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PubMed1994

Noninvasive evaluation of the patient with a pleural effusion.

Pleural fluid formation is an indicator of a pathologic process that may be of primary pulmonary origin but also may be a reflection of disease in virtually any other organ system or a systemic disease. A thoracentesis should be performed on any patient in whom the cause of the effusion has not been established yet. The possible exception to this is an effusion thought to be secondary to uncomplicated congestive heart failure. The presumptive or definitive diagnosis can be established in 75% of patients by following patient history, physical examination, and pleural fluid analysis.

Diagnosis, Differential↗
PubMed2000

[The significance of detecting tumor necrosis factor-alpha and its receptors in serum and pleural effusion in differentiating tuberculosis and malignant pleural effusions].

OBJECTIVE: To investigate the significance of TNF-alpha and its soluble receptors (sTNFR-I and sTNFR-II) in differentiating benign and malignant pleural disease. METHODS: TNF-alpha and its soluble receptors (sTNFR-I and sTNFR-II) were detected using ELISA method in the serum and pleural effusion of 25 cases of tuberculosis pleural effusion and 28 cases of malignant pleural effusion, and in the serum of 32 cases of normal control. RESULTS: TNF-alpha level in the serum of tuberculosis patients with pleural effusion is (16.4 +/- 6.2) ng/L, lower than that in the serum of malignant pleural effusion patients (20.5 +/- 10.9) ng/L (P < 0.01), but higher than that in the serum of normal control (11.0 +/- 2.9) ng/L (P < 0.01). TNF-alpha level in the pleural effusion of tuberculosis patients is (29.4 +/- 10.3) ng/L, significantly higher than that of malignant pleural effusion (11.7 +/- 2.0) ng/L (P < 0.01). The sTNFR-I and sTNFR-II level in the serum of malignant pleural effusion is (1,132 +/- 303) ng/L and (1,548 +/- 489) ng/L respectively, significantly higher than that in tuberculosis pleural effusion which is (979 +/- 146) ng/L and (977 +/- 93) ng/L (P < 0.01) respectively. The sTNFR-I and sTNFR-II level in malignant pleural effusion is (1,404 +/- 306) ng/L and (2,195 +/- 418) ng/L respectively, markedly higher than those in tuberculosis pleural effusion which is (1,185 +/- 215) ng/L and (1,195 +/- 300) ng/L (P < 0.01). CONCLUSION: There are highly elevated TNF-alpha in tuberculosis pleural effusion; The sTNFR-I and sTNFR-II level in the serum and pleural effusion of malignant pleural effusion patients are significantly higher than those in tuberculosis pleural effusion patients, suggesting they may play some role in differentiating benign and malignant pleural diseases.

Adult↗
PubMed1995

[Diagnostic value of tissue polypeptide antigen in pleural effusions with malignant pleural mesothelioma].

There are no known tumor makers of malignant pleural mesothelioma. We measured the concentration of TPA in the pleural effusions from patients with malignant pleural mesothelioma and from patients with other pleural diseases, evaluate its clinical usefulness. The concentration of TPA was more than 7,000 U/l (mean: 18,600 +/- 9,867 U/l, n = 5) in all patients with malignant pleural mesothelioma, but it was less than 4,000 U/l in those with benign asbestos pleurisy and other benign pleural effusion (benign asbestos pleurisy 1,598 +/- 570, n = 5: p < 0.01, tuberculous pleurisy 1.37 +/- 759, n = 11: p < 0.01, others 2,497 +/- 2,152 n = 3: p < 0.05). The concentration of TPA in the pleural effusions was not significantly different between malignant pleural mesothelioma and lung cancer (12,287 +/- 17,070 U/l). However, in all patients with lung cancer and high TPA concentrations, cytologically malignant cells were detected in the pleural effusions. TPA was high in all five patients with malignant pleural mesothelioma, but cytologically malignant cells were detected in only one patient. Only in malignant pleural mesothelioma (not in other benign disease or in lung cancer) was the concentration of TPA more than 4,000 U/l, and no evidence of malignancy was obtained by cytological methods. These findings suggest that assessing TPA in the pleural effusion might contribute to the diagnosis of malignant pleural mesothelioma.

Adult↗
PubMed2003

Eosinophilic pleural effusions.

Eosinophilic pleural effusions, defined as a pleural effusion that contains at least 10% eosinophils, may be caused by almost every condition that can cause pleural disease. Eosinophilic pleural effusion occurs most commonly during conditions associated with the presence of blood or air in the pleural space, infections, and malignancy. Drug-induced pleural effusions, pleural effusions accompanying pulmonary embolism, and benign asbestos pleural effusions are also among the common causes of eosinophilic pleural effusion. No etiology is found in as many as one third of patients. Because studies evaluating different diagnostic approaches with eosinophilic pleural effusions are lacking, the authors suggest that certain noninvasive and invasive diagnostic tools must be used based on the patient's clinical characteristics.

