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Doi:10.1016/j.ccm.2005.12.002
Vanderbilt University, T-1218 Medical Center North, Nashville, TN 37232 – 2659, USA
Frequently, the etiology of a pleural effusion is in
only minimally meet the exudative criteria (eg, the
question after the initial thoracentesis. In this article,
protein ratio is 0.52 or the LDH ratio is 0.63).
I assume that the pleural effusion persists after the
Moreover, the patients with transudates who are
initial diagnostic workup, which includes measure-
misclassified are usually receiving diuretics If
ment of a pleural fluid marker for tuberculosis, such
the pleural fluid LDH is more than the upper limit for
as adenosine deaminase (ADA) or g-interferon.
the serum LDH or if the protein level is more than4.0 g/dL, the patient does not have a transudate. These transudates that are misclassified as exudates
Diseases that cause undiagnosed persistent pleural
can be classified correctly if the difference or gradient
between the protein levels in the serum and thepleural fluid is measured. If this gradient is greater
When a patient with a persistent undiagnosed
than 3.1 g/dL, the exudative classification by Light’s
pleural effusion is encountered, the first step to be
criteria can be ignored, because almost all such
considered is the list of the diseases most likely to be
patients have a transudative pleural effusion
associated with a persistent undiagnosed pleural
The protein gradient alone should not be used to
effusion The first question to answer in a
separate transudates from exudates because, by itself,
patient with a persistent undiagnosed pleural effusion
it misidentifies approximately 13% of exudates as
is whether the effusion is a transudate or an exudate.
For the past several decades, this differentiation hasbeen made by measuring the levels of protein andlactate dehydrogenase (LDH) in the pleural fluid and
in the serum (Light’s criteria). If one or more of thefollowing criteria are met, the patient has an exuda-
Congestive heart failure is the most common
1. Pleural fluid protein or serum protein > 0.5
cause of pleural effusion At times in patients with
2. Pleural fluid LDH or serum LDH > 0.6
persistent pleural effusion, it is not obvious that the
3. Pleural fluid LDH > 0.67 the normal upper limit
heart failure is the cause of the effusion. Certainly,
symptoms of congestive heart failure, such asdyspnea on exertion, orthopnea, paroxysmal noctur-
Light’s criteria are sensitive at identifying exu-
nal dyspnea, and nocturia, should be sought when the
dates, but they also identify up to 25% of transudative
history is taken. In addition, signs of congestive heart
pleural effusions as being exudative pleural effusions
failure, such as basilar rales, S3 gallop, distended
Usually, the transudates that are misclassified
neck veins, and pedal edema, should be soughtduring the physical examination. If the patientclinically has congestive heart failure but the initial
pleural fluid analysis reveals an exudate that just
0272-5231/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
have pleural fluid N terminal pro-BNP levels less
produce a persistent undiagnosed pleuraleffusion
If the patient has overt cirrhosis and massive
ascites, the diagnosis of hepatic hydrothorax is easy.
If the patient does not have ascites, however, the
diagnosis of hepatic hydrothorax may be difficult to
establish. In 1998, Kakizaki and colleagues
reviewed the literature and were able to find 28 cases
of hepatic hydrothorax without ascites. Of these
Cerebrospinal fluid leaks to the pleura
28 cases, 27 were on the right side. The only left-sided effusion occurred in a patient who had a tear
in the left diaphragm as a result of a splenectomy. Themean serum albumin in these 28 cases was 2.7 g/dL,
with a range of 1.9 to 3.6 g/dL The explanation
for the pleural effusion in the absence of overt ascites
is that the patients have defects in their diaphragm.
When fluid is present in the peritoneal space, it flows
immediately into the pleural space, because the pleu-
ral pressure is negative compared with the peritoneal
pressure. This diagnosis can be established by dem-
onstrating radioactivity in the thorax after the intra-
peritoneal injection of technetium-99m (99mTc)-sulfur
Ovarian hyperstimulation syndrome Rheumatoid pleuritis
Another cause of a chronic transudative pleural
effusion is the nephrotic syndrome. More than 20%
of patients with the nephrotic syndrome have pleural
effusions, which are usually bilateral Therefore,
all patients with chronic transudative pleural effu-
sions should be evaluated for proteinuria and
hypoproteinemia. It should be remembered that the
incidence of pulmonary emboli is high with the
nephrotic syndrome and this possibility shouldbe considered in all patients with the nephroticsyndrome and a pleural effusion.
