Routine measurement of pleural fluid amylase is not indicated

Pleural effusion in a patient with previous alcohol excess

Pleural amylase and/or lipase should be analysed in cases of pleural effusion in patients with pancreatic disease or a history of excess alcohol consumption. https://bit.ly/3Rk5UfO.

Bilateral Empyema With Beta Hemolytic Group C Streptococcus and Streptococcus constellatus Co-infection Resulting From an Esophageal Perforation and Associated With Septic Shock, Diffuse ST Elevation, and New-Onset Atrial Fibrillation

Empyema is the collection of pus in the pleural cavity and most times, it occurs unilaterally. It is often associated with underlying pneumonia, but other causes have been identified as well. When it occurs after an esophageal perforation, which in itself is also rare, morbidity and mortality are even higher. Esophageal perforation can cause life-threatening complications due to its close proximity to the vital organs of the mediastinum, necessitating its timely diagnosis and aggressive management. Bacteria forming part of the normal esophageal and oral flora are the most common causative pathogens for empyema from an esophageal perforation. Streptococcus constellatus and group C Streptococci, though both rare and often not taken seriously, have been identified as individual causes of empyema. We present a case of a 58-year-old male who presented with a worsening cough, chest pain, and shortness of breath after choking on a fish bone. He was diagnosed with bilateral loculated empyema resulting from esophageal perforation with the pleural fluid culture isolating both group C streptococcus and Streptococcus constellatus. He also developed respiratory failure, mediastinitis, and septic shock. This case will enable physicians to take empyema caused by these bacteria seriously and also to include esophageal perforation as a differential diagnosis when a patient presents with bilateral empyema associated with chest pain and electrocardiographic changes.

Diagnostic flowchart for tuberculous pleurisy, pleural infection, and malignant pleural effusion

BACKGROUND

Several markers for the diagnosis of pleural effusion have been reported; however, a comprehensive evaluation using those markers has not been performed. Therefore, this study aimed to develop a diagnostic flowchart for tuberculous pleurisy, pleural infection, malignant pleural effusion, and other diseases by using these markers.

METHODS

We retrospectively collected data from 174 patients with tuberculous pleurisy, 215 patients with pleural infection other than tuberculous pleurisy, 360 patients with malignant pleural effusion, and 209 patients with other diseases at Fukujuji Hospital from January 2012 to October 2022. The diagnostic flowchart for four diseases was developed by using several previously reported markers.

RESULTS

The flowchart was developed by including seven markers: pleural ADA ≥40 IU/L, pleural fluid LDH <825 IU/L, pleural fluid ADA/TP < 14, neutrophil predominance or cell degeneration, peripheral blood WBC ≥9200/μL or serum CRP ≥12 mg/dL, pleural amylase ≥75 U/L, and the presence of pneumothorax according to the algorithm of a decision tree. The accuracy ratio of the flowchart was 71.7 % for the diagnosis of the four diseases, with 79.3 % sensitivity and 75.4 % positive predictive value (PPV) for tuberculosis pleurisy, 75.8 % sensitivity and 83.2 % PPV for pleural infection, 88.6 % sensitivity and 68.8 % PPV for malignant pleural effusion, and 33.0 % sensitivity and 60.0 % PPV for other diseases in the flowchart. The misdiagnosis ratios were 4.6 % for tuberculosis pleurisy, 6.8 % for pleural infection, and 8.3 % for malignant pleural effusion.

CONCLUSION

This study developed a useful diagnostic flowchart for tuberculous pleurisy, pleural infection, malignant pleural effusion, and other diseases.

