Diagnostic value of pleural effusion

Pleural Effusion evaluation and differential diagnosis

1. Pleural EffusionPleural Effusion
S. A. SaleemiS. A. Saleemi

2. PLEURAL EFFUSIONPLEURAL EFFUSION
•Fluid production exceeds absorption.
•Fluid is formed in the parietal pleura and absorbed in
parietal pleural lymphatics.
•Lymphatics have the capacity to absorb 20 times more
than what is Produced.
•Fluid can also enter the pleural cavity from interstitial
spaces of lung through visceral pleura.
•Peritoneal fluid can enter the pleural cavity via
diaphragm pores.

4. Mechanism of Pleural effusionsMechanism of Pleural effusions

increased hydrostatic pressure(LVF)increased hydrostatic pressure(LVF)
decreased oncotic pressure in microcirculation decreased oncotic pressure in microcirculation
(hypoalbuminemia)(hypoalbuminemia)
decrease in pleural pressure (atelectasis)decrease in pleural pressure (atelectasis)
increased permeability of microcirculation increased permeability of microcirculation
( pneumonia)( pneumonia)
impaired lymphatic drainage from pleural space impaired lymphatic drainage from pleural space
(malignancy)(malignancy)
movement of fluid from abdomen to pleural movement of fluid from abdomen to pleural
space ( cirrhosis) space ( cirrhosis)

5. In health, the volume of pleural fluid in
humans is small (<1 ml), forming a film
about 10 micro thick between the visceral
and parietal pleural surfaces.

6. VolumeVolume
Cells/mm³Cells/mm³
%mesothelial cells%mesothelial cells
%monocytes%monocytes
%lymphocytes%lymphocytes
%granulocytes%granulocytes
% eosinophils% eosinophils
ProteinProtein
%albumin%albumin
GlucoseGlucose
LDHLDH
0.1-0.2 ml/kg0.1-0.2 ml/kg
1000-50001000-5000
3-70%3-70%
30-70%30-70%
2-30%2-30%
~~ 10% 10%
0 %0 %
1-2 gm/dl1-2 gm/dl
50-70%50-70%
~plasma level~plasma level
<50% plasma level<50% plasma level
Normal composition of pleural fluid

7. parameterparametertransudatetransudateexudateexudate
Total proteinTotal protein<30 g/l<30 g/l >30 g/l>30 g/l
Pleural-serum Pleural-serum
protein ratioprotein ratio
<0.5<0.5 >0.5>0.5
LDHLDH <200 u/l<200 u/l >200 u/l>200 u/l
Pleural-serum Pleural-serum
LDH ratioLDH ratio
<0.6<0.6 >0.6>0.6
cholestrolcholestrol <45mg/dl<45mg/dl >45 mg/dl>45 mg/dl
Bilirubin pleural-Bilirubin pleural-
serum rationserum ration
<0.6<0.6 >0.6>0.6
Differentiation between transudate and exudate

8. Light CriteriaLight Criteria
1- Pleural fluid protein-to-serum protein
ratio more than 0.5
2- Pleural fluid LDH-to-serum LDH
ratio more than 0.6
3-Pleural fluid LDH level greater than
two third the upper limit of normal
serum level

9. Modified 1997 (NO SERUM LEVELS)
(by Haffner)
1-Pl. fluid protein more than 2.9g/dl(29g/L
2- Pl. fluid LDH more than 66% of upper limit
of normal serum reference range
3- Pl. fluid cholestrol more than 45 mg/dl

10. Serum-effusion albumin gradient (SAG)Serum-effusion albumin gradient (SAG)
In general Light’s criteria occasionally In general Light’s criteria occasionally
misidentify a transudative effusion as an misidentify a transudative effusion as an
exudative effusion as in cardiac failure exudative effusion as in cardiac failure
with diuretic therapywith diuretic therapy
Clinically if a patient should have a Clinically if a patient should have a
transudative effusion, but meets Light’s transudative effusion, but meets Light’s
criteria for an exudative effusion, measure criteria for an exudative effusion, measure
serum - pleural fluid albumin gradientserum - pleural fluid albumin gradient
Serum- effusion albumin gradient of more Serum- effusion albumin gradient of more
than 1.2 g/dl is used to diagnose presence than 1.2 g/dl is used to diagnose presence
of transudate effusion.of transudate effusion.