barely meets Light’s criteria, the difference betweenthe pleural fluid and serum protein should be
measured as detailed previously. If this gradient isgreater than 3.1 g/dL, the effusion can be attributed to
A transudative pleural effusion can result when
the congestive heart failure. If the patient has a
there is retroperitoneal urinary leakage secondary to
transudative effusion but does not have obvious heart
urinary tract obstruction or trauma with subsequent
failure, further investigations of cardiac function,
dissection of the urine into the pleural space
such as echocardiography, are indicated. It has
This diagnosis is easy if it is considered as the pleural
recently been shown that measurement of the levels
fluid looks and smells like urine. Confirmation of the
of pro-brain natriuretic peptide (BNP) in pleural fluid
diagnosis can be made by demonstrating that the
is useful in establishing the diagnosis of congestive
pleural fluid creatinine is greater than the serum
heart failure. Patients with congestive heart failure
creatinine The pleural fluid with urinothorax
have pleural fluid N terminal pro-BNP levels greater
may also have a low glucose level and a low pH
than 1500 pg/mL, whereas almost all other patients
level. The only other instances in which a transuda-
tive pleural effusion has a low glucose or low pH
suggestive of malignancy All 28 patients who
level is when there is systemic hypoglycemia or
had all four characteristics had a malignancy, whereas
none of the 21 patients with one criterion at most hada malignancy
When patients with pleural effusions attributable
to the most common types of tumors are analyzed,
On rare occasions, cerebrospinal fluid (CSF) can
some interesting observations can be made. The
collect in the pleural space and produce a pleural
tumor that causes the highest number of pleural
effusion. This most commonly occurs after ventricu-
effusions is lung cancer When patients with lung
lopleural shunting but can also occur after pene-
cancer are first evaluated, approximately 15% have a
trating injuries and fractures of the thoracic spine
pleural effusion but 50% of patients with
as well as after thoracic spinal surgery The
disseminated lung cancer develop a pleural effusion
diagnosis should be suggested by the appearance
The tumor that causes the second highest number
of the pleural fluid, which appears to be CSF. The
of pleural effusions is breast cancer Patients with
protein levels are usually very low. The diagnosis
breast carcinoma rarely present with a pleural
can be confirmed by radionuclide cisternography
effusion. The mean interval between the diagnosis
Another way to establish the diagnosis is by
of the primary tumor and the appearance of a pleural
demonstrating the presence of b2-transferrin in the
effusion is 2 years Hematologic malignancies
pleural fluid This substance is normally present
(lymphomas and leukemias) cause the third highest
number of malignant pleural effusions Approxi-mately 10% of patients with Hodgkin’s lymphomaand 25% of patients with non-Hodgkin’s lymphoma
have pleural effusions at presentation. Those who doalmost invariably have intrathoracic lymph node
involvement If the patient has AIDS andcutaneous Kaposi’s sarcoma, the likely diagnosis is
There is no doubt that malignancy causes more
a pleural effusion attributable to Kaposi’s sarcoma.
persistent undiagnosed exudative pleural effusions
This diagnosis is usually established at bronchoscopy,
than any other cause. It should be emphasized that
which demonstrates erythematous or violaceous
there is no huge hurry to establish this diagnosis,
macules or papules in the respiratory tree
however, because (1) the presence of the effusion
There are several primary tumors of the pleura that
indicates that the patient has metastases to the pleura
should be considered if the patient has an undiag-
and the malignancy cannot be cured surgically, (2)
nosed pleural effusion. If the patient has a history of
most malignant pleural effusions are attributable to
asbestos exposure, mesothelioma should be consid-
tumors that cannot be cured with chemotherapy, and
ered. Thoracoscopy or thoracotomy is usually
(3) there is no evidence that attempts to create a
necessary to make this diagnosis If the patient
pleurodesis early improve the quality of the pa-
has AIDS and has a lymphocytic pleural effusion
with a high LDH level, the diagnosis of a primary
Most patients who have a pleural malignancy
effusion lymphoma is likely This diagnosis
usually have other characteristics suggesting malig-
can usually be established with pleural fluid
nancy. For example, in the series of 211 patients
cytology and flow cytometry If the patient had
received an artificial pneumothorax many years
biopsy of the pleura was negative in 29 patients who
previously, a likely diagnosis is pyothorax-associated
were eventually proven to have malignant pleural
effusions. All these patients were strongly suspectedof having a malignant effusion by clinical criteria,
such as weight loss, constitutional symptoms, or ahistory of a previous cancer, however Ferrer and
The diagnosis of parapneumonic effusion is easy
coworkers recently evaluated the characteristics
in the patient with an acute febrile illness, purulent
of patients undergoing thoracoscopy who turned out
sputum, and pulmonary infiltrates. On occasion,
to have a malignancy. They found four clinical
however, particularly with anaerobic infections, the
characteristics that were suggestive of malignancy:
patient may present with a chronic illness. In one
symptoms for more than 1 month, absence of fever,
study of 47 patients with anaerobic parapneumonic
blood-tinged pleural fluid, and chest CT scan findings
effusions, the median duration of symptoms before
presentation was 10 days and 60% of the patients had
onstrates concomitant parenchymal and pleural ab-
substantial weight loss (mean of 29 lb) There-
normalities and mediastinal lymphadenopathy.
fore, if the patient has a chronic illness withpredominantly neutrophils in the pleural fluid, it is
imperative to obtain anaerobic cultures of the pleuralfluid. Because patients with actinomycosis and
Fungal disease is responsible for a small percent-
nocardiosis sometimes have a chronic pleural effu-
age of pleural effusions At times, however,
sion with predominantly neutrophils, cultures for
blastomycosis and coccidioidomycosis may cause a
these organisms should be obtained in patients with
chronic lymphocytic pleural effusion Accord-
chronic neutrophilic pleural effusions.
ingly, cultures for fungi should be obtained in thepatient with a chronic undiagnosed pleural effusion
with predominantly lymphocytes in the pleural fluid. It is unknown whether the lymphocytic effusions
Throughout the world, tuberculosis remains one
attributable to fungal diseases have a high ADA level.