Differences in Pleural Fluid Amylase Levels in Patients with Malignant Pleural Effusion Based on Cancer Type, Histologic Type, and Epidermal Growth Factor Receptor Mutations

Objective High pleural amylase levels have been reported in patients with malignant pleural effusion; however, the characteristics of this association are uncertain. Therefore, this study investigated the factors, such as cancer type and oncogenic drivers, related to pleural amylase levels in patients with malignant pleural effusion. Methods We retrospectively collected the data of 362 cancer patients [lung adenocarcinoma (n=256), lung squamous carcinoma (n=12), small-cell lung carcinoma (n=32), other lung cancers (n=5), mesothelioma (n=31), and metastatic cancer (n=26)] with malignant pleural effusion at Fukujuji Hospital from January 2012 to October 2022. Pleural amylase levels were compared. Results Pleural amylase levels were significantly higher in patients with lung adenocarcinoma [median 58.6 IU/L (interquartile range (IQR) 33.8-139.3)] than in those with small-cell lung carcinoma [median 37.2 IU/L (IQR 26.3-63.7), p=0.012]. The median pleural amylase level was higher in patients with lung adenocarcinoma than in those with other cancer or histologic types, although the difference was not significant. Pleural amylase levels were higher in epidermal growth factor receptor (EGFR) mutation-positive patients than in EGFR mutation-negative patients [median 95.8 IU/L (IQR 52.7-246.5) vs. median 51.2 IU/L (IQR 27.8-96.9), p<0.001]. The Kaplan-Meier survival curves of pleural amylase ≥75 IU/L were higher than those of pleural amylase <75 IU/L [log-rank test p<0.001, hazard ratio 0.54 (95% confidence interval: 0.41-0.71)]. Conclusion This study demonstrates that pleural amylase levels were elevated in patients with lung adenocarcinoma and EGFR mutations. Furthermore, a high pleural amylase level was associated with a good prognosis.

The laboratory investigation of pleural fluids: An update based on the available evidence

Selecting appropriate laboratory tests based on available evidence is central to improve clinical effectiveness and impacting on patient outcome. Although long studied, there is no mutual agreement upon pleural fluid (PF) management in the laboratory context. Given the experienced confusion about the real contribution of laboratory investigations to guide clinical interpretation, in this update, we tried to identify useful tests for the PF analysis, aiming to unravel critical points and to define a common line in requesting modalities and practical management. We performed a careful literature review and a deepened study on available guidelines to finalize an evidence-based test selection, intended for clinicians' use to streamline PF management. The following tests depicted the basic PF profile routinely needed: (1) abbreviated Light's criteria (PF/serum total protein ratio and PF/serum lactate dehydrogenase ratio) and (2) cell count with differential analysis of haematological cells. This profile fulfils the primary goal to determine the PF nature and discriminate between exudative and transudative effusions. In specific circumstances, clinicians may consider additional tests as follows: the albumin serum to PF gradient, which reduces exudate misclassification rate by Light's criteria in patients with cardiac failure assuming diuretics; PF triglycerides, in differentiating chylothorax from pseudochylothorax; PF glucose, for identification of parapneumonic effusions and other causes of effusion, such as rheumatoid arthritis and malignancy; PF pH, in suspected infectious pleuritis and to give indications for pleural drainage; and PF adenosine deaminase, for a rapid detection of tuberculous effusion.

Endoscopic management of pleural effusion caused by a pancreatic pleural fistula

Pancreatic-pleural fistula (PPF) is a rare sequela of pancreatitis. High degree of clinical suspicion is required to diagnose a PPF. Confirmation is done by high amylase content in pleural fluid analysis. Here, we present two cases with varied presentation of PPF. A 43-year-old man presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion. Another 57-year-old man, previously diagnosed with chronic calcific pancreatitis, presented with left pleural effusion. Both cases were effectively managed with endoscopic pancreatic duct stenting.

Rare case of bilateral pleural effusion caused by pancreaticopleural fistula

A 51-year-old man presented with dyspnoea and basithoracic pain. Chest X-ray revealed bilateral pleural effusion, which was managed by bilateral chest drain placement. The pleural fluid analysis showed elevated lipase. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a large fistula from the tail of the main pancreatic duct to the left pleural space. Definitive treatment was accomplished with ERCP guided large pancreatic stents placement.

