Common pleural effusions in children

The evaluation of pleural effusions in children differ from that of the adult in cause, symptom presentation, character of the fluid, techniques for diagnosis, treatment or management, and prognosis. These similarities and differences are reviewed with emphasis on the treatment of empyema.     

Malignant pleural effusions treated with high dose intrapleural doxycycline: clinical efficacy and tolerance

Chronic malignant pleural effusion may be treated by instillating products in the pleural space to induce pleurodesis. We used intrapleural doxycycline at doses greater than 2000 mg in 16 malignant pleural effusion (14 patients). Patient survival ranged from 1 day to 19.5 months. Mean drainage duration was 7.5 days (range, 5-10 days). Pain (moderate n=7; severe n=2) was the most frequent side-effect with hypotension (moderate n=3; severe n=1). Five cases were not evaluable at one month because of death during the month following treatment (n=3) or during treatment (n=2). At one month follow-up, success was defined as no pleural effusion (n=5), partial response as minimal effusion (n=4) and we considered that treatment had failed if pleural drainage was necessary (n=2). Five patients died within one month and 5 had more than 3 months survival (4 without recurrence).     

Positivity of pleural fluid cytologic examination in transudative pleural effusions

Because of the increased fragility of a freshly dissected aorta, the anastomosis between the aortic root and a tubular prosthesis is not forgiving of technical imperfections and may lead to troublesome bleeding. Providing an appropriate everting surface of contact and a homogeneous distribution of tension between the graft and aorta, as described here, should help obtain a hemostatic suture line.     

Immunoglobulins and complement in pleural effusions associated with bronchogenic carcinoma

Levels of IgG, IgA, IgM, the total haemolytic complement (CH50), and the individual components C1q, C3, C4, C6, and C7 were measured in 29 pleural effusions. Of these, 18 were associated with carcinoma of the bronchus and 11 were non-malignant effusions including empyemas. The level of IgG was significantly lower in the malignant group when compared with non-malignant effusions. The usefulness of measurements of IgG with respect to malignant effusions associated with carcinoma of the bronchus requires an expanded study to show whether it has any real diagnostic value. There were no significant differences in other immunoglobulins, the CH50, and individual complement components between the two groups. The identification of total haemolytic activity in the majority of effusions in both groups indicates that all nine components of the classical pathway of complement, including macromolecules such as C1, can be present in pleural fluids.     

Indwelling small pleural catheter needle thoracentesis in the management of large pleural effusions

STUDY OBJECTIVES: To evaluate the clinical safety, efficacy, and cost of a small indwelling pleural catheter (7F, Turkel Safety Thoracentesis System [Sherwood, Davis, and Geck; St. Louis]) vs repeated needle thoracentesis or closed tube thoracostomy as a means to drain a large-volume pleural effusion. SETTING: Inpatients in a tertiary care university teaching hospital in urban Chicago. DESIGN: Prospective, consecutive patient comparative study using historical controls. PATIENTS: Fifty-seven therapeutic aspirations in 23 patients with large pleural effusions as defined by opacification of at least one third of the hemithorax on chest radiography. Patients were excluded if they had a history of thoracic surgery, documented loculations, structural chest abnormalities, severe coagulopathy, or refused to give informed consent. MEASUREMENTS: Volume of each pleural aspiration, total fluid removed, pleural fluid lactate dehydrogenase, protein, glucose, cytologic analysis, microbiologic stains, and cultures based on clinical indications. RESULTS: We found that initial thoracentesis and repeated pleural drainage using the indwelling catheter system is a safe, efficacious, and cost-effective procedure that may aid the evacuation and management of a large-volume pleural effusion. There were fewer adverse effects and complications such as pneumothorax, splenic laceration, hemopneumothorax, local pain, dry tap, and hematomas, as compared with previous reports. The overall complication rate was 12% (7/57). There were two pneumothoraces detected (3.5%), one of which required closed tube thoracostomy for treatment (1.75%). A further benefit comes in the form of a significant cost savings at our institution ($80 vs $240) when this needle-catheter system is used in place of closed tube thoracostomy in the drainage of a large-volume pleural effusion. CONCLUSION: An indwelling pleural catheter with the Turkel safety needle-catheter (as described in the study) can be used to successfully drain the pleural space with reduced morbidity and a significant cost saving in comparison to repeated needle thoracenteses or closed tube thoracostomy.     

