MANAGEMENT OF UNDIAGNOSED PERSISTENT PLEURAL EFFUSIONS
Section snippets
DIAGNOSTIC APPROACH: INITIAL CONSIDERATIONS
In brief, the approach to a difficult-to-diagnose pleural effusion should begin with a review of the clinical information available, with special emphasis on certain unusual characteristics of common and uncommon pleural effusions. Further diagnostic procedures should next be considered, based on clinical suspicion and the characteristics of the pleural fluid. Finally, it is worth noting that watchful waiting may be all that is needed in carefully evaluated cases, after treatable causes of
Pleural Transudates
Few of the difficult-to-diagnose pleural effusions are transudates, but further evaluation of the pleural fluid is most often unnecessary once a transudative classification is confirmed. In that instance, the diagnosis is usually made on a clinical basis.
The list of possible causes for transudative pleural fluids is not very long (Table 3). Pleural transudates are overwhelmingly associated with underlying congestive heart failure. The diagnosis of congestive heart failure should be reconsidered
CONDITIONS CAUSING DIFFICULT-TO-DIAGNOSE PLEURAL EFFUSIONS
Some clinical conditions, such as tuberculosis and other granulomatous diseases, malignancy, and pulmonary emboli, are more commonly proven to be the underlying cause of undiagnosed pleural effusions (Table 4). Awareness of the clinical features that suggest those conditions will help the clinician more quickly arrive at the correct diagnosis.
CONCLUSIONS AND WORKING RECOMMENDATIONS
A clinician faced with a pleural effusion that defies diagnosis will need to ensure that all the unusual causes of pleural effusion are considered and requisite studies are obtained. Even then, a significant number of pleural effusions remain undiagnosed.
We define an undiagnosed pleural effusion as one that has not revealed a cause despite initial work-up that includes repeated thoracentesis and pleural biopsy. After ensuring that clinical studies have been obtained that could assist in
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Management of pleural effusions
2023, Surgery (United Kingdom)Management of pleural effusions
2020, Surgery (United Kingdom)Citation Excerpt :Lymphocytic effusions are most commonly caused by malignancy (including metastatic disease and mesothelioma), TB, lymphoma and iatrogenic causes (Box 4). Neutrophil-predominant effusions are commonly acute and seen in para-pneumonic effusions, pulmonary embolism, acute TB and benign asbestos effusions.9,10 Cytology is not very sensitive and is only positive in 60% of malignant effusions.
Pleural fluid characteristics of tuberculous pleural effusions
2010, Heart and Lung: Journal of Acute and Critical CareCitation Excerpt :Low pleural-fluid ADA levels are more in keeping with a nontuberculous pleural effusion, particularly when levels are similar after repeated thoracentesis.2,18,19 The level of ADA can also be elevated in empyema, lymphoma, lung cancer, mesothelioma, leukemia, brucellosis, Q fever, rheumatoid arthritis, and systemic lupus erythematosis.13,20,21 However, ADA >40 U/L in the context of a lymphocytic pleural effusion is tuberculosis-related in >95% of cases.6,22-24
Diagnosis and management of pleural effusions in critically III patients
2005, Revue des Maladies RespiratoiresPleural effusions in critically ill patients
2004, ReanimationInvestigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010
2010, ThoraxCitation Excerpt :Cardiac failure is also a common cause of a lymphocytic effusion. Very high lymphocyte proportions (>80%) occur most frequently in TB, lymphoma, chronic rheumatoid pleurisy, sarcoidosis and late post-coronary artery bypass grafting (CABG) effusions (see box 5).44 Neutrophil-predominant pleural effusions are associated with acute processes.
Support: NIG R01-45018-06, The Gina Sabatasse and Cindy Brown Research Grant Awards, The RGK Foundation, and the Temple Chair in Pulmonary Fibrosis (SI).
Address reprint requests to Tariq Ansari, MD, Pulmonary Medicine, Greenville Memorial Hospital, 701 Grour Road, Greenville, SC 29605