Eosinophilia↗
PubMed1994

Mononuclear cells in exudative malignant pleural effusions. Characterization of pleural phagocytic cells.

The aims of this study were to develop a methodology for the isolation of highly enriched mononuclear phagocyte populations from exudative malignant pleural effusions (EMPE) and to characterize the phenotype and functional properties of these cells. Pleural effusion mononuclear cells (PEMC) were isolated by Ficoll centrifugation of EMPE and transudative pleural effusions and allowed to adhere to plastic for 1 h to obtain a pleural effusion mononuclear adherent cell (PEMAC) fraction. Only 66.0 +/- 4.2 percent of PEMAC ingested latex particles, indicating that a significant proportion of PEMAC were not phagocytic cells. Latex-positive PEMAC had the morphologic appearance of macrophages and stained positive (97.3 +/- 4.3 percent) with the anti-CD68 monoclonal antibody (MoAb), specific for macrophages. Conversely, latex-negative PEMAC (34.0 +/- 4.1 percent of PEMAC) did not react with the anti-CD68 MoAb and stained with anti-CD3 (34.7 +/- 10.7 percent) and anticytokeratin (50.5 +/- 16.4 percent) MoAbs, indicating that T cells and mesothelial cells were present in the PEMAC fraction. To improve the purification of pleural macrophages, PEMAC were cultured for an additional 18 h and the cells that remained adherent after this period constituted the firmly adherent mononuclear cell (FAMC) fraction. Nearly 90 percent of FAMC ingested latex particles and were CD68-positive. Virtually all FAMC were CD3-negative and cytokeratin-negative. Similar percentages of FAMC from EMPE and transudative effusions expressed the monocyte-lineage markers CD11b and CD14, suggesting that the proportion of monocyte-like mononuclear phagocytes in the pleural space is not increased during local tumor-associated inflammatory responses. The FAMC from EMPE (1) expressed HLA-DR antigens, (2) released interleukin 1 (IL-1) beta and tumor necrosis factor (TNF) alpha, and (3) stimulated allogeneic T-lymphocyte proliferation. The results of this study suggest that pleural mononuclear phagocytes may be involved in tumor-associated inflammatory reactions in the pleural compartment by stimulating the proliferation of other inflammatory cells and by releasing inflammatory cytokines.

Aged↗
PubMed1991

Recurrent massive pleural effusion due to pleural, pericardial, and epicardial fibrosis in histoplasmosis.

Acute histoplasmosis is generally a benign, self-limited pulmonary infection. Although Histoplasma capsulatum pneumonitis is common, pleural effusions associated with histoplasmosis are quite rare, and massive pleural effusions have not been reported. There have been several reports of pericardial fibrosis secondary to histoplasmosis, but epicardial fibrosis has not been described. We report a biopsy-proven case of histoplasmosis initially associated with recurrent massive pleural effusions and excessive pleural fibrosis causing a trapped lung. The patient later developed constrictive pericarditis. Despite pericardiectomy, severe cor pulmonale occurred, and the patient died. Necropsy demonstrated fibrosis of the epicardium.

Acute Disease↗
PubMed1999

Massive pleural effusions in cryptococcal meningitis.

Cryptococcal infection uncommonly presents with pulmonary manifestations and even more rarely so as massive bilateral effusions. Pleural involvement is usually associated with underlying pulmonary parenchymal lesions and is unusual while on antifungal therapy. We report a patient with cryptococcal meningitis who, while on intravenous 5-flucytosine and amphotericin B, developed life-threatening bilateral massive pleural effusions with evidence of spontaneous resolution, consistent with prior hypothesis of antigenic stimulation as the cause of pleural involvement.

Adult↗
PubMed1995

Pulmonary paragonimiasis with pleural effusion containing paragonimus ova: sonographical appearance of pleural effusion.

In the pleural effusion of a 46-year-old man with pulmonary paragonimiasis, numerous floating particles containing parasitic ova and granulation tissue were observed. The floating particles appeared as diffuse hyperechoic foci in the anechoic pleural effusion on ultrasonography. We concluded that rupture of the intrapulmonary paragonimiasis lesion into the pleural cavity caused the formation of these floating particles.

Humans↗
PubMed2006

Accuracy and reliability of physical signs in the diagnosis of pleural effusion.

