Analysis of pleural fluid in idiopathic spontaneous pneumothorax; correlation of eosinophil percentage with the duration of air in the pleural space

Silicosis-related pleural effusion diagnosed using elemental analysis of the pleural fluid cell block: A case report

Pleural disease in silicosis remains an underrecognized entity. Herein, we describe the case of an 85-year-old man with a 20-year history of silica exposure between the ages of 9–28 years. He presented with bilateral exudative pleural effusions, and chest computed tomography revealed typical silicosis findings. Thoracentesis was performed thrice, but did not reveal the cause of effusion. However, pleural fluid cell-block elemental analysis revealed a silicon compound, suggesting that silicosis-related pleural effusion had developed after a long latency period. Therefore, elemental analysis of the pleural fluid cell block may help diagnose occupational lung diseases with pleural effusion.

Updates in Effusion Cytology

Effusion cytology plays multiple roles in the management of benign and malignant disease, from primary diagnosis to tissue allocation for ancillary diagnostic studies and biomarker testing of therapeutic targets. This article summarizes recent advances in pleural effusion cytology, with a focus on the practical application of immunohistochemical markers, cytogenetic techniques, flow cytometry, and molecular techniques for the diagnosis and management of primary and secondary neoplasms of the pleura.

Approach to Lung Biopsies From Patients With Pneumothorax

Context.—Patients with pneumothorax occasionally require limited lung resections to control persistent air leaks. In some patients, especially smokers, histopathologic findings suggest that a ruptured bulla or bleb caused the pneumothorax. Other patients only exhibit histopathologic changes related to the physical trauma of acute, and likely occult recurrent, peripheral lung injury in the setting of “spontaneous,” or idiopathic, lung rupture. Sometimes, pneumothorax occurs secondary to an underlying localized or diffuse parenchymal lung disease. A comprehensive description of the morphologic findings that may be seen in these specimens will help the surgical pathologist distinguish patients with more common and indolent occurrences of pneumothorax from those requiring additional workup or treatment.

Objective.—To develop a diagnostic approach for surgical pathologists encountering lung specimens obtained in the context of pneumothorax repair.

Data Sources.—Literature review and consultation experience of the authors.

Conclusions.—Two general categories of histopathologic changes can be identified: (1) nonspecific changes, reflecting the lung's acute and chronic response to localized injury, and (2) changes suggesting an underlying lung disease that may have played an etiologic role in the development of pneumothorax. The latter changes are important to recognize because they may require additional workup or treatment of clinically occult lung disease. Difficulty arises when nonspecific histopathologic changes overlap with those of an underlying lung disease. Awareness of these diagnostic challenges and pitfalls, together with clinicoradiographic correlation, is essential in these situations and will help guide the surgical pathologist toward an accurate diagnosis and the appropriate management of clinically occult disease.

Induction of heme oxygenase-1, biliverdin reductase and H-ferritin in lung macrophage in smokers with primary spontaneous pneumothorax: role of HIF-1alpha

Background

Few data concern the pathophysiology of primary spontaneous pneumothorax (PSP), which is associated with alveolar hypoxia/reoxygenation. This study tested the hypothesis that PSP is associated with oxidative stress in lung macrophages. We analysed expression of the oxidative stress marker 4-HNE; the antioxidant and anti-inflammatory proteins heme oxygenase-1 (HO-1), biliverdin reductase (BVR) and heavy chain of ferritin (H-ferritin); and the transcription factors controlling their expression Nrf2 and HIF-1α, in lung samples from smoker and nonsmoker patients with PSP (PSP-S and PSP-NS), cigarette smoke being a risk factor of recurrence of the disease.