Laboratory testing of extravascular body fluids: National recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine. Part I - Serous fluids

Extravascular body fluids (EBF) analysis can provide useful information in the differential diagnosis of conditions that caused their accumulation. Their unique nature and particular requirements accompanying EBF analysis need to be recognized in order to minimize possible negative implications on patient safety. This recommendation was prepared by the members of the Working group for extravascular body fluid samples (WG EBFS). It is designed to address the total testing process and clinical significance of tests used in EBF analysis. The recommendation begins with a chapter addressing validation of methods used in EBF analysis, and continues with specific recommendations for serous fluids analysis. It is organized in sections referring to the preanalytical, analytical and postanalytical phase with specific recommendations presented in boxes. Its main goal is to assist in the attainment of national harmonization of serous fluid analysis and ultimately improve patient safety and healthcare outcomes. This recommendation is intended to all laboratory professionals performing EBF analysis and healthcare professionals involved in EBF collection and processing. Cytological and microbiological evaluations of EBF are beyond the scope of this document.

[Pleural effusion: diagnosis and management]

Pleural effusion management is a common clinical situation associated with numerous pulmonary, pleural or extra-pulmonary diseases. A systematic approach is needed to enable a rapid diagnosis and an appropriate treatment. Pleural fluid analysis is the first step to perform which allows a presumptive diagnosis in most cases. Otherwise, further analysis of the pleural fluid or thoracic imaging or pleural biopsy may be necessary. This review aims at highlighting the important elements of the work-up required by a pleural effusion.

[Contribution of pleural fluid analysis to the diagnosis of pleural effusion]

Analysis of pleural fluid can have, on its own, a high diagnostic value. In addition to thoracocentesis, a diagnostic hypothesis based on medical history, physical examination, blood analysis and imaging tests, the diagnostic effectiveness will significantly increase in order to establish a definite or high probable diagnosis in a substantial number of patients. Differentiating transudates from exudates by the classical Light's criteria helps knowing the pathogenic mechanism resulting in pleural effusion, and it is also useful for differential diagnosis purposes. An increased N-terminal pro-brain natriuretic peptide, both in the fluid and in blood, in a due clinical context, is highly suggestive of heart failure. The presence of an increased inflammatory marker, such as C-reactive protein, together with the presence of over 50% of neutrophils is highly suggestive of parapneumonic pleural effusion. If, in these cases, the pH is<7.20, then the likelihood of complicated pleural effusion is high. There remains to be demonstrated the usefulness of other markers to differentiate complicated from uncomplicated effusions. An adenosine deaminase > 45 U/L and>50% lymphocytes is suggestive of tuberculosis. If a malignant effusion is suspected but the cytological result is negative, increased concentrations of some markers in the pleural fluid can yield high specificity values. Increased levels of mesothelin and fibruline-3 are suggestive of mesothelioma. Immunohistochemical studies can be useful to differentiate reactive mesothelial cells, mesothelioma and metastatic adenocarcinoma. An inadequate use of the information provided by the analysis of pleural fluid would results in a high rate of undiagnosed effusions, which is unacceptable in current clinical practice.

Pleural, peritoneal and pericardial effusions - a biochemical approach

The pathological accumulation of serous fluids in the pleural, peritoneal and pericardial space occurs in a variety of conditions. Since patient management depends on right and timely diagnosis, biochemical analysis of extravascular body fluids is considered a valuable tool in the patient management process. The biochemical evaluation of serous fluids includes the determination of gross appearance, differentiation of transudative from exudative effusions and additional specific biochemical testing to assess the effusion etiology. This article summarized data from the most relevant literature concerning practice with special emphasis on usefulness of biochemical tests used for the investigation of pleural, peritoneal and pericardial effusions. Additionally, preanalytical issues concerning serous fluid analysis were addressed and recommendations concerning acceptable analytical practice in serous fluid analysis were presented.