of the principal causes of pleural effusion. It isimportant to make this diagnosis, because if the
patient has pleural tuberculosis and is not treated, theeffusion resolves but the patient has a greater than
This is one diagnosis that should always be
50% chance of developing active pulmonary or
considered in a patient with a chronic undiagnosed
extrapulmonary tuberculosis over the next 5 years
pleural effusion. Some patients with a pancreatic
Therefore, all patients with a chronic undiag-
pseudocyst develop a direct sinus tract between the
nosed pleural effusion should be evaluated for tuber-
pancreas and the pleural space The sinus tract
culosis. The easiest way to do this is to measure
decompresses the pancreas; therefore, the patient
the pleural fluid level of ADA or g-interferon. If the
presents with symptoms usually referable only to
level of ADA is less than 40 IU/L or the level of
the chest. The patient with a chronic pancreatic
g-interferon is less than 140 pg/mL, the diagnosis can
pleural effusion is usually chronically ill and looks
be virtually excluded In one study, Ferrer and
like he or she has cancer. The diagnosis is virtually
colleagues followed 40 patients with a chronic
established if the level of amylase in the pleural fluid
undiagnosed pleural effusion and a pleural fluid ADA
is greater than 1000 U/L It is important to
level less than 43 IU/L for a mean of 5 years, and
consider this diagnosis, because the patient can be
none developed tuberculosis. Patients with lympho-
cytic pleural effusions because of other etiologiesalmost always have pleural fluid ADA levels less
than 40 IU/L If the pleural fluid ADA level isgreater than 40 IU/L or the level of g-interferon
Subphrenic, intrahepatic, intrasplenic, and intra-
exceeds 140 pg/mL and empyema and rheumatoid
pancreatic abscesses are all associated with a pleural
pleuritis are excluded, the patient probably has
effusion in a large percentage of patients Patients
with an intra-abdominal abscess are usually chroni-cally ill with fever and weight loss. The pleural fluid
is sterile and contains predominantly neutrophils. Thediagnosis can be made with a CT or ultrasound scan
The diagnosis of a pulmonary embolism should
be considered in every patient with an undiagnosedpleural effusion. Pleural effusions occur in at least
Effusion after coronary artery bypass graft surgery
30% of patients with pulmonary emboli andthey are almost always exudative Most pleural
Approximately 10% of patients who undergo
effusions associated with pulmonary emboli are
coronary artery bypass graft (CABG) surgery have
small, and it is uncommon for the effusion to occupy
a pleural effusion that occupies more than 25% of
more than one third of the hemithorax Patients
their hemithorax 28 days after surgery The
with undiagnosed pleural effusions should have the
primary symptom (if any) of a patient with a post-
possibility of a pulmonary embolism investigated
CABG pleural effusion is dyspnea; chest pain and
with a spiral CT scan The spiral CT scan not
fever are distinctly unusual The pleural fluid in
only identifies vascular filling defects, which are
these patients is an exudate characterized by a
highly suggestive of pulmonary embolism, but dem-
predominance of lymphocytes and an LDH level
approximately equal to the upper limit of normal for
and an exudative pleural effusion, the diagnosis of
serum Although the pleural fluid is similar to
constrictive pericarditis should be considered. It is
the pleural fluid in patients with tuberculous pleuritis,
important to realize that the findings of echocardi-
these two entities may be differentiated by the pleural
ography may be normal in the patient with constric-
fluid level of ADA; the ADA level is less than 40 U/L
tive pericarditis and that cardiac catheterization may
in patients with a post-CABG effusion The
importance of these effusions is to know that they canpersist for years on rare occasions and not to be
too aggressive in pursuing a diagnosis if the pleuralfluid findings are as expected.
Meigs’ syndrome is the constellation of a benign
pelvic neoplasm associated with ascites and pleural
effusion in which surgical extirpation of the tumorresults in permanent disappearance of the ascites and
Postcardiac injury syndrome (PCIS), also known
pleural effusion The pleural fluid is an exudate
as Dressler’s syndrome, is characterized by the
with a relatively low cell count, which may some-
development of fever, pleuropericarditis, and paren-
chymal pulmonary infiltrates in the weeks after
importance of Meigs’ syndrome is that not all patients
trauma to the pericardium or myocardium The
with a pelvic mass, ascites, and a pleural effusion
PCIS has been reported after myocardial infarction,
cardiac surgery, blunt chest trauma, percutaneous leftventricular puncture, pacemaker implantation, and
angioplasty. The PCIS differs from the pleuraleffusion after CABG surgery, because fever and chest
This syndrome is a serious complication of
pain invariably occur with the PCIS and are rare after
ovulation induction. The clinical picture is charac-
CABG surgery. After cardiac injury, symptoms
terized by massive ovarian enlargement with multiple
usually develop between the first and third weeks
cysts, hemoconcentration, and the third space accu-
but can develop any time between 3 days and 1 year
mulation of fluid. Patients with the syndrome present
The pleural fluid is frankly bloody in approxi-
within 2 to 3 weeks after receiving the human
mately 30% of patients, and the differential cell count
chorionic gonadotropin with abdominal pain and
may reveal predominantly neutrophils or mononu-
distention; a nonproductive cough; and dyspnea
clear cells, depending on the acuteness of the pro-
caused by the ascites, pleural effusion, or both. The
pleural effusion is usually bilateral, and the pleuralfluid is an exudate with predominantly neutrophils
pericardial effusion have a concomitant pleuraleffusion In patients with inflammatory pericar-
Chronic pleural effusions may be a manifestation
ditis, most of the associated pleural effusions are
of rheumatoid pleuritis, and the diagnosis is usually
unilateral and left-sided The characteristics of
straightforward. Classically, the effusion occurs in
the pleural fluid seen in conjunction with pericardial
older men who have subcutaneous nodules. The pleu-
disease are not well described The possibility
ral fluid is an exudate with low glucose, low pH, and
of pericardial effusion should be evaluated in any
high LDH levels. The first manifestation of rheuma-
patient with cardiomegaly and an isolated left pleu-
toid disease is virtually never a pleural effusion
Approximately 60% of patients with constrictive
pericarditis have a concomitant pleural effusion The associated pleural effusion is bilateral and
In contrast to rheumatoid pleuritis, patients with
symmetric in most of these patients. In one report of
systemic lupus erythematosus (SLE) may present
four patients with constrictive pericarditis, the pleural
with a pleural effusion. The possibility of drug-
fluid was transudative in one and exudative in three
induced lupus should always be considered in a
We recently reported one patient with constric-
patient with an undiagnosed pleural effusion. Drugs
tive pericarditis who had a pleural fluid protein level
that are most commonly incriminated in drug-induced
of 4.0 g/dL When a patient is seen with edema
lupus are hydralazine, procainamide, isoniazid, phe-
nytoin, and chlorpromazine The diagnosis of
manifest at widely varying times. The pleural
SLE with pleural involvement is based on the usual
effusions are bilateral in approximately 50% of
criteria for the diagnosis of lupus. Measurement of
patients and vary in size from small to massive
the pleural fluid antinuclear antibody (ANA) levels
Once a pleural effusion has occurred with this
or performance of lupus erythematosus prepa-
syndrome, it tends to persist and recur rapidly after
rations on the pleural fluid do not assist in
a thoracentesis. The pleural fluid is usually a clear
yellow exudate with a normal glucose level andpredominantly lymphocytes in the pleural fluid
differential. The pleural fluid LDH level tends to below relative to the pleural fluid protein level.
