0.821 (p = 0.0077) but with low sensitivity. In conclusion, prosaposin and SULF-1 levels determined in pleural effusion may be promising biomarkers for differential diagnosis between mesothelioma and non-malignant pleural disease. Instead, more patients need to be enrolled before granting the possible usefulness of these soluble proteins in differentiating mesothelioma pleural effusions from those linked to lung cancer.

Unilateral Transudative Pleural Effusion due to rare Cause – A Case Report

Transudative pleural effusions are characterized by low protein and lactate dehydrogenase according to Light’s criteria. Common causes are congestive cardiac failure, nephrotic syndrome, liver cirrhosis, and protein-losing enteropathy. Constrictive pericarditis is a rare cause of transudative pleural effusion. It can cause bilateral or unilateral recurrent effusions and chylothorax rarely. Common causes of constrictive pericarditis include infections such as viruses and tuberculosis, radiation, and cardiac surgery. We present a treated case of pulmonary tuberculosis presenting with massive, left-sided, and transudative pleural effusion due to constrictive pericarditis diagnosed by computed tomography scan and 2D echo with classical findings. Incidental findings were internal jugular vein thrombus and right lower lobar pulmonary embolus. This case highlights the atypical presentation of constrictive pericarditis as unilateral pleural effusion. A proper history with a high index of suspicion is essential in the workup of constrictive pericarditis which can be cured by pericardiectomy.

Subcutaneous Emphysema Risk Following Indwelling Pleural Catheter Insertion During Rigid Local Anesthetic Thoracoscopy: Via Thoracoscopy Port Versus Separate Incision Site.

Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this. Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall). 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up. IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

Tubercular pleural effusion with epithelioid cells– A rare cytological case presentation

Tuberculosis is one of the most prevalent disease of the developing countries resulting in significant morbidity. Extra pulmonary tuberculosis results in pleurisy among predilection to other organ and organ systems like lymph nodes. Pleurisy results in tubercular pleural effusion. Pleural effusions are mostly seen in immunocompetent patients. Here we present a case of tubercular pleural effusion which was diagnosed by cytology examination of pleural fluid in a 22-year-old female, who presented with shortness of breath, generalized weakness with decreased appetite. Radiological investigations revealed a unilateral pleural effusion. Pleural tapping was done and sent for cytological examination. Cytospin aspirate smear showed degenerated mesothelial cells, histiocytes, few epithelioid cells, mature lymphocytes and lymphocytes with splintered chromatin. A diagnosis of tubercular pleural effusion was made with further tests like CBNAAT for confirmation of diagnosis. CBNAAT was positive with a strain of Rifampicin sensitive mycobacterial tuberculosis identified. Patient was started on anti tubercular drugs according to the National Tuberculosis Elimination Program. To conclude, cytology is a fast inexpensive method for diagnosing the etiology of pleural effusions by pointing us in the right direction.

A sweet unilateral pleural effusion: pleuro-peritoneal communication in a patient on dialysis

A 79-year-old woman was referred to our department with a sudden onset of dyspnoea. She had end-stage kidney disease secondary to IgA nephropathy and, 6 months earlier, had started peritoneal dialysis. The patient did not report a cough, fever, or chills.

Diagnostic Accuracy of Multiple D-Dimer Cutoff Thresholds and Other Clinically Applicable Biomarkers for the Detection and Radiographic Evaluation of Pulmonary Embolism.

Diagnostic work-up of pulmonary embolism (PE) remains a challenge. We retrospectively studied all patients referred for computed tomography pulmonary angiography (CTPA) with suspicion of PE during a 12-month period (2018). The diagnostic accuracy of different D-dimer (Dd) cutoff thresholds for ruling out PE was evaluated. Furthermore, the association of Dd and red cell distribution width (RDW) with embolus location, CTPA findings, and patient outcome was recorded. One thousand seventeen (n = 1017) patients were finally analyzed (mean age: 64.6 years (SD = 11.8), males: 549 (54%)). PE incidence was 18.7%. Central and bilateral embolism was present in 44.7% and 59.5%, respectively. Sensitivity and specificity for conventional and age-adjusted Dd cutoff was 98.2%, 7.9%, and 98.2%, 13.1%, respectively. A cutoff threshold (2.1 mg/L) with the best (64.4%) specificity was identified based on Receiver Operating Characteristics analysis. Moreover, a novel proposed Dd cutoff (0.74 mg/L) emerged with increased specificity (20.5%) and equal sensitivity (97%) compared to 0.5 mg/L, characterized by concurrent reduction (17.2%) in the number of performed CTPAs. Consolidation/atelectasis and unilateral pleural effusion were significantly associated with PE (p < 0.05, respectively). Patients with consolidation/atelectasis or intrapulmonary nodule(s)/mass on CTPA exhibited significantly greater median Dd values compared to patients without the aforementioned findings (2.34, (IQR 1.29-4.22) vs. 1.59, (IQR 0.81-2.96), and 2.39, (IQR 1.45-4.45) vs. 1.66, (IQR 0.84-3.12), p < 0.001, respectively). RDW was significantly greater in patients who died during hospitalization (p = 0.012). Age-adjusted Dd increased diagnostic accuracy of Dd testing without significantly decreasing the need for imaging. The proposed Dd value (0.74 mg/L) showed promise towards reducing considerably the need of CTPA. Multiple radiographic findings have been associated with increased Dd values in our study.

