Evolution of idiopathic pleural effusion: a prospective, long-term follow-up study

Non-specific pleuritis: long-term follow-up outcomes

BACKGROUND

The definitive etiology of nonspecific pleuritis (NSP), the influence of the type of pleural biopsy on clinical results and the minimum duration of follow-up is controversial.

RESEARCH DESIGN AND METHODS

A retrospective, observational study of patients ≥ 18 years with NSP confirmed by closed pleural biopsy (CPB), local anesthesia pleuroscopy (LAP), or video-assisted thoracic surgery (VATS).

RESULTS

A total of 167 patients were included (mean follow-up, 14.4 months), of which 25 (15%) were diagnosed within one month; [15 (60%) malignant]. Of the remaining 142 pleural effusions (PEf), 69 (48.6%) were idiopathic; 49 (34.5%) not-malignant and 24 (16.9%) malignant (4 mesotheliomas and 20 metastasic). The diagnosis of NSP was established by CPB (7; median time to diagnosis, 9.4 months), LAT (5; 15.8 months), and VATS (8; 13.5 months) (p = 0.606). Sixty-eight patients (40.7%) died during follow-up (mean time, 12 months).

CONCLUSIONS

In a substantial percentage of patients diagnosed with NSP, a definitive diagnosis will not be obtained, a relevant number of patients will develop a malignant PEf. The diagnostic procedure used for the diagnosis of NSP does not seem to influence delay in the diagnosis of malignant PEf. The data obtained suggest that follow-up should be maintained for at least 24 months.

Diagnosis and outcome of patients with idiopathic pleural effusions

INTRODUCTION

Long-term follow-up course for patients with idiopathic pleural effusions has not been established.

METHODS

From October 2013 to June 2021 all patients with idiopathic effusion were prospectively followed up with clinical examination and imaging at 1, 3, 6 and every 6 months for a minimum of 1 year.

RESULTS

Twenty-nine patients were diagnosed with idiopathic effusion and followed up. Mesothelioma was detected during the follow-up in two patients at 7 and 18 months, one of whom had blood-tinged pleural fluid and the other reported a 10% weight loss. Mesothelioma was not diagnosed in any of the patients with effusion covering less than two thirds of the hemithorax, and without constitutional symptoms or a blood-tinged fluid appearance. Most of the effusions resolved or showed a clear improvement in the first six months.

CONCLUSION

Patients without weight loss and with small, non-hematic effusions, may benefit from conservative treatment and clinical-radiological follow-up.

Evaluation of first and second trimester maternal thyroid profile on the prediction of gestational diabetes mellitus and post load glycemia

Maternal thyroid alterations have been widely associated with the risk of gestational diabetes mellitus (GDM). This study aims to 1) test the first and the second trimester full maternal thyroid profile on the prediction of GDM, both alone and combined with non-thyroid data; and 2) make that prediction independent of the diagnostic criteria, by evaluating the effectiveness of the different maternal variables on the prediction of oral glucose tolerance test (OGTT) post load glycemia. Pregnant women were recruited in Concepción, Chile. GDM diagnosis was performed at 24-28 weeks of pregnancy by an OGTT (n = 54 for normal glucose tolerance, n = 12 for GDM). 75 maternal thyroid and non-thyroid parameters were recorded in the first and the second trimester of pregnancy. Various combinations of variables were assessed for GDM and post load glycemia prediction through different classification and regression machine learning techniques. The best predictive models were simplified by variable selection. Every model was subjected to leave-one-out cross-validation. Our results indicate that thyroid markers are useful for the prediction of GDM and post load glycemia, especially at the second trimester of pregnancy. Thus, they could be used as an alternative screening tool for GDM, independently of the diagnostic criteria used. The final classification models predict GDM with cross-validation areas under the receiver operating characteristic curve of 0.867 (p<0.001) and 0.920 (p<0.001) in the first and the second trimester of pregnancy, respectively. The final regression models predict post load glycemia with cross-validation Spearman r correlation coefficients of 0.259 (p = 0.036) and 0.457 (p<0.001) in the first and the second trimester of pregnancy, respectively. This investigation constitutes the first attempt to test the performance of the whole maternal thyroid profile on GDM and OGTT post load glycemia prediction. Future external validation studies are needed to confirm these findings in larger cohorts and different populations.

