Differential diagnosis of pleural effusion

The results of following up 598 patients diagnosed as having pleural exudate were used to analyze the potentialities of complex radiation and clinical differential diagnoses of this abnormality. The authors identified 4 most common nosological entities (tuberculosis, pleuropneumonia, cancer, mesothelioma) among patients of diagnostic hospitals. The diagnostic algorithm should be derived by taking into account the current techniques applicable to each disease form. With this, valid diagnosis may be made in 98.5% of cases.     

Markedly elevated cytokines in pleural effusion during the ovarian hyperstimulation syndrome: transudate or ascites?

OBJECTIVE: To study levels of proinflammatory cytokines in pleural fluid during the severe ovarian hyperstimulation syndrome (OHSS). DESIGN: Case report. SETTING: Tertiary academic medical center. PATIENT(S): A 35-year-old female with a 6-year history of unexplained infertility on menotropin therapy and 28 healthy normal controls. INTERVENTION(S): Thoracentesis for severe pleural effusion and venipunctures. MAIN OUTCOME MEASURE(S): Interleukin-1 beta (IL-beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) levels were measured by ELISA and compared between pleural effusion and serum from normal controls. RESULT(S): Pleural effusion IL-1 beta and IL-6 levels were higher than serum. Interleukin-6 levels were elevated particularly in pleural effusion (1,961.89 pg/mL) compared with serum (3.9 +/- 0.41 pg/mL). CONCLUSION(S): Our results confirm the high cytokine levels observed in OHSS. Cytokines have been implicated in capillary permeability, extravasation of fluid, oliguria, and shock. We have postulated that these mediators are released from the corpora lutea into the peritoneum and systemic circulation. Alternatively, the presence of high cytokine levels in pleural fluid maybe the result of diaphragmatic defects, which allow for the migration of ascites into the pleural space.     

CT diagnosis of pleural dissemination without pleural effusion in primary lung cancer

We retrospectively reviewed the CT scans of 25 primary lung cancers with disseminated pleural nodules or minimal malignant pleural effusions that were not recognized preoperatively. Special attention was devoted to abutting interlobar fissures, thick major fissures, and disseminated nodules on the chest wall, the diaphragm, and in the interlobar fissures. Among 10 primary tumors abutting interlobar fissures, nine (90%) had at least one of these findings. Among 15 primary lung tumors which did not abut interlobar fissures, four (27%) had at least one of these findings. We conclude that CT is a useful modality for detecting the pleural dissemination of primary lung cancers when primary lung cancers abut interlobar fissures even if no pleural effusion is detectable on CT.     

Fibrous pleural tumour producing 171 litres of transudate

Localized fibrous tumours of the pleura (or localized benign mesothelioma) are rare, and in most cases, asymptomatic. This report describes a 48 yr old female with a right-sided fibrous pleural tumour, which produced 171 L of transudate before a correct diagnosis was reached. The tumour was surgically removed and the transudation stopped immediately.     

Exudative pleural effusion and pleural leukocytoclastic vasculitis in limited scleroderma

Chlorofluorocarbons (CFCs) damage stratospheric ozone permitting enhanced levels of ultraviolet B radiation to reach the Earth's surface. As a result, production of CFCs is now banned under the Montreal Protocol with the exception of their temporary continued use in pressurized metered dose inhalers used to treat those with airway disorders. Replacement propellants have now been identified and shown to be safe and a major exercise is under way to reformulate the commonly used aerosolized medicines with the new propellants. The new products are now undergoing clinical trials and the first reformulated beta-agonist and corticosteroid inhalers have reached the marketplace. The majority of the current products will have been changed over to the new types over the next 3 yrs, and each country will adapt a transition strategy to oversee this process. The politicians, the environmentalists, the pharmaceutical industry and the regulatory authorities have fulfilled their part in this changeover, and respiratory interested health professionals now need to address what this means for them and their patients so that there may be a seamless transition for the millions of people who use inhaled medicines worldwide.     

Pleurodesis in malignant pleural effusion

About 50% of the pleural effusions diagnosed are caused by a malignancy, especially by thoracic, pulmonary and ovarian cancer and lymphomas. The accumulation of fluid is caused by metastasization to the pleura and obstruction of lymph vessels and nodes. The effusion generally decreases if the tumour responds to systemic treatment. However, frequently this does not occur and the fluid has to be removed, to alleviate symptoms such as dyspnoea, coughing and a heavy sensation in the chest. Possible surgical therapies are draining through a needle or a drain, (partial) pleural resection and the creation of a pleuro-peritoneal shunt. Disadvantages of these are early recurrences, the severity of the intervention and (or) the high morbidity and mortality. The current standard treatment is pleurodesis brought about by a sclerosing agent, usually via a drain. The substances preferably used for this purpose are, in the order of decreasing importance, tetracycline, bleomycin or talc, doxycycline or minocycline. The most frequent adverse effects are chest pain and fever during and after the pleurodesis.     

Benign postpartum pleural effusion

The conditions of labour appear to favour the development of pleural effusion. The frequency of postpartum pleural effusion was investigated in this study using thoracic ultrasonography. Thirty one postpartum and 22 healthy nonpregnant women of the same age-group were examined, both supine and seated, via an intercostal approach. Seven of the 31 (23%) postpartum women had pleural effusion within 1-24 h of normal delivery. None of the nonpregnant women had pleural effusion. No correlation was found between postpartum pleural effusion and age, weight-gain during pregnancy, duration of labour, use of intravenous fluid, or oxytocin administration. Pleural effusion seems to be a common finding postpartum, but of no clinical significance.     

