This combination is common and requires especially careful correlation with. Diagnostic approach to pleural effusion in adults american. Conventional diagnostic tests, such as microscopic examination of the pleural fluid, biochemical tests, culture of pleural fluid, sputum or pleural tissue, and histopathological examination of pleural tissue, have known limitations. The advance metabolomics approach is mentioned for the usefulness for. Parapneumonic pleural effusions are exudates that accompany bacterial pneumonias. Differential diagnosis issues of atypical pleural lesions study cap. The use of certain pleural fluid tests such as leukocyte count and differential, glucose, ph and, when indicated, pleural fluid amylase determinations, helps to narrow the differential diagnosis of an exudative pleural effusion. Significance of serum effusion albumin gradient in the differential diagnosis of pleural effusion mc dhar1, s chaudhuri2 k basu2tj sau3, d pal4 and k mitra1 received on 16 6. Key points evaluation of the patient with pleural effusion is challenging, because the differential diagnosis is broad and includes both benign and lifethreatening conditions.
Tuberculous pleuritis is a common manifestation of extrapulmonary tuberculosis and is the most common cause of pleural effusion in many countries. It is the most common manifestation of pleural disease, with etiologies ranging from cardiopulmonary disorders to symptomatic inflammatory or malignant diseases requiring urgent evaluation and trea. The differential diagnosis between tuberculous effusion and other effusions usually requires a good diagnostic test. We conclude that ct is helpful in the differential diagnosis of diffuse pleural disease, particularly in differentiation of malignant from benign conditions. Recommendations of diagnosis and treatment of pleural effusion.
Pleurisy and pleural effusion in differential diagnosis the bmj. Many pleural fluid tests are useful in the differential diagnosis of. Pleural effusion in adultsetiology, diagnosis, and treatment. In 164 diagnostic thoracenteses, 6 cytologic examinations were done. Pleural effusion is a major diagnostic problem, since the pleura is an inner cavity with no direct access.
Clinical features in the diagnosis of pleural effusions and identifying etiology. Initial investigations showed a rightsided pleural effusion and pleural thickening suggestive of malignancy, which would have been in keeping with the clinical presentation. In contrast, our decision tree enables a specific diagnosis of the most common causes of pleural effusion. Thoracentesis is a simple bedside procedure with imaging guidance that permits fluid to be rapidly sampled, visualized, examined microscopically, and quantified for chemical and cellular content. One purpose of this paper is to report that the cause of such an effusion may be a fungus infection. Estimated prevalence of pleural effusion is 320 cases per 100,000 people in industrialized countries, with a distribution of etiologies related to the prevalence of.
Treatment for pleural effusion is based on what caused the pleural effusion. The modern diagnosis and management of pleural effusions. Pleural fluid studies were suggestive of a transudative process, though with some abnormal characteristics including lymphocyte predominance, as well as presence of signet cells. There is also a right pleural effusion with fluid tracking into the minor fissure. However, no studies evaluating the efficacy of ue for diagnosing mpe are available. The differential diagnosis of pleural effusions request pdf.
Three quarters of patients with pe in whom a diagnostic thoracentesis was indicated had cancer, heart failure, pneumonia or tuberculosis. This brought about a full resolution of the effusions and he made a complete recovery. Evaluation of the patient with pleural effusion cmaj. Pleural effusion in which a high proportion of the cells are eosinophils is not a widely recognized phenomenon. Pdf pleural effusion is defined as an abnormal amount of pleural fluid. Symptoms may resemble other respiratory problems, and diagnosis and treatment depend on the underlying cause. Pleural effusions may be classified by differential diagnosis table 925 or by. This video will guide you with laboratory examination of pleural effusion and how to read the chest xray in case of pleural effuion. Other tests help ful for diagnosis include helical computed tomography and thoracoscopy. Approach to diagnosis of pleural effusion page 1 of 3 department of clinical effectiveness v4 approved by the executive committee of the medical staff on 03262019 prior thoracentesis performed. Pleural effusion pleff, mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. There is a large left pleural effusion obscuring the lower half of the left hemi thorax. The differential diagnosis may include benign squamous cells associated with fistula, extraneous contamination, and possibly squamous metaplasia of mesothelium. Jun 30, 2016 a pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption or both.