Methodology/Principal Findings

mRNA was assessed by RT-PCR and proteins by western blot, immunohistochemistry and confocal laser analysis. 4-HNE, HO-1, BVR and H-ferritin were increased in macrophages from PSP-S as compared to PSP-NS and controls (C). HO-1 increase was associated with increased expression of HIF-1α mRNA and protein in alveolar macrophages in PSP-S patients, whereas Nrf2 was not modified. To understand the regulation of HO-1, BVR and H-ferritin, THP-1 macrophages were exposed to conditions mimicking conditions in C, PSP-S and PSP-NS patients: cigarette smoke condensate (CS) or air exposure followed or not by hypoxia/reoxygenation. Silencing RNA experiments confirmed that HIF-1α nuclear translocation was responsible for HO-1, BVR and H-ferritin induction mediated by CS and hypoxia/reoxygenation.

Conclusions/Significance

PSP in smokers is associated with lung macrophage oxidative stress. The response to this condition involves HIF-1α-mediated induction of HO-1, BVR and H-ferritin.

Pneumatosis intestinalis: a challenging biopsy diagnosis

BACKGROUND

Pneumatosis intestinalis is characterized by the accumulation of gas in the gastrointestinal wall. The histopathologic diagnosis is easily made on resection specimens in which the presence of submucosal or subserosal empty spaces lined by histiocytes and giant cells presents little diagnostic dilemma. In biopsy material, though, the diagnosis is more challenging, as giant cells and histiocytes can be interpreted as granulomatous inflammation indicative of other conditions such as infection or Crohn disease.

DESIGN

Nine gastrointestinal biopsies diagnosed as pneumatosis intestinalis from 7 patients were reviewed. Clinical history, radiologic features, and endoscopic findings were obtained from patient records.

RESULTS

Five patients presented with blood in the stool (one also with diarrhea) and 2 patients were diagnosed after screening colonoscopies. The endoscopist frequently described polyps or raised mucosal folds (6 cases). In all biopsies submucosal cystic spaces lined by giant cells could be observed. The cysts were intact (2 biopsies), partially intact (5 biopsies), or collapsed (5 biopsies), with 3 biopsies showing 2 cyst architectural conformations. The arrangement of the giant cells lining a rounded or cleft-like space was the most helpful feature in distinguishing pneumatosis intestinalis from granulomatous colitis. Additional useful features included the recognition of "pseudolipomatosis" (n=4) and the presence of round empty spaces in the submucosa resembling fat (n=3). Nonspecific findings included variable inflammation, eosinophilia, mild gland disarray, vascular ectasia and edema, and mild melanosis coli. Two cases were initially given a diagnosis of granulomatous inflammation. One patient with acquired immunodeficiency syndrome and positive cytomegalovirus antigenemia assay had ischemic colitis on the biopsy and another had a subsequent resection with ischemic colitis. A third patient was treated for cytomegalovirus colitis. None had a history of or developed Crohn disease.

CONCLUSIONS

Pneumatosis intestinalis remains a challenging diagnosis on biopsy material, particularly because endoscopy usually does not suggest that diagnosis. The presence of giant cells in the submucosa, variable inflammation, and crypt disarray can be easily confused with Crohn disease. Attention to the arrangement of the giant cells lining intact, partial, or collapsed cysts is crucial to making the correct diagnosis. Although nonspecific by itself, pseudolipomatosis may also indicate the presence of gas within the tissue and suggest the diagnosis.

Pleural fluid and peripheral eosinophilia from hemothorax: hypothesis of the pathogenesis of EPE in hemothorax and pneumothorax

Blood and air in the pleural space are the most common conditions associated with an eosinophilic pleural effusion. The recruitment of eosinophils is dependent upon stimulation by cytokines, specifically interleukin (IL)-3, IL-5, granulocyte-monocyte cell stimulating factor (GM-CSF), and RANTES (regulated upon activation, normal t-cell expressed and secreted), that cause eosinophil proliferation in the bone marrow, movement into the circulation, and adhesion and migration across endothelial barriers into tissues. There are several possible mechanisms that can explain eosinophilic pleural effusions. We report a case of an eosinophilic pleural effusion after spontaneous hemothorax that illustrates the course of pleural fluid and blood eosinophilia in following hemothorax and describe the different pathophysiology of eosinophil trafficking in the pleural space and serum following hemothorax and pneumothorax.