Diagnostic value of closed percutaneous pleural biopsy vs pleuroscopy in suspected malignant pleural effusion or tuberculous pleurisy in a region with a high incidence of tuberculosis: a comparative, age-dependent study

OBJECTIVE: To compare the value of closed percutaneous pleural biopsy versus pleuroscopy for diagnosis of undiagnosed exudative pleural effusion in an age-dependent manner. DESIGN: Prospective clinical study. SETTING: University hospitals. PATIENTS: Forty-nine consecutive patients with undiagnosed exudative pleural effusion following the initial clinical and paraclinical investigations, including bronchoscopy. Cases were divided into younger and older groups according to their ages. INTERVENTION: Closed pleural biopsy immediately followed by pleuroscopy with a flexible fiberoptic bronchoscope from the same incision site. RESULTS: In the older age group, pleuroscopy was superior to closed pleural biopsy for the diagnosis of the underlying pleural disease (P = 0.0007), while they were almost equally diagnostic in the younger cases (P = 0.58). CONCLUSION: For those patients with undiagnosed exudative pleural effusion who are older than 50 years of age, pleuroscopy could be chosen as the first procedure of choice as compared to closed pleural biopsy if malignant pleural effusion is suspected.     

Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas

In the treatment of multiloculated pleural effusions and empyemas tube thoracostomy often fails and more aggressive surgical therapy is required. Intrapleural administration of fibrinolytics is a valuable alternative. Between October 1994 and December 1995 28 patients (aged 22 to 62 years) with multiloculated pleural effusions were treated with intrapleural instillations of streptokinase after unsuccessful conventional chest tube drainage. Twenty-three pleural effusions were grossly purulent, others were loculated effusions with low pH. The most common cause of the pleural effusions was pneumonia. Duration of illness before hospitalization was 3 to 105 (mean 21.8) days. Treatment with streptokinase was started most commonly one day after chest tube placement. Once a day after clamping the chest tube streptokinase was administered intrapleurally for 10-15 minutes as a solution of 250,000 units in 100 ml normal saline. The tube remained clamped for 3 hours. Two to 8 (mean 3.7) instillations per patient were needed. Twenty-one cases (72.4%) showed excellent resolution of pleural effusion and needed no more therapy. However, one patient died in hospital due to purulent meningitis and bilateral pneumonia. Eight patients needed further surgical treatment, e.g. decortication, in 5 cases together with wedge lung resection. Eleven patients experienced some adverse effects of streptokinase therapy, most frequently chest pain and elevation of body temperature in one case pleural effusion became hemorrhagic, and one patient had nasal bleeding. We conclude that usage of intrapleural streptokinase in the treatment of multiloculated pleural effusions (including pleural empyemas) reduces the need for major surgical interventions in quite a large group of patients.     

Experience with closed needle biopsy and pleural fluid cytology in the diagnosis of malignant pleural effusions in Yaounde, Cameroon

To determine and compare the efficacy of pleural fluid cytology and closed needle biopsy of the pleura in establishing the diagnosis of malignant pleural effusions in Yaounde, we reviewed the medical records of all consecutive patients with a pleural effusion admitted in unit B of the Chest Clinic of the Jamot Hospital between January 1990 and December 1994. Fifty four cases of malignant pleural effusion were diagnosed over this period. Closed needle biopsy of the pleura alone permitted a diagnosis of malignancy involving the pleura in 32 instances while cytological studies of pleural fluid provided a diagnosis in thirty six cases. A combination of both techniques was diagnostic in 48 (88.9%) patients. We recommend that both pleural fluid cytology and closed needle biopsy of the pleura be used concomitantly in the evaluation of pleural effusion for which malignancy is suspected.     