Ipsilateral and contralateral hemidiaphragm dynamics in symptomatic pleural effusion: The 2nd PLeural Effusion And Symptom Evaluation (PLEASE-2) Study.

The pathophysiology of breathlessness in pleural effusion is unclear. In the PLEASE-1 study, abnormal ipsilateral hemidiaphragm shape and movement, assessed qualitatively, were independently associated with breathlessness relief after pleural drainage. Effects of pleural effusion on contralateral hemidiaphragm function are unknown. PLEASE-2, a prospective exploratory pilot study, assessed the effects of unilateral effusion and drainage on both hemidiaphragms using advanced quantitative bedside ultrasonography. Individuals with symptomatic unilateral pleural effusion undergoing therapeutic drainage were included. Measurements pre- and post-drainage included severity of breathlessness (visual analogue scale) and ultrasound measurements of diaphragm excursion and thickness, in addition to shape and movement. Diaphragm measurements were compared to published reference values. Twenty participants were recruited (mean age 68.9 [SD 12.8] years, 12 females). During tidal breathing, contralateral hemidiaphragm excursion exceeded ipsilateral excursion and reference values (all p ≤ 0.001). Contralateral excursion was greatest in participants with abnormal ipsilateral hemidiaphragm movement and was inversely correlated with ipsilateral tidal excursion (r= -0.676, p= 0.001). Following drainage (mean volume 2121 [SD=1206] ml), abnormal shape (n= 12) and paradoxical movement (n= 9) of the ipsilateral hemidiaphragm resolved in all participants, and tidal excursion of the contralateral hemidiaphragm normalized. Relief of breathlessness post-drainage correlated with improvement in ipsilateral hemidiaphragm excursion (r= 0.556, p= 0.031). This pilot study suggests, for the first time, that unilateral pleural effusion not only impairs ipsilateral hemidiaphragm function but also causes compensatory hyperactivity of the contralateral hemidiaphragm, which resolves post-drainage. These findings provide a basis for detailed studies of diaphragmatic function and ventilatory drive in patients with symptomatic pleural effusion.

A RETROSPECTIVE COHORT STUDY INVESTIGATING CYTOLOGICAL SENSITIVITY IN MALIGNANT PLEURAL EFFUSION

TYPE: Abstract TOPIC: Disorders of the Pleura PURPOSE: Cytological analysis of pleural fluid is a first line investigation for evaluating a unilateral pleural effusion. Despite long-standing use, diagnostic sensitivity of pleural fluid sampling for malignant pleural effusions (MPEs) is highly variable, between 46-91%. Our objective was to analyse cytological sensitivity in patients with confirmed malignancy using a large retrospective cohort, comparing to previous studies including Arnold et al [1]. METHODS: Consecutive patients with unilateral pleural effusions who underwent thoracocentesis at a district general hospital between 2015-2020 were recruited. Cytology was reported by consultant histopathologists. Sensitivity was calculated based on final diagnosis, confirmed by medical consultants. All data was collected retrospectively using an electronic records system. RESULTS: Of 419 patients recruited, 162 had confirmed malignancy and 146 had cytology reported. Overall sensitivity for pleural cytology to diagnose MPEs was 48.8%. Sensitivity varied according to cancer primary with gynaecological malignancy most sensitive (78%), then lung adenocarcinoma (72%) and breast cancer (68%). Mesothelioma (26%) and Haematological malignancy (20%) had comparatively lower sensitivity which reflects results in previous studies. CONCLUSIONS: Cytological sensitivity for MPEs varies according to cancer primary. CLINICAL IMPLICATIONS: Our results are comparative to previous studies and further highlight the importance of pleural analysis and further diagnostic testing in the diagnosis of MPEs. DISCLOSURE: Nothing to declare. KEYWORD: pleural effusion