Pneumothorax-Associated Pleural Eosinophilia in Mice Is Interleukin-5 but Not Interleukin-13 Dependent

STUDY OBJECTIVES

To establish a murine model of pneumothorax-associated pleural eosinophilia and to examine the role of interleukin (IL)-5 and IL-13 in the pathogenesis of this reaction.

DESIGN

An animal study.

INTERVENTIONS

One hundred thirty-seven C57/Bl-6 mice were used in this study. Wild-type animals were injected intrapleurally with 0.4 mL of air and were killed at different time points (30 min to 7 days) after the injection. IL-5 knockout and IL-13 knockout animals were killed 24 h and 48 h after the injection. Pleural inflammation was assessed by pleural lavage (PL).

MEASUREMENTS AND RESULTS

PL cells were significantly increased following the induction of pneumothorax. The peak number of neutrophils, observed at 12 h, was 900 times higher than the control. The peak number of eosinophils, observed at 48 h, was 700 times higher than the control. Lymphocytes and mononuclear cells increased threefold and fourfold, respectively. IL-5 knockout mice had significantly less PL eosinophils than that the wild-type or the IL-13 knockout mice at 24 h (150 +/- 46/microL, 903 +/- 244/microL, and 912 +/- 168/microL, respectively; p = 0.013) and 48 h (181 +/- 45/microL, 1,587 +/- 212/microL, and 1,379 +/- 364/microL, respectively; p = 0.003).

CONCLUSION

Pneumothorax induces an inflammatory reaction of the mouse pleura, mainly characterized by increased neutrophils and eosinophils. IL-5 but not IL-13 is required for pneumothorax-associated pleural eosinophilia.

Eotaxin-3 and interleukin-5 pleural fluid levels are associated with pleural fluid eosinophilia in post-coronary artery bypass grafting pleural effusions

OBJECTIVES

The primary aim of this study was to examine the association between pleural fluid (PF) eosinophilia, and the PF and serum levels of interleukin (IL)-5, eotaxin-2, eotaxin-3, and vascular cell adhesion molecule (VCAM)-1 in patients with post-coronary artery bypass grafting (CABG) pleural effusions.

DESIGN

A prospective observational study.

SETTING

A tertiary teaching hospital.

PATIENTS AND METHODS

Thirty-eight patients with post-CABG pleural effusions were recruited into the study. An effusion that contained at least 10% eosinophils was called "eosinophilic." The PF and serum levels of the cytokines and VCAM-1 were measured using an enzyme-linked immunosorbent assay.

RESULTS

(1) The number of PF eosinophils significantly correlated with the number of blood eosinophils. (2) PF IL-5 levels were significantly higher than the corresponding serum levels, and there was a significant correlation between the PF and serum IL-5 levels. PF IL-5 levels significantly correlated with the PF eosinophil count, and serum IL-5 levels significantly correlated with the number of blood eosinophils. (3) PF eotaxin-3 levels were significantly higher than serum levels, and PF eotaxin-3 levels significantly correlated with the PF eosinophil count. (4) PF VCAM-1 levels were significantly lower than the corresponding serum levels, and PF VCAM-1 levels were significantly higher in eosinophilic pleural effusions (EPEs) than in non-EPEs.

CONCLUSION

In patients with post-CABG pleural effusions, IL-5 and eotaxin-3 are produced preferentially in the pleural cavity, and they are strongly associated with PF eosinophilia.

Pathogenesis of the eosinophilic pleural effusions

PURPOSE OF REVIEW

Eosinophilic pleural effusions (EPE) are defined as those that contain at least 10% eosinophils. EPEs account for 5 to 16% of exudative pleural effusions. However, their pathogenesis is poorly understood. The purpose of this review is to discuss the mechanisms that lead to eosinophilic pleural inflammation.