When a patient is evaluated with a chronic
undiagnosed pleural effusion, the list of drugs that
the patient is taking should be carefully reviewed,because the ingestion of certain drugs can lead to the
The prevalence of pleural effusions with uremia is
development of a pleural effusion. The primary drugs
approximately 3% As many as 50% of patients
associated with the development of a pleural effusion
on long-term hemodialysis have a pleural effusion
are nitrofurantoin (a urinary antiseptic), dantrolene
There is not a close relation between the degree
(a muscle relaxant), and the ergot alkaloids, such as
of uremia and the occurrence of a pleural effusion
bromocriptine or pergolide, that are used to treat
More than 50% of the patients are symptomatic,
Parkinson’s disease Other drugs that have been
with fever (50%), chest pain (30%), cough (35%),
reported to induce pleural effusions include methy-
and dyspnea (20%) being the most common symp-
sergide, amiodarone, procarbazine, methotrexate,
toms The pleural fluid is an exudate, and the
clozapine, dapsone, metronidazole, mitomycin, iso-
differential usually reveals predominantly lym-
tretinoin, propylthiouracil, simvastatin, warfarin, and
phocytes Tests of renal function should be
obtained in every patient with an undiagnosed exu-
induced pleural effusions have peripheral eosino-
philia. When the drug is discontinued, the effusionusually resolves rapidly
When there is intense inflammation in the pleural
space, a fibrous peel may form over the visceral
Exposure to asbestos can lead to the development
pleura. This peel can prevent the underlying lung
of an exudative pleural effusion. In one series of
from expanding; therefore, the lung is said to be
1135 asymptomatic asbestos workers, the prevalence
trapped The initial event producing the pleural
of pleural effusion was 3% In this series, all the
inflammation is usually a pleural infection or a
patients developed effusions within 20 years of the
hemothorax, but it can be a spontaneous pneumo-
initial exposure and many had done so within 5 years
thorax, thoracic operations (particularly CABG sur-
of the initial exposure The prevalence of pleural
gery) uremia, or collagen vascular disease. The
effusion was directly related to the total asbestos
pleural fluid is usually clear yellow and is a border-
exposure. Patients with asbestos pleural effusions are
line exudate with predominantly mononuclear cells.
usually asymptomatic The effusion tends to
The diagnosis can be made by measuring the pleu-
last several months and then clears, leaving no
ral pressure while fluid is withdrawn during a
residual disease. The pleural fluid is an exudate and
thoracentesis. If the initial pleural pressure is less
can contain predominantly neutrophils or mononu-
than À10 cm H2O or if the pleural pressure falls more
clear cells If a patient with a pleural effusion has
than 20 cm H2O per 1000 mL of fluid removed, the
a history of asbestos exposure and is asymptomatic,
diagnosis is confirmed provided that the patient
the patient can probably be observed to determine if
the effusion disappears spontaneously.
When pleural fluid is found to be milky or ex-
The yellow nail syndrome consists of the triad of
tremely turbid, the possibility of a chylothorax or a
deformed yellow nails, lymphedema, and pleural
pseudochylothorax should be considered. When tur-
effusions The three separate entities may become
bid fluid is found, the first step is to centrifuge
the fluid. If the supernatant remains turbid, the
The patient should be questioned carefully regarding
turbidity is attributable to a high lipid content in
the medications he or she is taking to determine
the pleural fluid and the patient has a chylothorax
whether he or she is taking a medication that causes a
pleural effusion or is associated with drug-induced
A chylothorax is usually easy to differentiate from
lupus erythematosus. The patient should be ques-
a pseudochylothorax on clinical grounds. Patients
tioned carefully about previous pleural problems,
with a chylothorax have an acute illness, and their
which raise the likelihood of a pseudochylothorax or
pleural surfaces are normal on CT. In contrast,
patients with a pseudochylothorax usually have hada pleural effusion for more than 5 years, and their
pleural surfaces are markedly thickened on CT. Measurement of the lipid levels in the pleural fluid
In the patient with a chronic undiagnosed pleural
is also useful in distinguishing these two conditions.
effusion, it is worthwhile to repeat a careful physical
Pleural fluid from a chylothorax has a triglyceride
examination. If the patient has a transudative pleural
level greater than 110 mg/dL, and the ratio of the
effusion, signs of congestive heart failure, such as
pleural fluid to serum cholesterol is less than 1.0. In
basilar rales, an S3 gallop, or distended neck veins,
contrast, fluid from a pseudochylothorax has choles-
should be sought. In addition, evidence of ascites
terol crystals or a cholesterol level greater than
should be carefully sought. The presence of pedal
200 mg/dL and higher than the simultaneous serum
edema suggests congestive heart failure, cirrhosis
with hepatic hydrothorax, nephrotic syndrome, peri-cardial disease, or the yellow nail syndrome.