11. Causes of transudative pleural effusionsCauses of transudative pleural effusions
Very common causesVery common causes
–Left ventricular failureLeft ventricular failure
–Liver cirrhosisLiver cirrhosis
–HypoalbuminaemiaHypoalbuminaemia
–Peritoneal dialysisPeritoneal dialysis
Less common causesLess common causes
–HypothyroidismHypothyroidism
–Nephrotic syndromeNephrotic syndrome
–Mitral stenosisMitral stenosis
–Pulmonary embolismPulmonary embolism
Rare causesRare causes
–Constrictive percarditisConstrictive percarditis
–UrinothoraxUrinothorax
–Superior vena cava obstructionSuperior vena cava obstruction
–Ovarian hyperstimulationOvarian hyperstimulation
–Meigs’ syndromeMeigs’ syndrome

12. Causes of exudative pleural effusionsCauses of exudative pleural effusions
Common causesCommon causes
–MalignancyMalignancy
–Parapneumonic effusionsParapneumonic effusions
Less common causesLess common causes
–Pulmonary infarctionPulmonary infarction
–Rheumatoid arthritisRheumatoid arthritis
–Autoimmune diseasesAutoimmune diseases
–Benign asbestos effusionBenign asbestos effusion
–PancreatitisPancreatitis
–Post-myocardial infarction syndromePost-myocardial infarction syndrome
Rare causesRare causes
–Yellow nail symdromeYellow nail symdrome
–Drug (see box1 )Drug (see box1 )
–Fungal infectionsFungal infections

13. Drugs known to cause pleural effusionsDrugs known to cause pleural effusions
Over 100 reported cases globallyOver 100 reported cases globally
–AmiodaroneAmiodarone
–NitrofurantoinNitrofurantoin
–PhenytoinPhenytoin
–MethotrexateMethotrexate
20-100 reported cases globally20-100 reported cases globally
–CarbamazepineCarbamazepine
–ProcainamideProcainamide
–PropylthiorucilPropylthiorucil
–PenicillaminePenicillamine
–GCSFGCSF
–CyclophosphamideCyclophosphamide
–BromocriptineBromocriptine
* pneumotox.com (2001)* pneumotox.com (2001)

14. Approximate annual incidence of various Approximate annual incidence of various
types of pleural effusions in the USAtypes of pleural effusions in the USA
Congestive heart failureCongestive heart failure
Other causesOther causes
PneumoniaPneumonia
Malignant diseaseMalignant disease
Pulmonary embolismPulmonary embolism
Cirrhosis with ascitesCirrhosis with ascites
Gastrointestinal diseaseGastrointestinal disease
Collagen vascular diseaseCollagen vascular disease
TuberculosisTuberculosis
Asbestos pleuritisAsbestos pleuritis
MesotheliomaMesothelioma
TOTALTOTAL
500,000500,000
400,000400,000
200,000200,000
150,000150,000
50,00050,000
25,00025,000
6,0006,000
2,5002,500
2,0002,000
1,5001,500
37.537.5
63.663.6
100.0100.0
48.048.0
24.024.0
18.018.0
6.06.0
3.03.0
0.70.7
0.30.3
0.250.25
0.20.2
100.0100.0
Percentage
of noncardiac
Etiology Number Percentage effusions

15. Frequency distribution of Frequency distribution of
noncardiac effusionsnoncardiac effusions
Storey et al.Storey et al.
Hirsch et al.Hirsch et al.
Lamy et al.Lamy et al.
Engel,Engel,
LoddenkemperLoddenkemper
,,
TOTALTOTAL
115115
295295
194194
646646
250250
15001500
5656
3939
4646
34.534.5
3434
4242
66
3131
33.533.5
26.526.5
3939
2929
Authors Number Neoplastic Infectious Various Idiopathic
% % % %
1616
99
1212
1515
1818
1414
2222
2121
2020
12.512.5
99
1515