Elevated sialyl Lewis X-i antigen levels in pleural effusions in patients with carcinomatous pleuritis

The levels of sialyl Lewis X-i antigen (SLX), which is one of the cancer-associated carbohydrate antigens, were evaluated in 83 malignant and 46 benign pleural effusions. SLX levels in pleural effusion due to lung adenocarcinoma were significantly higher than those due to benign diseases (p < 0.0001), lung cancer other than adenocarcinoma (p = 0.0052), and adenocarcinoma originating from other organs (p = 0.0492). According to receiver operating characteristic (ROC) curve analysis, the optimal cut-off level in the discrimination between malignant and benign pleural effusions was 92 U/ml, which gave a sensitivity of 57.1% and a specificity of 77.8%. The cut-off level of pleural effusion in patients with carcinomatous pleuritis might be higher than that of serum (38 U/ml).     

Usefulness of chromosome examination in the diagnosis of malignant pleural effusions

To determine whether chromosome analysis could facilitate the diagnosis of malignant pleural effusions, we examined chromosomes in effusions from 104 unselected patients. An effusion was regarded as malignant if at least three of 30 metaphase cells were hyperdiploid or contained a marker chromosome. Results were compared with standard cytologic diagnoses. All 22 benign effusions were diagnosed correctly by cytologic examination, but one nosed correctly by cytologic examination, but one (acute rheumatoid lung disease) was misclassified as positive by chromosome criteria. Of the 82 malignant effusions, 53 (65 per cent) were diagnosed correctly by cytologic tests, as compared with 58 (71 per cent) by chromosome analysis (P greater than 0.2). Among patients with malignant neoplasms, 13 had leukemia or lymphoma; only four of these (31 per cent) were diagnosed by cytologic tests as compared with 11 (85 per cent) by chromosome analysis (P less than 0.01). The combination of standard cytologic and chromosome analyses correctly identified 83 per cent of the neoplasms, a result significantly better than that with either technic alone (P less than 0.01).     

MMP and TIMP expression pattern in pleural effusions of different origins

The matrix metalloproteinases (MMP) are proteolytic enzymes that are essentially involved in the turnover of the extracellular matrix (ECM). Their activity is counterbalanced by specific antagonists, the tissue inhibitors of metalloproteinases (TIMP). In this study, we sought to analyze the expression of MMP and TIMP isoforms in pleural effusions from 88 patients. We compared MMP and TIMP isoform expression in transudates (n = 21) and exudates (n = 67), the latter divided into exudates of paraneoplastic (n = 46) or parainfectious (n = 21) origin. Zymographic and Western blot analyses revealed constant expression of interstitial collagenase (MMP-1), gelatinase-A (MMP-2), and TIMP-1 in all 88 samples. In contrast, analyses of gelatinase-B (MMP-9) demonstrated a specific expression pattern, with high expression in exudates and lack of expression in transudates. Neutrophil collagenase (MMP-8) was detected in trace amounts, and correlated with the number of neutrophils in the effusion. Low levels of TIMP-2 were detected only in exudates and not in transudates. Quantitative analysis of the expression ratio of gelatinase-B to gelatinase-A revealed statistically significant differences between effusions of different origin. The ratio was highest in exudates of paraneoplastic origin and lowest in transudates. Our data thus suggest that interstitial collagenase, gelatinase-A, and TIMP-1 play a role in homeostasis of the pleural space in vivo as constitutively expressed proteins, whereas gelatinase-B and TIMP-2 expression are induced in specific disease states. These observations contribute to the understanding of the pathophysiology of pleural effusions, and may help to characterize and possibly distinguish effusions of different origin.     

Chylous pleural effusions simulating leukemic infiltrate associated with thoracoabdominal disease and surgery in infants

Charcot-Marie-Tooth type 1B (CMT 1B) disease, an inherited demyelinating peripheral neuropathy, results from different point mutations located in the P0 gene on chromosome 1 q21-23. We have quantified, at the ultrastructural level, the immunocytochemical expression of the P0 protein in two unrelated CMT 1B patients with mutations (Ser 78 to Leu and Asn 122 to Ser) located in two different exons in the extracellular domain of the protein. A twofold decrease in P0 expression was observed in compact myelin in each case, compared with age-matched controls. The severity of the phenotypes showed no direct relationship to the levels of P0 protein expression in these 2 patients.     