Pleural tuberculosis: experiences from two centers in Brazil

ObjectiveThis study aimed to describe the clinical and laboratory findings of patients diagnosed with pleural tuberculosis at two hospitals in southern Brazil. MethodsPatients aged < 18 years were evaluated retrospectively. The patients’ medical and epidemiological history, tuberculin skin test results, radiological and pathological findings, and pleural fluid analysis results were retrieved. ResultsNinety-two patients with pleural tuberculosis were identified. The mean age was 10.9 years old. Twenty-one percent were children aged six years or less. The most common symptoms were fever (88%), cough (72%), and chest pain (70%). Unilateral pleural effusion was observed in 96% of the cases. Lymphocyte predominance was found in 90% of the pleural fluid samples. The adenosine deaminase activity of the pleural fluid was greater than 40 U/L in 85% of patients. A diagnosis of community-acquired pneumonia with antibiotic prescriptions was observed in 76% of the study population. ConclusionsTuberculosis etiology must be considered in unilateral pleural effusion in a child with contact with a case of tuberculosis. Pleural fluid biomarkers contribute to the diagnosis of pleural tuberculosis in children and adolescents.

Ultrasonographic assessment of dengue fever and its correlation with platelet count

&lt;p&gt;&lt;em&gt;Background:&lt;/em&gt; Dengue virus infections are a significant threat to human populations particularly in the tropical and subtropical regions. This is mainly transmitted by Aedes aegypti mosquito from humans to humans. The main pathological mechanisms associated include thrombocytopenia, haemorrhagic diathesis with haemoconcentration. Ultrasonography is used because of its ability to detect plasma leakage signs and prediction of disease severity.&lt;/p&gt; &lt;p&gt;&lt;em&gt;Objective:&lt;/em&gt; To evaluate the usefulness of ultrasonographic findings of dengue fever and its correlation with platelet count.&lt;/p&gt; &lt;p&gt;&lt;em&gt;Methods:&lt;/em&gt; It was a prospective observational study, carried out in Bangladesh Medical College Hospital, Dhaka from May 2019 to August 2019. A total of 213 patients of suspected dengue fever during the epidemic were included in this study. All the cases were serologically diagnosed and evaluated with ultrasonographic findings. Platelet counts were estimated in all the cases and compared with findings recorded on ultrasonographic findings.&lt;/p&gt; &lt;p&gt;&lt;em&gt;Results:&lt;/em&gt; The mean age of the study population was 28.7 years. The male female ratio was 1.7:1. The common features on ultrasonography were thickened and oedematous gall bladder wall, mild to moderate ascites, pleural effusion (unilateral and bilateral), and hepatosplenomegaly. Thickened and oedematous gall bladder wall were observed in 68.8%, mild to moderate ascites 65.3%, bilateral pleural effusion 58.2 %, unilateral pleural effusion 40.4%, hepatomegaly 34.3 % and splenomegaly 13.6 % Platelet counts were significantly lower in abnormal ultrasonographic findings (&lt;em&gt;p&lt;/em&gt;=0.001).&lt;/p&gt; &lt;p&gt;&lt;em&gt;Conclusion:&lt;/em&gt; In a febrile patient with thrombocytopenia and positive dengue serology, ultrasonography of the abdomen is a useful tool to evaluate the severity of illness. Ultrasound findings of gall bladder wall oedema, ascites, and pleural effusion were correlated with the severity of thrombocytopenia. In epidemic scenarios, Ultrasonographic features may help in roughly estimating the platelet count even before serology and platelet results are available. Thus, it helps in treatment planning without waiting for the laboratory results.&lt;/p&gt; Bangladesh Med Res Counc Bull 2021; 47(1): 23-28

Abstract #1182431: Unilateral Massive Pleural Effusion as Manifestation of Severe Hyperthyroidism

Non-cardiogenic pleural involvement in hyperthyroidism is rare, with unilateral involvement being rarer still. We present the case of a patient with Graves’ disease (GD) with thyroid storm criteria who presented right pleural effusion compatible with exudate.