16. Useful Tests in the Evaluation of Pleural Useful Tests in the Evaluation of Pleural
EffusionsEffusions
TestTest Abnormal ValuesAbnormal Values Frequently Associated Frequently Associated
ConditionCondition
Red blood cells, per Red blood cells, per
mmmm
33
>100.000>100.000 Malignancy, trauma, Malignancy, trauma,
pulmonary embolismpulmonary embolism
White blood cells, per White blood cells, per
mmmm
33
>10.000>10.000 Pyogenic infectionPyogenic infection
neutorphils, %neutorphils, % >50>50 Acute pleuritisAcute pleuritis
lymphocytes, %lymphocytes, % >90>90 Tuberculosis, Tuberculosis,
malignancy, lymphomamalignancy, lymphoma
eosinophilia, %eosinophilia, % >10>10 Asbestos effusion, Asbestos effusion,
hydro-pneumothorax, hydro-pneumothorax,
resolving infectionresolving infection
mesothelial cellsmesothelial cells absentabsent TuberculosisTuberculosis

17. Cont:-Cont:-
Glucose, mg/dlGlucose, mg/dl<40<40 Empyema, TB, Empyema, TB,
malignancy, rheumatoid malignancy, rheumatoid
arthritisarthritis
pHpH <7.20<7.20 Esophageal rupture, Esophageal rupture,
empyema, TB, empyema, TB,
malignancy, rheumatoid malignancy, rheumatoid
arthritisarthritis
Amylase, PF/SAmylase, PF/S>1>1 Pancreatitis,Pancreatitis,
esophageal ruptureesophageal rupture
BacteriologicBacteriologicPositivePositive Etiology of effusionEtiology of effusion
CytologyCytology PositivePositive Diagnostic of malignancyDiagnostic of malignancy

18. Pleural fluid eosinophilia (>10%)Pleural fluid eosinophilia (>10%)
Usually due to air or blood in the pleural spaceUsually due to air or blood in the pleural space
Consider drug reactionsConsider drug reactions
–Dantrolene, bromocriptine, nitrofurantoinDantrolene, bromocriptine, nitrofurantoin
Frequent with asbestos pleural effusionFrequent with asbestos pleural effusion
Rarely paragonimiasis or Churg-Strauss Rarely paragonimiasis or Churg-Strauss
syndromesyndrome
–also low glucose and pHalso low glucose and pH
Frequently no diagnosis obtainedFrequently no diagnosis obtained

19. Appearance of pleural fluidAppearance of pleural fluid
FluidFluid Suspected diseaseSuspected disease
Putrid odourPutrid odour Anaerobic empyemaAnaerobic empyema
Food particlesFood particles Oesophageal ruptureOesophageal rupture
Bile stainedBile stained Cholothorax (biliary Cholothorax (biliary
fistula)fistula)
MilkyMilky Chylothorax/pseudochChylothorax/pseudoch
ylo- thoraxylo- thorax
““Anchovy sauce” like Anchovy sauce” like
fluidfluid
Ruptured amoebic Ruptured amoebic
abscessabscess

20. Pleural infectionsPleural infections

21. Pleural infection was first described by
Hippocrates in 500BC.
Open thoracic drainage was the only
treatment for this disorder until the 19th
century when closed chest tube drainage
was first described.
open surgical drainage was associated
with a mortality rate of up to 70%.

22. Characteristics of parapneumonic pleural Characteristics of parapneumonic pleural
effusionseffusions
StagesStages Macroscopic Macroscopic
appearanceappearance
Pleural fluid Pleural fluid
characteristicscharacteristics
CommentsComments
Simple Simple
parapneumonicparapneumonic
Clear fluidClear fluid pH >7.2pH >7.2
LDH <1000 IU/lLDH <1000 IU/l
Glucose >2.2 mmol/LGlucose >2.2 mmol/L
No organism on No organism on
culture or Gram stainculture or Gram stain
Will usually resolve Will usually resolve
with antibiotics alonewith antibiotics alone
Perform chest tube Perform chest tube
drainage for symptom drainage for symptom
relief if requiredrelief if required
Complicated Complicated
parapneumonicparapneumonic
Clear fluid or Clear fluid or
cloudy/turbidcloudy/turbid
pH <7.2pH <7.2
LDH >1000 IU/lLDH >1000 IU/l
Glucose <2.2 mmol/lGlucose <2.2 mmol/l
May be positive Gram May be positive Gram
stain/culturestain/culture
Requires chest tube Requires chest tube
drainagedrainage
EmpyemaEmpyema Frank pusFrank pus May be positive Gram May be positive Gram
stain/culturestain/culture
Requires chest tube Requires chest tube
drainagedrainage
No additional No additional
biochemical tests biochemical tests
necessary on pleural necessary on pleural
fluid (do not measure fluid (do not measure
pH)pH)