If the patient has an exudative effusion, a careful
Tests to consider for patients with persistent
search for lymphadenopathy or other masses that
would suggest malignancy is indicated. In women,a careful breast examination and a careful pelvic
examination should be done to evaluate these loca-tions for masses. Abdominal tenderness suggests an
There are certain points in the patient’s history that
intra-abdominal abscess. Distant heart sounds, a peri-
should receive special attention if the patient has a
cardial friction rub, or Kussmaul’s sign (increased
persistent undiagnosed pleural effusion. If a patient
jugular venous pressure that increases during inspi-
has a transudative pleural effusion, particular attention
ration) suggests pericardial disease. Ascites and a
should be paid to symptoms of congestive heart
pelvic mass raise the possibility of Meigs’ syndrome.
failure, such as dyspnea on exertion, orthopnea,
Deformed joints and subcutaneous nodules make
paroxysmal nocturnal dyspnea, and nocturia. In
rheumatoid pleuritis likely. The presence of yel-
addition, historical evidence of cirrhosis, alcoholism,
low nails establishes the diagnosis of the yellow
or chronic hepatitis should be sought with the
possibility of a hepatic hydrothorax in mind. A historyof trauma or surgery to the thoracic spine should be
sought with the diagnosis of a CSF leak in mind.
If the patient has an exudative pleural effusion, a
Several blood tests should be routinely obtained in
history of malignancy should be sought. Malignant
patients with a persistent undiagnosed pleural effu-
pleural effusions have been known to develop as long
sion. The level of albumin and globulin should be
as 20 years after the primary tumor was diagnosed
measured to determine whether the patient has
A history of exposure to asbestos should be
cirrhosis or the nephrotic syndrome, and liver
sought, because this would suggest mesothelioma or
function tests should be obtained to ascertain if there
an asbestos pleural effusion. A history of fever
is chronic hepatitis. Additionally, I obtain a complete
suggests a chronic anaerobic, tuberculous, or fungal
blood cell count with a differential. A serum ANA
infection or an intra-abdominal abscess. A history of
test should be obtained with the diagnosis of SLE in
alcoholism or previous pancreatic disease raises the
mind. Blood urea nitrogen (BUN) and creatinine
possibility of a chronic pancreatic pleural effusion. A
levels should be obtained to evaluate the possibility
history of CABG surgery or myocardial trauma
of uremia, and a urinalysis should be obtained to
suggests a post-CABG surgery pleural effusion or
the PCIS, respectively. A history of rheumatoid
Several special tests on the pleural fluid are also
disease raises the possibility of rheumatoid pleuritis.
indicated. The least expensive test is to smell the
pleural fluid. If the pleural fluid smells like urine, the
most series, however, cytology is much more
patient probably has an urinothorax, whereas if the
sensitive in establishing the diagnosis. Moreover,
pleural fluid smells feculent, the patient probably has
if the cytology of the fluid is negative, the pleural
an anaerobic pleural infection. As mentioned pre-
biopsy is usually nondiagnostic. In one series of
viously, the ADA or g-interferon should be measured
118 patients from the Mayo Clinic who had a ma-
in the pleural fluid to assess whether the patient has
lignancy involving the pleura but negative pleu-
pleural tuberculosis. Flow cytometry on the pleural
ral fluid cytology, the needle biopsy of the pleura
fluid is indicated if lymphoma is suspected If
was positive in only 20 (17%) patients Because
the pleural fluid is milky or cloudy, it should be
thoracoscopy is diagnostic in more than 90% of pa-
centrifuged, and if the supernatant remains milky or
tients with a pleural malignancy and negative cy-
cloudy, the pleural fluid should be sent for measure-
tology, it is the preferred diagnostic procedure in
ment of cholesterol and triglycerides. Every time a
patients with a cytology-negative pleural effusion
thoracentesis is performed in a patient with a
who are suspected of having a pleural malignancy.
persistent undiagnosed pleural effusion, a pleural
A needle biopsy of the pleura is indicated if the pa-
fluid LDH level should be determined. If this LDH
tient has an undiagnosed pleural effusion that is
level tends to decrease with time, the pleural process
not improving and thoracoscopy is not available. A
is resolving and one can be conservative in the
needle biopsy of the pleura is also indicated if pleural
approach to the patient. Alternatively, if the LDH
tuberculosis is suspected and a pleural fluid marker
level is increasing with time, the process is getting
for tuberculosis is unavailable or equivocal If the
worse and one should be aggressive in pursuing a
patient has pleura thickening on contrast-enhanced
CT, consideration should be given to performing animage-guided cutting needle biopsy of the pleura. In
one report the diagnosis of mesothelioma wasestablished in 18 (86%) of 21 patients.