Factores de riesgo y mortalidad de los derrames pleurales que precisan de una toracocentesis diagnóstica

Introduction

Occurrence of malignant pleural effusion (PE) is known to be associated with a poor prognosis, but the mortality of patients with non-malignant effusions has not been sufficiently studied. Our objective was to describe the clinical course and explore risk factors associated with all-cause mortality at 1, 5 and 10 years in patients who develop a PE.

Methods

Retrospective observational study of patients undergoing diagnostic thoracentesis during the decade 2008-2017 in a pulmonology service. Demographic, biochemical, pathological and evolutionary variables were evaluated. The etiology of the effusions was determined using standardized criteria.

Results

Pleural fluid samples from 358 patients with a mean age of 68.9 years (SD 15.1 years), 69.2% males, were analyzed. Malignant (29.4%), parapneumonic (19.8%) and secondary to heart failure (18.9%) effusions predominated. Patients with malignant and heart failure related PE had 1-year mortality rates of 60.0% and 30.8%, respectively, and 85% and 64.7% at 5 years. Male gender (hazard ratio [HR] 1.46; 95% CI: 1.03-2.07), positive cytology for malignancy (HR 1.66; 95% CI: 1.03-2.68) and effusion recurrence (HR 1.61; 95% CI: 1.17-2.21) were associated with a worse prognosis and 5-year mortality.

Conclusions

Patients undergoing thoracentesis for effusion have a high short and long-term mortality. In our series of hospitalized patients with PE, the factors associated with higher mortality at 1 and 5 years were age, male sex, recurrence of PE, and coexistence of malignancy.

Investigating the appropriate adenosine deaminase cutoff value for the diagnosis of tuberculous pleural effusion in a country with decreasing TB burden

As the burden of tuberculosis (TB) in South Korea decreases while that of malignancy increases with an aging society, the composition of etiology for pleural effusion is changing. The aim of this study was to investigate the diagnostic value of adenosine deaminase (ADA) for diagnosis of tuberculous pleural effusion (TPE) in this circumstance. Medical records of patients who underwent medical thoracoscopy from May 2015 to September 2020 in Incheon St. Mary Hospital, Korea were retrospectively reviewed. TPE was diagnosed if one of the following criteria was met: (1) granuloma in pleura, (2) positive TB polymerase chain reaction or culture in pleural fluid or tissue with non-specific pathologic findings in pleura, or (3) bacteriologically confirmed pulmonary TB with non-specific pathologic findings in pleura. A total of 292 patients, including 156 with malignant pleural effusion (MPE), 52 with TPE, and 84 with other benign effusion, were analyzed. Among 206 patients with lymphocyte dominant pleural effusion, the area under receiver characteristic curve of ADA for diagnosis of TPE was 0.971. The sensitivity and specificity of a current cutoff value of 40 IU/L were 1.00 and 0.61, respectively, whereas those of a raised cutoff value of 70 IU/L were 0.93 and 0.93, respectively. Among 54 patients with ADA levels of 40–70 IU/L, 30 (55.6%) patients were diagnosed as MPE, 21 (38.9%) as other benign effusion, and only 3 (5.6%) as TPE. Caution is needed in clinical diagnosis of TPE with current ADA cutoff value in countries with decreasing TB incidence, due to many false positive cases.

Diagnostic value and safety of thoracoscopic pleural biopsies in pleural exudative effusions of unknown origin, including follow-up

INTRODUCTION

Pleural exudative effusions without diagnosis after initial work up are a frequent problem in any respiratory division. Several ways to obtain pleural biopsy exist. Thoracoscopy is one of the most frequently used. Differential diagnosis mainly exists out of malignant pleuritis, tuberculosis, nonspecific pleuritis and rarely systemic or autoimmune disease. We performed a retrospective data analysis of our almost 10-year period experience, the first Belgian data to be published.

METHODS

We performed a retrospective data analysis of all patients with unexplained pleural exudates who underwent diagnostic medical thoracoscopy under general anaesthesia in our respiratory department during the period 2006-2015. We report on diagnoses made, sensitivity and specificity, safety of thoracoscopy and follow-up of patients after thoracoscopy.

RESULTS

131 patients underwent diagnostic medical thoracoscopy during the inclusion period. 44.3% (n=58) of the patients were diagnosed with malignant pleuritis, 45.0% (n=59) with nonspecific pleuritis, 7.6% (n=10) with tuberculous pleuritis and some with other benign conditions. Complications are comparable to other data published. Six months follow-up of patients with non-specific pleuritis reveal 8.5% (n=5) of these patients to have malignant pleuritis, and another 8.5% (n=5) with infectious or other benign conditions.