RECENT FINDINGS

Eosinophilic pleural effusions are caused by the presence of air or blood or both in the pleural space, infectious or other inflammatory diseases, malignancy, pulmonary emboli, asbestos exposure, and drug reactions. Differences in the clinical features suggest that a variety of mechanisms operate to induce eosinophilic pleural inflammation and pleural fluid accumulation. Human and animal studies indicate that interleukin (IL)-5 is an important common contributor of different pathogenetic pathways. The possible role of other cytokines, chemokines, and adhesion molecules in the development of EPE is under investigation.

SUMMARY

Understanding the pathogenesis of EPE will permit the development of novel therapies for the persistent, symptomatic, posttraumatic and idiopathic EPE. Anti-IL-5 treatment is an interesting option that requires further research.

Repeated thoracentesis: an important risk factor for eosinophilic pleural effusion?

BACKGROUND

Eosinophilic pleural effusion (EPE) is a relatively rare clinical condition. Repeated thoracenteses (RTs) are normally considered a frequent cause of EPE. Yet, to our knowledge, there is no firm evidence (apart from anecdotal case reports) supporting such a statement.

OBJECTIVE

To investigate potential relationships between the number, type (with or without pleural biopsy) and time elapsed between RTs and the number of eosinophils present in pleural fluid samples.

METHODS

We reviewed retrospectively 273 pleural fluid samples belonging to 120 patients (79 males, 41 females), attended in our institution from 1992 to 2000, whose clinical management had required RTs. Apart from the anthropometric and clinical data of each patient, we included the following variables in the analysis: number of thoracenteses performed in each individual, number of pleural biopsies carried out at each thoracentesis and time between consecutive thoracenteses. We also recorded the total (and differential) leukocyte count, red blood cell count, as well as the main biochemical, microbiological and histological data of both the pleural fluid and peripheral blood samples.

RESULTS

We did not observe any significant change in the percentage of eosinophils in relation to the number of thoracenteses performed per patient. This lack of relationship was also observed in the subgroup of patients who required one (or more) pleural biopsies (n = 111) (regardless of the number of biopsies). Our results suggest that RTs are not an important risk factor for the development of EPE, regardless of the time elapsed between two thoracenteses.

CONCLUSION

We believe, therefore, that multiple punctures should not longer be considered a prevalent cause of pleural eosinophilia.

Pleural fluid levels of interleukin-5 and eosinophils are closely correlated

BACKGROUND

The mechanisms responsible for the accumulation of eosinophils in pleural fluid are not fully understood. The purpose of this study was to evaluate the relationship between eosinophil accumulation and the levels of interleukin (IL)-5, IL-3, and granulocyte/macrophage colony-simulating factor (GM-CSF) in pleural effusions.

METHODS

We evaluated 30 patients with eosinophilic pleural effusions (eosinophil count > 10% nucleated cells in pleural fluid) and 10 patients with noneosinophilic pleural effusions. The patients with eosinophilic pleural effusions included 22 patients with post-coronary artery bypass graft surgery pleural effusions and 8 patients with eosinophilic pleural effusions caused by other causes. IL-5, IL-3, and GM-CSF in all pleural fluids were measured using enzyme-linked immunosorbent assay kits.

RESULTS

The mean level of IL-5 in eosinophilic pleural effusions (283.1 +/- 341.6 pg/mL) was significantly (p < 0.025) higher than that in the noneosinophilic effusions (28.2 +/- 19.0 pg/mL). The absolute eosinophil count and percentage correlated significantly with the level of IL-5 in all patients (r = 0.55, p < 0.001, and r = 0.54, p < 0.001, respectively). There was no significant correlation between IL-5 levels and RBC counts in all patients (r = 0.24, p > 0.05). GM-CSF and IL-3 levels were below the detectable range in all pleural fluids.

CONCLUSION

There is a significant relationship between the levels of IL-5 in pleural fluid and the total number and percentage of eosinophils in the pleural fluid. IL-5 seems to be related to the eosinophil accumulation associated with blood or air in the pleural space and other eosinophilic pleural effusions.