Most patients with an undiagnosed persistent
pleural effusion should have a spiral CT scan of
the chest. With the spiral CT scan, the diagnosisof pulmonary emboli can be established In
When one is dealing with patients with pleural
addition, parenchymal infiltrates and masses, pleural
effusions, thoracoscopic procedures should be used
masses or thickening, and mediastinal lymphadenopa-
only when less invasive diagnostic methods, such as
thy can be identified. Finally, pericardial thickening
thoracentesis with cytology and markers for tuber-
and pericardial effusions can be identified on the
culosis, have not yielded a diagnosis. In the series of
CT scan. While the patient is receiving the CT scan, it
620 patients reported by Kendall and coworkers
is reasonable to obtain abdominal cuts also. These can
only 48 (8%) required thoracoscopy for a diagnosis.
demonstrate abdominal masses, lymphadenopathy,
The final diagnoses in these 48 patients were a
and ascites. An echocardiogram is indicated if
malignancy in 24, a parapneumonic effusion in 7, a
congestive heart failure is suspected but is not
rheumatoid pleural effusion in 4, congestive heart
definitely established and if a pericardial effusion is
failure in 3, and pulmonary interstitial fibrosis in 2. In
suspected. It is important to remember that the
8 patients, no diagnosis was established with the
echocardiogram may not reveal any abnormality if
combination of the clinical presentation and thora-
the patient has constrictive pericarditis If
coscopy; 6 of these patients were subsequently
constrictive pericarditis is suspected, the patient
diagnosed has having a malignancy (mesothelioma
should undergo right heart catheterization.
in 3 patients and adenocarcinoma in 3 patients)
In general, if the patient has a malignancy,
thoracoscopy establishes the diagnosis in approxi-mately 90% of cases The diagnosis of
For the past 50 years, most cases of tuberculous
tuberculous pleuritis can almost always be estab-
pleuritis have been diagnosed with a needle biopsy of
lished with thoracoscopy It should be empha-
the pleura. In the past 10 years, however, it has been
sized, however, that thoracoscopy rarely establishes
demonstrated that markers for tuberculosis obtained
the diagnosis of benign disease other than tuber-
from the pleural fluid, such as the ADA or
culosis One advantage of thoracoscopy in the
g-interferon, are efficient at establishing this diagno-
diagnosis of pleural disease is that pleurodesis can be
sis. The other diagnosis that can be established with
performed at the time of the procedure. In general,
a needle biopsy of the pleura is pleural malignancy. In
thoracoscopy is indicated in the patient with an
undiagnosed pleural effusion who is not improving
had no recurrence of their pleural effusion; however,
spontaneously, provided that the patient has a sig-
13 of these 51 patients were eventually found to have
nificant likelihood of malignancy or tuberculosis.
malignant disease (lymphoma in 6 patients, meso-thelioma in 4 patients, and other malignancy in3 patients). In another study of 21 patients subjected
to open pleural biopsy for undiagnosed pleural effu-sion, no diagnosis was obtained in 7 (33%)
Bronchoscopy can be diagnostically useful in
patients with a pleural effusion if the patient hasone of the following four characteristics
When faced with a patient with an undiagnosed
1. A pulmonary infiltrate is present on the chest
pleural effusion, the first question to be answered is
radiograph or chest CT. If an infiltrate is present,
whether the patient has a transudate or an exudate.
particular attention should be paid to the area
This is most commonly done with Light’s criteria. If
with the infiltrate at the time of bronchoscopy.
it seems clinically that the patient has a transudative
2. Hemoptysis is present. The presence of hemop-
effusion but Light’s exudative criteria are met, the
tysis in the patient with a pleural effusion in-
demonstration of a serum pleural fluid protein
creases the likelihood of malignancy with an
gradient of greater than 3.1 g/dL indicates that the
endobronchial lesion or pulmonary embolus. The
effusion is transudative. The diagnosis of congestive
former can be diagnosed with bronchoscopy.
heart failure is strongly suggested if the pleural fluid
3. The pleural effusion is massive. The most com-
BNP level is greater than 1500 pg/mL. Patients with
mon cause of a massive pleural effusion is
undiagnosed exudative effusions should have a spiral
malignancy, particularly lung cancer, and this
CT scan to evaluate the possibility of a pulmonary
diagnosis can be established at bronchoscopy.
embolism and to demonstrate parenchymal, pleural,
The other two leading causes of massive pleu-
or mediastinal disease. Patients with a malignant
ral effusion are hepatic hydrothorax and tuber-
pleural effusion usually have the following character-
culous pleuritis; these diagnoses cannot be
istics: symptoms for more than 1 month, absence of
fever, blood-tinged pleural fluid, and chest CT scan
4. The mediastinum is shifted toward the side
of the effusion. With this finding, an obstruct-ing endobronchial lesion is probably respon-sible, and this can be identified and biopsied
[1] Light RW, MacGregor MI, Luchsinger PC, et al.
Pleural effusions: the diagnostic separation of transu-dates and exudates. Ann Intern Med 1972;77:507 – 14.
In many institutions, open thoracotomy with
[2] Romero S, Candela A, Martin C, et al. Evaluation of
different criteria for the separation of pleural transu-
direct biopsy of the pleura has been replaced by
dates from exudates. Chest 1993;104:399 – 404.
video-assisted thoracoscopy. If both procedures are
[3] Burgess LJ, Maritz FJ, Taljaard JJ. Comparative
available, thoracoscopy is usually preferred because it
analysis of the biochemical parameters used to dis-
is associated with less morbidity. The primary
tinguish between pleural transudates and exudates.
indication for an open pleural biopsy is progressive
undiagnosed pleural disease in an institution where
[4] Romero-Candeira S, Hernandez L, Romero-Brufao S,
thoracoscopy is not available or when there is a
et al. Is it meaningful to use biochemical parameters to
contraindication for thoracoscopy, such as marked
discriminate between transudative and exudative pleu-
adhesions between the visceral and parietal pleura.
ral effusions? Chest 2002;122:1524 – 9.
One should realize that even with an open biopsy
[5] Romero-Candeira S, Fernandez C, Martin C, et al.
Influence of diuretics on the concentration of proteins
of the pleura, a diagnosis is not always obtained. In
and other components of pleural transudates in patients
one study, the experience at the Mayo Clinic between
with heart failure. Am J Med 2001;110:681 – 6.