Although pleural effusion is a common disorder among patients presenting with respiratory symptoms, there is limited evidence on the accuracy and reliability of symptoms and signs for the diagnosis of pleural effusion. In our study, conducted at a rural hospital in India, two physicians, blind to history and chest radiograph findings, and to each other's results, independently evaluated 278 patients (196 men), aged 12 and older, admitted with respiratory symptoms. We did a blind and independent comparison of physical signs (asymmetric chest expansion, vocal fremitus, percussion note, breath sounds, crackles, vocal resonance and auscultatory percussion) with the reference standard (chest radiograph). We measured diagnostic accuracy by computing sensitivity, specificity, and likelihood ratios (LRs), and inter-observer reliability by using kappa (kappa) statistic. We performed multivariate analysis to identify the clinical signs that independently predict pleural effusion. The prevalence of pleural effusion was 21% (57/278). The LRs of positive signs ranged from 1.48 to 8.14 and their 95% confidence intervals (CIs) excluded 1. Except for pleural rub, the LRs for negative signs ranged between 0.13 and 0.71. The interobserver agreement was excellent for chest expansion, vocal fremitus, percussion and breath sounds (kappa 0.84-0.89) and good for vocal resonance, crackles and auscultatory percussion (kappa 0.68-0.78). The independent predictors of pleural effusion were asymmetric chest expansion (odds ratio [OR] 5.22, 95% CI 2.06-13.23), and dull percussion note (OR 12.80, 95% CI 4.23-38.70). For the final multivariate model, the area under receiver operating characteristic curve (ROC curve) was 0.88. In conclusion, our data suggest that physical signs may be helpful to rule out but not rule in pleural effusion.

Adolescent↗
PubMed1992

An audit of the clinical investigation of pleural effusion.

BACKGROUND: Pleural aspiration with pleural biopsy is advised for the investigation of pleural effusion. The clinical investigation of pleural effusion in a group of teaching hospitals was audited with reference to adequacy and diagnostic value of sampling procedures. METHODS: A retrospective review of case records of all patients investigated for pleural effusion during an eight month period was performed. The records of 112 patients, age range 16-91 years, who underwent 150 procedures were reviewed. RESULTS: Microbiology samples were obtained from 137 procedures, of which five provided a positive culture, including one for mycobacteria. Cytology samples were obtained from 145 procedures though approximately two thirds of samples were less than the recommended 30 ml. The pleural biopsy rate was 30%, varying from 0% in general or thoracic surgery to 68% in thoracic medicine (thoracic surgeons carried out thoracoscopy). Twenty nine per cent of pleural biopsy samples were of poor quality. The complication rate was 2% for aspiration alone, and 4% for aspiration plus biopsy. The sensitivity of the first diagnostic procedure for a diagnosis of malignancy or tuberculosis was 53% for cytology alone, 50% for biopsy alone and 72% for cytology plus biopsy. CONCLUSION: The samples obtained from pleural aspiration and biopsy in the initial investigation of pleural effusion are often inadequate. Further education is necessary to improve the quantity and quality of specimens submitted for histological and cytological examination.

Bacterial Infections↗
PubMed1995

Thoracoscopic management of pleural effusions revisited.

Pleural effusion is a commonly encountered clinical condition. We report our experience with video assisted thoracoscopic surgery (VATS) in the management of pleural effusions in three groups of patients: (1) Patients with cryptogenic pleural effusions for diagnosis; (2) patients with established malignant effusions for talc insufflation and limited decortication; and (3) patients with early empyema for debridement and drainage. From September 1992 to March 1994, we have successfully managed 28 patients with pleural effusions (12 males, 16 females; age ranged from 22 days to 73 years). Management consisted of 16 diagnostic thoracoscopies with guided pleural biopsies, seven limited decortications for trapped lungs, 12 talc insufflation for recurrent symptomatic malignant effusions and debridement and drainage of five empyemata. There was no mortality or intra-operative complications. The procedure was tolerated well by all patients. The mean duration of chest drainage and hospital stay were 1.2 and 2.8 days for group 1 patients, 4.5 and 6.4 days for group 2, and 5.6 and 7.1 days for group 3. Specific histological diagnosis was obtained in all but two patients (88%). Thoracoscopic talc insufflation was successful in 92% of cases at mean follow up of 8 months. Thoracoscopic debridement and drainage of empyema resulted in rapid resolution of sepsis in all cases. Advances in video camera technology and instrumentation have allowed more therapeutic manoeuvres to be carried out. We conclude that VATS is a safe and effective way of managing selected patients with pleural effusions.

Adult↗