23. Classification of and Therapies for
Parapneumonic Effusion and Empyema
Appearance and Radiologic
ClassType Studies Appearance Treatment
1 Insignificant pleuralThoracentesis not
effusion (<10 mmindicated
thick) on decubitus
radiograph)
2 Typical para-Glucose >40 mg/dL Antibiotics alone
pneumonicpH >7.2
pleural effusionGram stain and culture
(>10 mm thick)negative

24. Classification of and Therapies for
Parapneumonic Effusion and Empyema (cont.)
Appearance and Radiologic
ClassType Studies Appearance Treatment
3 Bordeline ph 7.0-7.2 and/orNo loculationsAntibiotics and
complicated LDH >1000IU/L and repetition
pleural effusionGlucose >40 mg/dL
Gram stain and culture
negative
4 Simple compli-ph<7.0 and/orNot loculated,Tube thoracostomy
cated pleuralGlucose <40 mg/dLnonpurulent and antibiotics or
effusion and/or serial thoracentesis
Gram stain culture
positive

25. Classification of and Therapies for
Parapneumonic Effusion and Empyema (cont;)
Appearance and Radiologic
ClassType Studies Appearance Treatment
5 Complex complicated pH<7.0 and/orMultiloculatedTube thoracostomy a
pleural effusionGlucose <40 mg/dLnonpurulent & thrombolytic agent
and/or In rare instances
Gram stain or culture surgical intervention
positive
6 Simple empyemaFrank pus Single loculation orTube thoracostomy
with or without
decortication
7 Complex empyemaFrank pus Multiple loculesTube thoracostomy &
thrombolytic agents
Often thoracoscopy
or decortication

26. LoculationSeptation

27. Resolution of pleural effusionResolution of pleural effusion
DiseaseDisease Incidence%Incidence% TherapyTherapy Resolution timeResolution time
ParapneumonicParapneumonic 9-669-66 AntibioticsAntibiotics 2-8 weeks2-8 weeks
TubeculosisTubeculosis 3-233-23 No therapyNo therapy 2-4 months2-4 months
Anti-TB treatmentAnti-TB treatment1-2 months1-2 months
Post CABGPost CABG 40-9040-90 Self limitingSelf limiting 8 weeks(6w-20m)8 weeks(6w-20m)
RARA 4-74-7 NSAID, PrednisoneNSAID, Prednisone3-4m(1m-5y)3-4m(1m-5y)
SLESLE 16-3716-37 SteroidsSteroids 1-6w1-6w
PEPE 10-5010-50 HeparinHeparin 3-7d3-7d
PCISPCIS 40-6840-68 NSAID, SteroidsNSAID, Steroids 1w-4m1w-4m
SarcoidosisSarcoidosis 0-7.50-7.5 Self limiting,steroidsSelf limiting,steroids1-3m1-3m
Chest 119(5), 2001

28. <2 months<2 months 2-6 months2-6 months6m-1year6m-1year Benign persistentBenign persistent
ParapneumonicParapneumonic
CHFCHF
Acute pancreatitisAcute pancreatitis
PCISPCIS
Post CABGPost CABG
PEPE
SLESLE
SarcoidosisSarcoidosis
Traumatic chylothoraxTraumatic chylothorax
Uremic effusionUremic effusion
TBTB
PCISPCIS
Post CABGPost CABG
RARA
sarcoidosissarcoidosis
RARA
Benign Benign
asbestosisasbestosis
Trapped lungTrapped lung
LymphangiectasiaLymphangiectasia
Noonan’s syndromeNoonan’s syndrome
LAMLAM
Yellow nail syndromeYellow nail syndrome
Resolution of pleural effusion by time interval
Chest 119(5), 2001