CONCLUSION

Medical thoracoscopy under general anaesthesia for diagnostic work up of pleural exudates of unknown origin generally has a high diagnostic yield. It is generally safe, certainly compared with the information it delivers. During follow-up, minority of patients with nonspecific pleuritis will prove to be malignant in origin, benign or autoimmune disease related.

Diagnostic Value of Soluble Form of Mer Tyrosine Kinase (sMerTK) in Tuberculous Pleural Effusion and Malignant Pleural Effusion

Objectives. With the development of proteomics, it has been indicated that differentially expressed proteins are biological markers for the diagnosis of different types of pleural effusion (PE). The aim of our study was to explore the value of sMerTK (soluble form of Mer tyrosine kinase) in the differential diagnosis of tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE). In addition, we also wanted to explore whether MerTK was associated with IL-1β and TNF-α, which are inflammatory factors related to pleural effusion. Methods. We screened all patients who underwent thoracoscopy and had a definite diagnosis. In total, 136 patients were enrolled in this study and classified into two groups, with 64 patients in the TPE group and 72 patients in the MPE group. The concentrations of sMerTK in the TPE and MPE groups were detected by ELISA. The diagnostic accuracy was determined by generating receiver operating characteristic (ROC) curves and calculating the area under the curve (AUC). Correlations between the expression level of sMerTK and those of the inflammatory factors interleukin 1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) were also studied using Pearson’s linear correlation analysis. Results. The concentrations of sMerTK were $\mathrm{5,278.77}\pm \mathrm{2,479.98}\text{ng}/\text{L}$ and $859.91\pm 540.45\text{ng}/\text{L}$ in the TPE and MPE groups, respectively. The concentration of sMerTK in TPE was shown to be significantly higher than that in MPE ( $P<0.05$ ). The area under the ROC curve for sMerTK in distinguishing TPE from MPE was 0.958, with a cutoff value of 2,122 ng/L. The sensitivity and specificity for sMerTK were 98.61% and 90.63% ( $P<0.05$ ). The expression levels of sMerTK in these two groups were not correlated with those of the inflammatory factors IL-1β and TNF-α ( $P>0.05$ ). Conclusions. The expression level of sMerTK in PE could be a potential biomarker for common use in the diagnosis of TPE and MPE.

Pleural effusion related to IgG4

Purpose of review

The causes of exudative pleural effusions are diverse and frequently remain unclear despite exhaustive examinations. Recently recognized IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder that can affect nearly any organ including the lungs. This review will focus on the involvement of IgG4 in exudative pleural effusion of unknown cause.

Recent findings

IgG4 is found to be involved in a proportion of patients with undiagnosed pleural effusions. Pleural involvement in IgG4-RD can be seen in isolation or association with other organ disease. Pleural thickening and/or effusion are common clinical features of IgG4-related pleural lesions, and this condition is histologically characterized by a lymphoplasmacytic infiltrate enriched in IgG4-positive plasma cells in the pleura. Although the pathogenesis of IgG4-RD is poorly understood, there is a growing body of evidence that indicates an antigen-driven process requiring T-cell and B-cell interaction in which autoantibodies, plasmablasts, follicular helper T cells and CD4+ cytotoxic T lymphocytes participate.

Summary

The possibility of IgG4-related pleural lesion should be considered in patients with pleural effusion of unexplained cause when lymphoplasmacytic infiltration is seen in a pleural biopsy specimen. This condition is responsive to systemic steroid therapy.

Clinical long-term outcome of non-specific pleuritis (NSP) after surgical or medical thoracoscopy

Background

Thoracoscopy, either “medical” or “surgical”, is the gold standard to reveal the cause of pleural effusion by taking large biopsies. However, in some cases, the histology of pleural biopsies is inconclusive for a specific cause, describing a variable process of inflammation, encompassing for non-specific pleuritis (NSP). Questions are raised whether the surgical (or video-assisted thoracoscopic surgery, VATS) is doing better than the medical thoracoscopy (MT or pleuroscopy), but no direct comparison between the two techniques exist in the current bibliography. The aim of our retrospective study was to compare these two techniques to find whether there is any difference in the false negative cases of NSP.

Methods

We included in our study 295 patients with NSP, 179 patients who underwent VATS comparing to 116 patients who underwent MT for pleural effusion of initially undetermined cause, having a follow-up of at least one year. Analysis of patients’ files, history, clinical examinations, further tests, and follow-up were recorded.