Pancreaticopleural fistula: an overlooked entity

Pleuropulmonary complications of pancreatitis are well known. Less commonly encountered is pancreaticopleural fistula. We describe the case of a 15-year-old boy with a presumed episode of pancreatitis, complicated by pseudocyst and development of a pancreaticopleural fistula. Successful medical management was achieved, and he made a full recovery. This case demonstrates that the rarity of such a condition leads to delay as well as challenges in diagnosis and management.

The use of non-routine pleural fluid analysis in the diagnosis of pleural effusion

The investigation of a pleural effusion is, in general, a very straight forward process with the combination of clinical history, examination, radiology and pleural fluid analysis leading to diagnosis in most cases. While most fluid samples are sent for routine analysis including protein, LDH, glucose, cytology and microbiology, there are a number of more unusual fluid analyses available which in some cases directly lead to, and in others are suggestive of the diagnosis. Moreover, other fluid markers are constantly being evaluated as a diagnostic tool. In this review, we describe these non-routine pleural fluid analyses in detail. English language publications in MEDLINE and references from relevant articles from January 1 1990 to August 1 2009 were reviewed. Keywords searched in combination were pleural fluid, effusion, analysis, transudate, exudate and diagnosis.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Importancia de la determinación de la amilasa pleural en los pacientes con derrame neoplásico

BACKGROUND AND OBJECTIVE

To analyze the utility of the measurement of pleural amylase levels (AL) and pleural fluid/serum amylase ratio (AR) in malignant pleural effusions.

PATIENTS AND METHOD

Prospective and comparative study of AL and its AR in relation to the patient and pleural fluid characteristics in 295 malignant effusions and 673 nonmalignant.

RESULTS

There were 103 patients with AL greater than 100 U/l (11%) and 268 with AR greater than 1 (28%): 53 (18%) and 109 (37%) in malignant effusions respectively. Patients with malignant effusions had higher AL and AR, especially when tumour origin was lung cancer, had positive pleural citology or biopsy and showed an adenocarcinoma. Multivariate regression analysis revealed a significant difference in the changes in AL associated with positive pleural citology or biopsy and massive pleural effusion. The malignant effusions had higher AL in lung cancer of stage IV.

CONCLUSIONS

AL and AR should not be routinely measured to exclude a malignant effusion. A high AL or AR was related to positive pleural citology or biopsy, a massive pleural effusion and lung cancer with an advanced disease.

Pancreaticopleural fistula: a rare thoracic complication of pancreatic duct disruption

Pancreaticopleural fistula resulting in a chronic pleural effusion is a rare complication of pancreatic duct disruption. We describe the presentation and management of 2 children with pancreaticopleural fistulas. Pleural fluid amylase concentration and contrast computed tomography were sufficient to establish the diagnosis in both cases. The initial management of these fistulas should be conservative, by tube thoracostomy and suppression of pancreatic secretion. Operative treatment is necessary for those who fail to resolve. Complete diversion of the pancreatic juice into the gastrointestinal tract by longitudinal pancreaticojejunostomy has been an effective surgical option leading to fistula closure.

[Diagnosis and management of pleural effusions in critically iII patients]

INTRODUCTION

Pleural effusions are common in ICU patients. Causes include massive fluid resuscitation in shock, pneumonia--either community acquired or nosocomial, cardiac insufficiency, hypoalbuminemia and hepatic impairment. Pleural effusions frequently complicate cardiac and abdominal surgery and haemothorax may complicate trauma.

STATE OF THE ART

The incidence of pleural effusions in the intensive care unit (ICU) varies depending on the screening method used, from about 8% for physical examination to more than 60% for routine ultrasonography. In the absence of clinical parameters to exclude infection pleurocentesis remains an essential aspect of management and is not contraindicated mechanical ventilation. This review of the diagnosis and management of pleural effusions in ICU patients reports the most recent data from the literature. Pleurocentesis can be performed safely in the ICU, even in mechanically ventilated patients. The absence of reliable clinical or laboratory test criteria for determining the cause of pleural effusions and the potentially devastating consequences of failing to diagnose and treat pleural infection are strong reasons to perform pleurocentesis in patients with clinically detectable pleural effusions and no contraindication to the procedure.