Its most common causes are congestive heart failure, cancer, pneumonia, and pulmonary embolism. Pleural effusion has a wide differential diagnosis. The majority resolve with antibiotic treatment, but a certain number will progress to an infected pleural space. A delayed etiological diagnosis can be associated with markedly higher morbidity and mortality, e. Differential diagnosis issues of atypical pleural lesions. This combination is common and requires especially careful correlation with the clinical data. T he pleural effusion is a medical condition in which excess of fluid accumulates in pleural space, an area between the layers of tissue that line the lungs and the chest cavity. Gathering of initial clinical data guided by the differential diagnosis can orient care by identifying patients in need of urgent evaluation and by. In our study malignant mesothelioma was second to adenocarcinoma as a cause of malignant pleural effusion. Malignancy accounts for about 40 of symptomatic pleural effusions, with congestive heart failure and infection being the other leading causes national cancer institute, 2006 29 fluid collection in both lower lobes of the lungs due to chf. Pleural disease remains a commonly encountered clinical. Thoracentesis should always be performed, because the differential diagnosis includes heart failure, pulmonary embolism, chylothorax or infectious pe.
Pleural fluid adenosine deaminase ada is a wellknown biomarker for the diagnosis of tuberculous pleural effusion tpe in patients with lymphocytic exudative pleural effusion 68. This material may not otherwise be downloaded, copied, printed. A case study of a patient with a pleural effusion is presented, as well as a brief description of the signs and symptoms, pathophysiology, and management of this disease process. This brought about a full resolution of the effusions and he made a complete. A pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption or both. Pleural effusions may be classified by differential diagnosis table 925 or by underlying pathophysiology. However, elevated pleural fluid ada levels, a finding that is uncommon in solid tumors, is frequently.
In summary, we have shown that pleural fluid ldh isoenzyme pattern may be useful in the differential diagnosis of pleural effusion when the diagnostic possibilities are limited to malignancy, pneumoniarelated effusion, and chf. Clinical assessment alone is often capable of identifying transudative effusions. Moreover, the invasive and noninvasive tests required to make an etiological diagnosis may not be readily available in a. Pneumonia is associated with an exudative pleural effusion in up to 57% of cases and is the most common cause of pleural effusion in young patients. The differential diagnosis of pleural fluids is wide and may indicate the presence of pleural, pulmonary or extrapulmonary disease. If the pleural fluid differential cell count shows a predomi nant lymphocytosis, the most likely diagnoses are tuberculosis and malignancy. Novel tests for diagnosing tuberculous pleural effusion. This critical distinction narrows the differential diagnosis and directs further investigation. Specific causes of pleural effusion parapneumonic effusion and empyema.
Pleural effusion is caused by many disorders and can potentially be lifethreatening. In 5060% of cases, classification of the effusion leads to a presumptive diagnosis. Pleural effusion, which in pediatric patients most commonly results from an infection, is an abnormal collection of fluid in the pleural space. A monoclonal antibody against soluble phaseterminal complement complex sc5b9 was used to try to differentiate pleural effusions of tuberculous vs malignant and other origin. Pleural effusion is defined as an abnormal amount of pleural fluid accumulation in the pleural space and is the result of an imbalance between excessive pleural fluid formation and pleural fluid. Effusions of tuberculous origin showed a significantly higher sc5b9 level than did plasma, suggesting activation of complement in the pleural space. Thoracic ultrasound tus helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Approach to diagnosis of pleural effusion page 1 of 3. Your doctor will perform a physical exam, listen to your chest and discuss your symptoms.