Sonography of malignant pleural effusion

Two hundred and ten patients with exudative pleural effusion were studied by ultrasound for sonographic signs of pleural carcinomatosis. Images were evaluated for echoes within the fluid, septations, sheet-like or nodular pleural masses, and associated lesions of the lung. Our results showed that sonographic findings of echogenic or septated fluid were unspecific for malignancy. Only the evidence of pleural masses was characteristic of malignant effusion. Ultrasound of the chest should therefore be carried out before invasive diagnostic procedures are planned.     

Management of malignant pleural effusion

Malignant pleural effusion is a frequent cause of morbidity in cancer patients. Pleural aspiration relieves dyspnoea usually only for a matter of days, and if the tumour type is not chemosensitive, some form of pleurodesis is commonly required. Tube thoracostomy is widely used to achieve pleural drainage prior to attempting pleurodesis by instillation of a variety of 'sclerosants'. Recently thoracoscopic instillation of talc has been advocated and some authors report high rates of fluid control. Randomised trials comparing this approach compared to tube thoracostomy and chemical pleurodesis are required.     

Usefulness of computerized tomography in the study of pleural effusion with no presumed diagnosis

To establish the diagnostic yield of computerized tomography (CT) in pleural effusions with no presumed diagnosis arising from standard clinical examination. A prospective protocol study enrolling all cases of effusion admitted to our hospital between January 1994 through July 1995 without a presumed diagnosis after initial testing that included thoracocentesis. Twenty-two patients were enrolled. All were given a CT scan as well as other complementary examinations considered appropriate and were referred to our outpatient clinic for follow-up. The CT images were read by an expert radiologist and their contribution was classified as "diagnostic", "suggestive" or "nil". A definitive etiologic diagnosis was achieved in 14 cases (8 neoplasms, 4 benign due to asbestos, 1 tuberculosis and 1 pulmonary embolism). The CT contribution was nil in 13 cases (59%), "diagnostic" in 6 (2 mesotheliomas, 1 hypernephroma, 1 lymphoma, 1 adenocarcinoma of the colon and another of the ovary) and "suggestive" in 3 (2 benign due to asbestos and 1 lymphoma). Positive information was obtained in 9 cases (41%). CT gives good yield in the investigation of pleural effusions with no presumed diagnosis and should be made available to this group of patients before other more invasive procedures are resorted to. It is especially useful for detecting neoplastic disease of the upper abdomen, mesothelioma and sings of unsuspected exposure to asbestos.     

Pneumonia and pleural effusion. Therapeutic management

The pleural effusion with pneumonia is a common complication. Early diagnosis and adequate handling are required, being based fundamentally on the characteristics of pleural liquid. Antibiotic therapy and pleural drainage are, in most cases, the main basis for very best outcome. Un specific circumstances administration of intrapleural fibrinolysis is increased, giving up surgery for those difficult cases which are not resolved with the previous treatment. The clinical case and the therapeutical different choices are revised, and finally a guideline that helps to the best management of parapneumonic effusion, is suggested.     

Leukemic pleural effusion in B-cell prolymphocytic leukemia

BACKGROUND: Proinflammatory mediators that include tumor necrosis factor-alpha (TNF-alpha) and macrophage inflammatory protein-2 (MIP-2) and anti-inflammatory mediators such as interleukin-10 (IL-10) modulate the immune response to endotoxemia. IL-10 downregulates the production of TNF-alpha and MIP-2. Acute lung injury may occur secondary to neutrophil chemotaxis mediated by chemokine MIP-2. We studied the temporal relationship of TNF-alpha, MIP-2, and IL-10 in rat endotoxemia and correlation of MIP-2 concentrations with acute lung injury. METHODS: Ten ventilated rats were randomized to receive an intravenous infusion of 2 mg/kg Escherichia coli lipopolysaccharide (n = 6) or saline placebo (n = 4). Blood pressure was continuously monitored and arterial blood was obtained for lactate, blood gas, TNF-alpha, IL-10, and MIP-2 measurements at baseline, 2, 4, and 5.5 hours after LPS or saline infusion. RESULTS: Endotoxemia resulted in hypotension, lactic acidemia, and increased alveolar-arterial oxygen gradient (A-a O2 gradient) compared with the placebo group. TNF-alpha, MIP-2, and IL-10 levels were increased 2 hours after endotoxemia. Subsequently, TNF-alpha levels declined while IL-10 and MIP-2 levels remained elevated. Control rats had no significant increase in cytokine production at any time point. MIP-2 concentrations correlated with A-a O2 gradient, an indicator of lung injury (r = 0.56, p < 0.001). CONCLUSIONS: MIP-2, possibly released by TNF-alpha stimulation of macrophages, is associated with acute lung injury possibly by inducing neutrophil chemotaxis. IL-10 may exert its counter-inflammatory response by inhibiting the release of TNF-alpha in endotoxemia.     

Pancreatic pleural effusion. Diagnosis and therapy

Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis or pancreatic trauma. Clinical features include pleural effusion and resulting pulmonary symptoms. Abdominal pain and other clinical manifestations of pancreatitis may be minimal or absent. As in this case, computed tomography and endoscopic retrograde cholangiopancreatography may provide complementary diagnostic information in the evaluation of this condition. A discussion of the pathophysiology, diagnosis and management of pancreaticopleural fistula is presented.