PERSPECTIVES

Although the data reviewed indicate that the diagnosis and treatment of pleural effusions should follow the same rules in the ICU as they do elsewhere, several incompletely resolved issues deserve further investigation. These are summarised in an agenda for future research.

Biochemical analysis of pleural, peritoneal and pericardial effusions

Body fluids other than blood, urine and cerebrospinal fluid are often submitted for biochemical analysis. Of these, pleural, peritoneal and pericardial fluids are the most common. Laboratory tests are a useful tool to assess the aetiology, pathophysiology and subsequent treatment of effusions. A wide range of biochemical tests may be requested. This review critically examines the various analytes that have been used to investigate these body fluids.

Pleural effusions in the intensive care unit

The incidence of pleural effusions in the intensive care unit varies depending on the screening methods, from approximately 8% for physical examination to more than 60% for routine ultrasonography. Several factors contribute to the occurrence of pleural effusions in intensive care unit patients: large amounts of intravenous fluid are often administered, pneumonia is common, and heart failure, atelectasis, extravascular catheter migration, hypoalbuminemia, or liver disease are present in many intensive care unit patients. In surgical intensive care units, cardiac or abdominal surgery is often followed by pleural effusions, and in trauma patients, hemothorax is a dreaded event. Because no clinical parameter excludes pleural infection, and because of the impact of thoracentesis on diagnosis and treatment, this procedure should be performed unless contraindicated. Thoracentesis is safe in mechanically ventilated patients. The author discusses the following points regarding pleural effusions in the intensive care unit: screening intensive care unit patients for pleural effusion, safety of thoracentesis in patients receiving invasive mechanical ventilation, distinguishing exudates from transudates, and diagnosing and managing infected pleural effusions in critically ill patients. Lastly, the author suggests a research agenda for pleural effusions in intensive care unit patients.

Amylase levels in pleural effusions: a consecutive unselected series of 841 patients

STUDY OBJECTIVES

To describe the causes and relative frequency of amylase-rich pleural effusion (ARPE), and to study the origin and histologic type of the tumors with ARPE, the strength of the association between ARPE and the result of pleural cytology, and whether pleural amylase (PA) is a prognostic factor in the survival of patients with a malignant pleural effusion.

SETTING

Tertiary-care, university-affiliated hospital.

PATIENTS

Eight hundred forty-one consecutive patients with pleural effusion prospectively assessed from 1991 to 1999.

RESULTS

There were 66 ARPEs: 40 neoplastic, and 26 benign with tuberculosis, pancreatitis, and liver cirrhosis as the most frequent causes. Thirty-six percent of patients in our series and 61% of patients with ARPE had a neoplastic disease (odds ratio [OR], 3; p < 0.001); this association got much stronger for cases with PA levels > or = 600 IU/L (95th percentile); [OR, 10; p < 0.001]. The most frequent tumor origin was lung cancer (13 cases). Adenocarcinoma was the most frequent histologic type (18 cases). Two mesothelioma effusions were ARPEs. There was a positive association between ARPE and the finding of tumor cells in pleural fluid (OR, 2.79; p < 0.01). In the malignant group, PA levels > or = 600 IU/L identified a group of patients with quite a short median survival (p = 0.016).

CONCLUSIONS

The most common cause of ARPE was neoplasm. There was a positive association between ARPE and malignancy, stronger with the highest levels (95th percentile). Lung cancer and adenocarcinoma were the most common tumor and histologic type associated with ARPE. Mesothelioma may also produce ARPE. There was an association between ARPE and the finding of tumor cells in the pleural fluid. The highest PA levels identified a group of patients with a median shorter survival.