29. Resolution of parapneumonic pleural effusionResolution of parapneumonic pleural effusion
organismorganism Incidence%Incidence%TherapyTherapy Resolution time Resolution time
(Range)(Range)
S pneumoniaeS pneumoniae 30-6030-60 B-lactams, B-lactams,
macrolidesmacrolides
4-8 weeks4-8 weeks
M pneumoniaeM pneumoniae 4-204-20 Macrolide, Macrolide,
tetracyclinestetracyclines
2-3 weeks2-3 weeks
L pneumoniaeL pneumoniae 12-3512-35 MacrolidesMacrolides 3-4 weeks3-4 weeks
AdenovirusAdenovirus 2-182-18 Self limitingSelf limiting2-3 weeks2-3 weeks
Chest 119(5), 2001

30. Tuberculous pleural effusionTuberculous pleural effusion
AFB stain positive in only 10-20%AFB stain positive in only 10-20%
AFB culture positive 25-50%AFB culture positive 25-50%
Diagnostic yield increases to 90% with Diagnostic yield increases to 90% with
addition of pleural biopsy histology and addition of pleural biopsy histology and
biopsy cultures for AFBbiopsy cultures for AFB

31. Pleural fluid markers for Pleural fluid markers for
tuberculosistuberculosis
Adenosine Deaminase (ADA)Adenosine Deaminase (ADA)
Gamma interferonGamma interferon
PCR for DNA of M. tuberculosisPCR for DNA of M. tuberculosis

32. Pleural fluid ADAPleural fluid ADA
T-lymphocyte enzymeT-lymphocyte enzyme
Patients with TB have levels above 45 IU/L Patients with TB have levels above 45 IU/L
unless they are immunologically suppressedunless they are immunologically suppressed
High levels also seen with empyema and High levels also seen with empyema and
rheumatoid pleuritisrheumatoid pleuritis
Specificity increased if combined with PF Specificity increased if combined with PF
lymph/poly ratio greater than 3lymph/poly ratio greater than 3
Pleural fluid ADA helpful in areas of high TB Pleural fluid ADA helpful in areas of high TB
prevelanceprevelance
Fluid ADA levels not useful in HIV patients with Fluid ADA levels not useful in HIV patients with
TBTB

33. Pleural fluid gamma interferonPleural fluid gamma interferon
Produced by lymphocytesProduced by lymphocytes
Lymphocytes specifically sensitized to PPD produce Lymphocytes specifically sensitized to PPD produce
gamma interferon when incubated with PPDgamma interferon when incubated with PPD
PF levels above 140pg/ml are very suggestive of TBPF levels above 140pg/ml are very suggestive of TB
Elevated whether or not the patient is Elevated whether or not the patient is
immunosuppressedimmunosuppressed
Is more expensive than ADAIs more expensive than ADA

34. PCR for the diagnosis of PCR for the diagnosis of
tuberculous pleuritistuberculous pleuritis
With PCR one can identify the presence of With PCR one can identify the presence of
DNA from M. tuberculosis in the pleural fluidDNA from M. tuberculosis in the pleural fluid
Study from spain on 107 pleural fluidsStudy from spain on 107 pleural fluids
–PCR positive in 17/21 with TBPCR positive in 17/21 with TB
–PCR positive in only two others and they probably PCR positive in only two others and they probably
had TBhad TB
–PCR was not superior to an ADA level >45PCR was not superior to an ADA level >45
Querol JM et al. Am J Respir Crit Care Med 1995;152:1977

35. Diagnosis of tuberculous pleuritisDiagnosis of tuberculous pleuritis
If pleural fluid ADA >70 units - diagnosticIf pleural fluid ADA >70 units - diagnostic
If pleural fluid gamma interferon is high - If pleural fluid gamma interferon is high -
diagnosticdiagnostic
Granulomas on pleural biopsy - diagnosticGranulomas on pleural biopsy - diagnostic
If lymphocytic effusion and positive PPD, If lymphocytic effusion and positive PPD,
treat for TB pleuritis if pleural fluid ADA is treat for TB pleuritis if pleural fluid ADA is
above 40above 40