1962 and 1972 with an open pleural biopsy for
[6] Romero-Candeira S, Hernandez L. The separation of
undiagnosed pleural effusion was reviewed. It was
transudates and exudates with particular reference to
found that no diagnosis was established at open
the protein gradient. Curr Opin Pulm Med 2004;10:
biopsy in 51 patients Thirty-one of the patients
[7] Light RW. Pleural diseases. 4th edition. Baltimore7
computed tomography of thoracic involvement in
Lippincott, Williams & Wilkins; 2001.
previously untreated patients. Radiol Med (Torino)
[8] Porcel JM, Vives M, Cao G, et al. Measurement of
pro-brain natriuretic peptide in pleural fluid for the
[26] Huang L, Schnapp LM, Gruden JF, et al. Presentation
diagnosis of pleural effusions due to heart failure.
of AIDS-related pulmonary Kaposi’s sarcoma diag-
nosed by bronchoscopy. Am J Respir Crit Care Med
[9] Porcel JM. The use of probrain natriuretic peptide in
pleural fluid for the diagnosis of pleural effusions
[27] Ascoli V, Lo-Coco F. Body cavity lymphoma. Curr
resulting from heart failure. Curr Opin Pulm Med
[28] Nakatsuka S, Yao M, Hoshida Y, et al. Pyothorax-
[10] Kakizaki S, Katakai K, Yoshinaga T, et al. Hepatic
associated lymphoma: a review of 106 cases. J Clin
hydrothorax in the absence of ascites. Liver 1998;18:
[29] Bartlett JG, Finegold SM. Anaerobic infections of
[11] Ajmi S, Hassine H, Guezguez M, et al. Isotopic
the lung and pleural space. Am Rev Respir Dis 1974;
exploration of hepatic hydrothorax: ten cases. Gastro-
enterol Clin Biol 2004;28:462 – 6.
[30] Roper WH, Waring JJ. Primary serofibrinous pleural
[12] Cavina C, Vichi G. Radiological aspects of pleural
effusion in military personnel. Am Rev Respir Dis
effusions in medical nephropathy in children. Ann
Radiol Diagn (Bologna) 1958;31:163 – 202.
[31] Perez-Rodriguez E, Jimenez Castro D, Light RW.
[13] Llach F, Arieff AI, Massry SG. Renal vein thrombo-
Effusions from tuberculosis. In: Light RW, Lee YC,
sis and nephrotic syndrome: a prospective study of
editors. Textbook of pleural diseases. London7 Arnold
36 adult patients. Ann Intern Med 1975;83:8 – 14.
[14] Belie JA, Milan D. Pleural effusion secondary to
[32] Ferrer JS, Munoz XG, Orriols RM, et al. Evolution of
ureteral obstruction. Urology 1979;14:27 – 9.
idiopathic pleural effusion. A prospective, long-term
[15] Garcia-Pachon E, Padilla-Navas I. Urinothorax: case
follow-up study. Chest 1996;109:1508 – 13.
report and review of the literature with emphasis on
[33] Lee YC, Rogers JT, Rodriguez RM, et al. Adenosine
biochemical diagnosis. Respiration (Herrlisheim)
deaminase (ADA) levels in non-tuberculous lympho-
cytic pleural effusions. Chest 2001;120:356 – 61.
[16] Stark D, Shades J, Baron RL, et al. Biochemical
[34] Stein PD, Henry JW. Clinical characteristics of pa-
features of urinothorax. Arch Intern Med 1982;142:
tients with acute pulmonary embolism stratified
according to their presenting syndromes. Chest 1997;
[17] Beach C, Manthey DE. Tension hydrothorax due
to ventriculopleural shunting. J Emerg Med 1998;16:
[35] Romero-Candeira S, Hernnadez Blasco L, Soler MJ,
et al. Biochemical and cytologic characteristics of
[18] Monla-Hassan J, Eichenhorn M, Spickler E, et al.
pleural effusions secondary to pulmonary embolism.
Duropleural fistula manifested as a large pleural
transudate: an unusual complication of transthoracic
[36] Coche E, Verschuren F, Keyeux A, et al. Diagnosis of
diskectomy. Chest 1998;114:1786 – 9.
acute pulmonary embolism in outpatients: comparison
[19] Gupta SM, Frias J, Garg A, et al. Aberrant cerebro-
of thin-collimation multi-detector row spiral CT and
spinal fluid pathway. Detection by scintigraphy. Clin
planar ventilation-perfusion scintigraphy. Radiology
[20] Huggins JT, Sahn SA. Duro-pleural fistula diagnosed
[37] Rockey DC, Cello JP. Pancreaticopleural fistula.
by beta2-transferrin. Respiration (Herrlisheim) 2003;
Report of 7 patients and review of the literature.
[21] Poe RH, Israel RH, Utell MJ, et al. Sensitivity,
[38] Light RW, Rogers JT, Moyers JP, et al. Prevalence and
specificity, and predictive values of closed pleural
clinical course of pleural effusions at 30 days post
biopsy. Arch Intern Med 1984;144:325 – 8.
coronary artery bypass surgery. Am J Respir Crit Care
[22] Ferrer J, Roldan J, Teixidor J, et al. Predictors of
pleural malignancy in patients with pleural effusion
[39] Sadikot RT, Rogers JT, Cheng D-S, et al. Pleural fluid
undergoing thoracoscopy. Chest 2005;127:1017 – 22.
characteristics of patients with symptomatic pleural
[23] Naito T, Satoh H, Ishikawa H, et al. Pleural effusion as
effusion after coronary artery bypass graft surgery.
a significant prognostic factor in non-small cell lung
Arch Intern Med 2000;160:2665 – 8.
cancer. Anticancer Res 1997;17:4743 – 6.