Pleural effusion current medical diagnosis and treatment. Differential diagnosis of pleural effusions jmaj 49910. In a retro spective study, we found that measurement of cea couldbe helpfulinthisrespect. A premature neonate who developed respiratory distress in the first few days of life was found to have a pleural effusion, which reaccumulated following drainage. The aim of the stuidy, carried out in the department of medicine, r. Introduction traditional thoracic ultrasound tus is often the initial tool used to help diagnose malignant pleural effusion mpe. The resultant homeostasis leaves 515 ml of fluid in the normal pleural space. Benign asbestos pleural effusions occur within 20 years after exposure. Diagnostic approach to pleural effusion in adults jose m.
Pleural effusion results from fluid accumulating in the potential space between the visceral and parietal pleurae when there is an imbalance between formation and absorption in various disease states, in response to injury, inflammation, or both locally and systematically. The commonly used criteria of light et al 2 for the differentiation of pleural effusion establish the exudative or transudative nature of the pleural fluid but do not determine its specific etiology. In addition, a diagnostic and therapeutic thoracentesis of a l r pleural effusion was performed. Bts guidelines for the investigation of a unilateral pleural effusion in. A definitive diagnosis is made through cytology or identification of causative organism in 25% of cases. Jun 21, 2017 pleural effusion is caused by many disorders and can potentially be lifethreatening. Two patients with eosinophilic effusion are described in detail, and several others of. Differential diagnosis of pleural effusion by lactate.
Differential diagnosis of pleural effusion by lactate dehydrogenase isoenzyme analysis. Ct in differential diagnosis of diffuse pleural disease. Diagnostic approach to pleural effusion in adults american family. All 26 patients with tuberculous effusions showed sc5b9 levels in. A pleural effusion is an abnormal accumulation of fluid in the pleural space. Dec 19, 2014 in addition, a diagnostic and therapeutic thoracentesis of a l r pleural effusion was performed. R pleurisy and pleural effusion in differential diagnosis br med j 1943. Pleural effusion differential diagnoses medscape reference. Malignant mesothelioma n 11 could not be reliably differentiated from pleural metastases n 24. Mar 12, 2018 key points evaluation of the patient with pleural effusion is challenging, because the differential diagnosis is broad and includes both benign and lifethreatening conditions. Pleural effusion develops because of excessive filtration or defective absorption of accumulated fluid. Estimated prevalence of pleural effusion is 320 cases per 100,000 people in industrialized countries, with a distribution of etiologies related to the prevalence of underlying diseases. Pdf a pleural effusion is an excessive accumulation of fluid in the pleural space. Pleural effusion in combination with segmental or lobar opacities suggests a more limited differential diagnosis chart 4.
The history and physical examination of a patient with a pleural effusion may guide the clinician as to whether the effusion is a transudate or an exudate. Pleural effusion current medical diagnosis and treatment 2020. Determining the cause of a pleural effusion is greatly facilitated by analysis of the pleural fluid. Ultrasound elastography ue, a relatively new technique, has been used to differentiate malignant disease from benign disease by evaluating tissue stiffness. Additionally, betas microglobulin, whichwas found increased in some malignant pleural ef. The serum to pleural fluid protein or albumin gradients may help better. Apr 30, 2018 pleural effusion, which in pediatric patients most commonly results from an infection, is an abnormal collection of fluid in the pleural space. Absorption of pleural fluid occurs through parietal pleural lymphatics. She had a previous history of breast malignancy and no clear risk factors for tuberculosis tb. When we attempt to identify the cause of the pleural effusion, most patients undergo various diagnostic procedures. Pleural effusions are common, with an estimated 11. Utility of hyaluronic acid in pleural fluid for differential.
We report the case of a 64yearold woman, presenting with pleuritic chest pain and weight loss. He required multiple chest drains and was started on a medium chain triglyceride formula feed. The differential diagnosis of exudate poses a more difficult challenge for clinicians. Accumulation of fluid between the pleural layers epidemiology of pleural effusion. A diagnosis of pleural effusion may be sug gested by characteristic symptoms e. The cause of pleural effusion in 108 of 3 patients was determined by laboratory tests and clinical examination. Differential diagnosis between lymphomaassociated malignant.