36. Pleural effusions in HIV infectionPleural effusions in HIV infection
A pleural effusion is seen in 7–27% of A pleural effusion is seen in 7–27% of
hospitalised patients with HIVhospitalised patients with HIV
Leading causes areLeading causes are
Kaposi sarcomaKaposi sarcoma
parapneumonic effusionparapneumonic effusion
TuberculosisTuberculosis
LymphomaLymphoma
pneumocystic carinii pneumoniapneumocystic carinii pneumonia

37. Chylothorax and PsudochylothoraxChylothorax and Psudochylothorax

38. Fluid Triglyceride >110 mg /dl - DiagnosticFluid Triglyceride >110 mg /dl - Diagnostic
Presence of Chylomicron - DiagnosticPresence of Chylomicron - Diagnostic
Fluid Triglyceride 50-110 mg/dl – probable Fluid Triglyceride 50-110 mg/dl – probable
Fluid Triglyceride <50 mg/dl – Not chylothoraxFluid Triglyceride <50 mg/dl – Not chylothorax

39. Laboratory differentiation of chylothorax and Laboratory differentiation of chylothorax and
pseudothoraxpseudothorax
FeatureFeature PseudochylothoraxPseudochylothorax ChylothoraxChylothorax
TriglyceridesTriglycerides<0.56 mol/l <0.56 mol/l
(50mg/dl)(50mg/dl)
>1.24 mmol/l >1.24 mmol/l
(110 mg/dl)(110 mg/dl)
CholesterolCholesterol >5.18 mmol/l >5.18 mmol/l
(200 mg/dl)(200 mg/dl)
>5.18 mmol/l >5.18 mmol/l
(200 mg/dl)(200 mg/dl)
Cholesterol Cholesterol
crystalscrystals
Often presentOften present AbsentAbsent
ChylomicronsChylomicrons AbsentAbsent PresentPresent

40. Causes of chylothorax and pseudochylothoraxCauses of chylothorax and pseudochylothorax
ChylothoraxChylothorax
–Neoplasm: lymphoma, metastatic carcinomaNeoplasm: lymphoma, metastatic carcinoma
–Trauma: operative, penetrating injuriesTrauma: operative, penetrating injuries
–Miscelaneous: tuberculosis, sarcoidosis, Miscelaneous: tuberculosis, sarcoidosis,
lymphangioleiomyomatosis, cirrhosis, obstruction of lymphangioleiomyomatosis, cirrhosis, obstruction of
central veins, amyloidosiscentral veins, amyloidosis
PseudochylothoraxPseudochylothorax
–TuberculosisTuberculosis
–Rheumatoid arthritisRheumatoid arthritis
–Poorly treated empyemaPoorly treated empyema

41. Malignant pleural effusionMalignant pleural effusion

42. Malignant pleural effusionMalignant pleural effusion

43. Pleural fluid cytologyPleural fluid cytology
Very useful testVery useful test
1st specimen positive in 60% and if three 1st specimen positive in 60% and if three
specimens submitted, may be positive in >80%specimens submitted, may be positive in >80%
Very effective with adenocarcinomaVery effective with adenocarcinoma
Less effective with lymphoma, squamous cell Less effective with lymphoma, squamous cell
carcinoma, mesothelioma or Hodgkin’s diseasecarcinoma, mesothelioma or Hodgkin’s disease
cytology much better than needle biopsy in most cytology much better than needle biopsy in most
series looking at malignant effusionsseries looking at malignant effusions
–in one series of patients with malignancy, pleural in one series of patients with malignancy, pleural
biopsy positive in only 20/118 (17%) with negative biopsy positive in only 20/118 (17%) with negative
cytologycytology
–rarely is needle biopsy indicatedrarely is needle biopsy indicated

44. Sensitivity of pleural fluid cytology in malignant pleural Sensitivity of pleural fluid cytology in malignant pleural
effusioneffusion
ReferenceReference No.of patientsNo.of patientsNo. caused by No. caused by
malignancymalignancy
% diagnosed % diagnosed
by cytologyby cytology
Salyer et alSalyer et al
1010
271271 9595 72.672.6
Prakash et alPrakash et al
1212
414414 162162 57.657.6
Nance et alNance et al
1111
385385 109109 71.071.0
HirschHirsch
3939
300300 117117 53.853.8
Total:Total: 13701370 371371 61.661.6