Diagnosis of pleural effusions. Experience with clinical studies, 1986 to 1990

OBJECTIVES: To identify in patients with pleural effusion which procedures are most useful in separating malignant from nonmalignant pleural effusions and to identify which procedures most commonly lead to a definitive diagnosis. DESIGN: Prospective consecutive case series. SETTING: Pulmonary referral hospital in Prague, Czech Republic. PATIENTS: One hundred seventy-one adults between ages 18 and 70 years with a pleural effusion and a Karnofsky score of 70 or above. INTERVENTIONS: All patients underwent history, physical, pleural fluid cytologic study, laboratory evaluation of serum and pleural fluid, pleural biopsy, bronchoscopy, and lung scan and/or pulmonary arteriogram. RESULTS: In this series in which 45% of the patients had malignant effusions, 19% had paramalignant effusions, and 36% had benign diseases, the pleural fluid cytologic study was the best for establishing a diagnosis. The pleural fluid carcinoembryonic antigen (CEA) levels above 10 had a high specificity (90%) for malignancy but had low sensitivity (37%). The pleural fluid CEA level was increased only in 19% of patients with paramalignant effusions. Although there were statistically significant differences in the mean results on several biochemical tests of pleural fluid, none were very accurate in separating malignant from benign disease. CONCLUSION: From this study, we conclude that patients with an undiagnosed pleural effusion should be evaluated in an individualized stepwise manner. If malignancy is strongly considered, the initial three steps should be relatively noninvasive and include clinical evaluation and cytologic study.     

Prevalence of nocardiosis in an area of endemic tuberculosis

OBJECTIVE: To assess the quantity and nature of the proteins that adsorb to hydrocephalus shunt catheters after implantation, and to determine whether sufficient could accumulate to obstruct the catheter. DESIGN: Elution of proteins from 102 explanted shunt catheters, with protein assay and electrophoresis of the eluate, and scanning electron microscopy (SEM) of the catheters. RESULTS: The amount of protein elutable was extremely low, and significant protein, apart from a thin film, was not found on SEM. Qualitative analysis disclosed that most of the adsorbed protein was albumin. CONCLUSIONS: Protein deposition on hydrocephalus catheters does not occur in sufficient quantities to cause catheter obstruction.     

Malignant pleural effusions: recourse to early use of talc

INTRODUCTION: Our purpose was to assess the efficacy, permanence and safety of thoracoscopic talc poudrage (TTP) for pleurodesis in malignant effusions. We report the follow-up of 360 patients who received TTP in two centers in Marseille (France). CURRENT KNOWLEDGE AND KEY POINTS: Eighty-eight patients presented with mesothelioma and 272 had pleural metastasis. The mean follow-up time was 12 months (range: 2-120). Out of the 327 patients whose response could be evaluated, 90.2% had a successful pleurodesis at 1 month, and 82.1% had a life-long pleural symphysis. Adverse effects included one death 3 days after the procedure in an end-stage patient, fever (9.8%), infection of the parietal scar (2.5%) and pulmonary infection (0.8%). FUTURE PROSPECTS AND PROJECTS: TTP is an effective and safe method of life-long pleurodesis. It should be performed early on in the history of malignant effusions to avoid failures of the technic, mainly linked to trapped lung and to the general condition of patients.     

Diagnostic value of pleural adenosine deaminase in tuberculous effusions of immunocompromised hosts

To investigate the diagnostic value of adenosine deaminase (ADA) in immunocompromised hosts with tuberculous pleural effusions, we collected and checked 60 pleural effusion specimens from admitted patients. These patients were divided into three groups: group I (n = 20), immunocompetent hosts with tuberculous pleural effusions; group II (n = 10), immunocompromised hosts with tuberculous pleural effusions; and group III (n = 30), patients with malignant pleural effusions. Using statistical analysis to compare the ADA value in each group, the p value was found to be significant between groups I and II (p < 0.01), groups I and III (p < 0.001) and groups I+II and III (p < 0.001); however, the p value was not significant between groups II and III. If the lowest ADA value for the tuberculous pleural effusion was designed as 80 U/L, the sensitivity/specificity was 1.0/0.90 (group I), 0.40/0.90 (group II), and 0.80/0.90 (group I+II), respectively. We conclude that the diagnostic value of ADA in immunocompromised hosts with tuberculous pleural effusions is not as significant as in immunocompetent hosts.