[40] Lee YC, Vaz MAC, Ely KA, et al. Symptomatic
[24] Apffelstaedt JP, Van Zyl JA, Muller AG. Breast cancer
persistent post-coronary artery bypass graft pleural
complicated by pleural effusion: patient characteristics
effusions requiring operative treatment. Clinical and
and results of surgical management. J Surg Oncol
histologic features. Chest 2001;119:795 – 800.
[41] Light RW. Pleural effusions following cardiac injury
[25] Romano M, Libshitz HI. Hodgkin disease and non-
and coronary artery bypass graft surgery. Sem Respir
Hodgkin lymphoma: plain chest radiographs and chest
[42] Stelzner TJ, King Jr TE, Antony VB, et al. The
[55] Moriarty AT, Wiersema L, Snyder W, et al. Immuno-
pleuropulmonary manifestations of the postcardiac
phenotyping of cytologic specimens by flow cytome-
injury syndrome. Chest 1983;84:383 – 7.
try. Diag Cytopathol 1993;9:252 – 8.
[43] Weiss JM, Spodick DH. Association of left pleural
[56] Goodman PC. Spiral CT for pulmonary embolism.
effusion with pericardial disease. N Engl J Med 1983;
Semin Respir Crit Care Med 2000;21:503 – 10.
[57] Prakash URS, Reiman HM. Comparison of needle
[44] Tomaselli G, Gamsu G, Stulbarg MS. Constrictive
biopsy with cytologic analysis for the evaluation
pericarditis presenting as pleural effusion of unknown
of pleural effusion: analysis of 414 cases. Mayo Clin
origin. Arch Intern Med 1989;149:201 – 3.
[45] Sadikot RT, Fredi JL, Light RW. A 43-year-old man
[58] Adams RF, Gray W, Davies RJ, et al. Percutaneous
with a large recurrent right-sided pleural effusion.
image-guided cutting needle biopsy of the pleura in
the diagnosis of malignant mesothelioma. Chest 2001;
[46] Timmerman D, Moerman P, Vergote I. Meigs’ syn-
drome with elevated serum CA 125 levels: two case
[59] Kendall SW, Bryan AJ, Large SR, et al. Pleural
reports and review of the literature. Gynecol Oncol
effusions: is thoracoscopy a reliable investigation? A
retrospective review. Respir Med 1992;86:437 – 40.
[47] Wang DY, Yang PC, Yu WL, et al. Serial antinuclear
[60] Hucker J, Bhatnagar NK, al-Jilaihawi AN, et al.
antibodies titre in pleural and pericardial fluid. Eur
Thoracoscopy in the diagnosis and management of
recurrent pleural effusions. Ann Thorac Surg 1991;52:
[48] Kalomenidis IT. Effusions due to drugs. In: Light RW,
Lee YC, editors. Textbook of pleural diseases. London7
[61] Menzies R, Charbonneau M. Thoracoscopy for the
Arnold Publishing; 2001. p. 382 – 93.
diagnosis of pleural disease. Ann Intern Med 1991;
[49] Epler GR, McLoud TC, Gaensler EA. Prevalence and
incidence of benign asbestos pleural effusion in a
[62] Hansen M, Faurschou P, Clementsen P. Medical tho-
working population. JAMA 1982;247:617 – 22.
racoscopy, results and complications in 146 patients:
[50] Hillerdal G, Ozesmi M. Benign asbestos pleural
a retrospective study. Respir Med 1998;92:228 – 32.
effusion: 73 exudates in 60 patients. Eur J Respir Dis
[63] Diacon AH, Van de Wal BW, Wyser C, et al. Diag-
nostic tools in tuberculous pleurisy: a direct compara-
[51] Berger HW, Rammohan G, Neff MS, et al. Uremic
tive study. Eur Respir J 2003;22:589 – 91.
pleural effusion: a study in 14 patients on chronic
[64] Daniel TM. Diagnostic thoracoscopy for pleural
dialysis. Ann Intern Med 1975;82:362 – 4.
disease. Ann Thorac Surg 1993;56:639 – 40.
[52] Coskun M, Boyvat F, Bozkurt B, et al. Thoracic
[65] Chang S-C, Perng RP. The role of fiberoptic bron-
CT findings in long-term hemodialysis patients. Acta
choscopy in evaluating the causes of pleural effusions.
[53] Light RW, Jenkinson SG, Minh V, et al. Observations
[66] Ryan CJ, Rodgers RF, Unni KK, et al. The outcome of
on pleural pressures as fluid is withdrawn during
patients with pleural effusion of indeterminate cause
thoracentesis. Am Rev Respir Dis 1980;121:799 – 804.
at thoracotomy. Mayo Clin Proc 1981;56:145 – 9.
[54] Fentiman IS, Millis R, Sexton S, et al. Pleural effusion
[67] Douglass BE, Carr DT, Bernatz PE. Diagnostic
in breast cancer: a review of 105 cases. Cancer
thoracotomy in the study of ‘‘idiopathic’’ pleural effu-
sion. Am Rev Tuberc 1956;74:954 – 7.
Effects of childhood body size on breast cancer tumour characteristics Jingmei Li1,2, Keith Humphreys1, Louise Eriksson1, Kamila Czene1, Jianjun Liu2 and Per 1Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Box 281, 171 2Human Genetics, Genome Institute of Singapore, 60 Biopolis Street, Singapore, 138672, Corresponding author: Jingmei Li, [email protected] A
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