45. Malignant pleural effusionMalignant pleural effusion
Observation
Observation is recommended if the patient is asymptomatic or there is
no recurrence of symptoms after initial thoracentesis. [C]
Therapeutic pleural aspiration
Repeat pleural aspiration is recommended for the
palliation of breathlessness in patients with a very short life
expectancy. [C]
Caution should be taken if removing more than 1.5 L
on a single occasion. [C]
The recurrence rate at 1 month after pleural
aspiration alone is close to 100%. [B]
Intercostal tube drainage without pleurodesis is not
recommended because of a high recurrence rate. [B]

46. Chemical Chemical
agentagent
Total Total
patients (n)patients (n)
Successful Successful
(%) (%)
dosedose
TalcTalc 165165 9393 2.5-10g2.5-10g
DoxycyclineDoxycycline6060 7272 500mg500mg
tetracyclinetetracycline359359 6767 500mg500mg
BleomycinBleomycin199199 5454 15-250 units15-250 units
Success rates of commonly used pleurodesis agents

48. Rheumatoid arthritis associated
pleural effusions

49. •Suspected cases should have a pleural fluid pH,
glucose and complement measured.
•Rheumatoid arthritis is unlikely to be the cause of an
effusion if the glucose level in the fluid is above
1.6 mmol/l (29 mg/dl).

50. EntityEntity Frequency (%)Frequency (%)
Rheumatoid Rheumatoid
ArthritisArthritis
8585
EmpyemaEmpyema 8080
Malignant Malignant
effusioneffusion
3030
TuberculousTuberculous 2020
LupusLupus 2020
Frequency of low glucose values in pleural effusions

51. SLE associated pleural SLE associated pleural
effusioneffusion

52. The presence of LE cells in pleural fluid The presence of LE cells in pleural fluid
is diagnostic of SLE.is diagnostic of SLE.
The pleural fluid ANA level should not The pleural fluid ANA level should not
be measured as it mirrors serum levels be measured as it mirrors serum levels
and is therefore unhelpful.and is therefore unhelpful.

53. Hepatic hydrothoraxHepatic hydrothorax

54. Pleural effusion associated with liver Pleural effusion associated with liver
cirrhosiscirrhosis
Mostly associated with ascites Mostly associated with ascites
Can occur without ascitesCan occur without ascites
Diagnostic tap of both pleural effusion and Diagnostic tap of both pleural effusion and
ascitesascites
Difficult to treat Difficult to treat
Pleurodesis usually unsuccessfulPleurodesis usually unsuccessful

55. MANAGEMENT OF PERSISTENT MANAGEMENT OF PERSISTENT
UNDIAGNOSED PLEURAL EFFUSIONUNDIAGNOSED PLEURAL EFFUSION
• In persistently undiagnosed effusions the possibility
of pulmonary embolism and tuberculosis should be
reconsidered since these disorders are amenable to
specific treatment.
• Undiagnosed pleural malignancy proves to be the
cause of many “undiagnosed” effusions with sustained
observation.

56. Presence of transudate effusion indicates the existence Presence of transudate effusion indicates the existence
of systemic disease.of systemic disease.
Exudative effusion is caused by a local pleural process.Exudative effusion is caused by a local pleural process.
Spontaneous bacterial empyema can complicate Spontaneous bacterial empyema can complicate
hepatic hydrothorax.hepatic hydrothorax.
TB and malignancy are the two commonest causes of TB and malignancy are the two commonest causes of
unexplained exudative effusion.unexplained exudative effusion.
TB effusion is caused with equal frequency by primary TB effusion is caused with equal frequency by primary
& reactivated TB& reactivated TB
Hemothorax if HCT > 20%Hemothorax if HCT > 20%
Pleural Effusion Pearls

57. Pleural Effusion Pearls
Massive pleural effusions are most
commonly due to malignancy. [B]
The majority of malignant effusions are
symptomatic. [C]
Very low glucose in the absence of infection
is highly suggestive of RA

58. Thank youThank you