Results

The mean age of our patients was 58.5±19.1 and M/F gender was 216/79; no difference was observed between the two groups. The mean follow-up period was 47.3±20.7 months. After VATS, only one patient (0.55%) was finally diagnosed with pleural malignancy (false negative) while after MT 2 patients (1.7%). Negative predictive value for pleura-related malignancy for VATS was 0.994 and for MT 0.982.

Conclusions

In patients with histological diagnosis of NSP both VATS and MT showed similar and excellent results of false negative cases and negative predictive value in excluding malignant pleural disease.

Idiopathic Pleural Effusions: Characteristics and Discrimination From Cytology-Negative Malignant Pleural Effusions

BACKGROUND

The etiology of pleural effusions often remained unknown notwithstanding surgical pleural biopsy and further clinical observation. A better understanding of clinical characteristics of patients with idiopathic pleural effusion (IPE) may improve the ability to differentiate between IPEs and cytology-negative malignant pleural effusions (MPEs) and facilitate the identification of patients requiring invasive investigation. However, little is known about the clinical factors that can help distinguish patients with IPE from those with cytology-negative MPE.

MATERIALS AND METHODS

Patients who were diagnosed with IPE or cytology-negative MPE between 2010 and 2017 were enrolled in this retrospective study. Clinical, laboratory and radiologic characteristics were compared between patients with IPE and cytology-negative MPE. Diagnostic performances of predictors for IPE were assessed using receiver operating characteristic curves.

RESULTS

Of 146 patients undergoing pleural biopsy owing to cytology-negative pleural effusion of uncertain cause, MPE was confirmed in 54 patients. IPE was ultimately diagnosed in 22 patients. Multivariate analysis demonstrated that a minimal amount of pleural effusion (odds ratio [OR] = 12.41, P = 0.039), presence of pleural nodularity (OR = 0.01, P < 0.001) and pleural fluid carcinoembryonic antigen levels less than 14 ng/mL (OR = 87.59, P = 0.002) were independent factors for distinguishing IPEs from cytology-negative MPEs. A combination of the absence of pleural nodularity with pleural fluid carcinoembryonic antigen levels less than 14 ng/mL yielded an area under the curve of 0.94 (sensitivity = 91% and specificity = 96%).

CONCLUSIONS

Using these readily available parameters to identify IPE in patients with cytology-negative exudative effusion of unknown cause can help guide decision-making when choosing to perform an invasive pleural biopsy or to take a conservative approach.

Spondylodiscitis initially presenting as exudative pleural effusion: A case report and review of the literature

Pleural effusions are associated with a variety of disease states, rendering the differential diagnosis challenging. Spondylodiscitis is an uncommon disease, and its prompt diagnosis can reduce morbidity and mortality. However, an atypical manifestation of the disease, such as pleural effusion, can result in delayed diagnosis. A 76-year-old woman presented with back pain and right pleural effusion. Magnetic resonance imaging revealed paravertebral soft tissue infiltration, with enhancement of bone marrow and intervertebral disk at the T8 and T9 levels, suggesting spondylodiscitis. In patients with exudative pleural effusion, spondylodiscitis may be the cause, so careful analysis of imaging is necessary.

An uncommon cause of pleural effusion

Pleural disease is a common respiratory condition affecting ∼3000 people per million population annually [1]. Pleural effusion has multiple underlying aetiological conditions and therefore requires a systematic assessment to reach a final diagnosis. Despite detailed evaluation, there may be situations, where the aetiology of a pleural effusion remains unknown [2]. Various experts have suggested a step-wise approach in the management of these undiagnosed pleural effusions [3]. The role of detailed history, proper clinical examination and appropriate investigations, including computed tomography (CT) of chest and pleural biopsy, in an attempt to establish the correct cause of pleural effusion cannot be overemphasised. We present an interesting case of pleural effusion that was managed at our institute.

Pleural effusions are associated with various aetiologies: systematic evaluation is needed to reach a correct diagnosis. In 20% of cases the aetiology of exudative pleural effusion is elusive and pleural biopsy is required to reach a diagnosis.http://bit.ly/2HyZGVZ

Chronic follicular pleuritis: a B cell-rich form of nonspecific pleuritis/fibrosis

The parietal pleura is often biopsied in patients with idiopathic pleural effusion, and in up to 40% of cases, a diagnosis of nonspecific pleuritis/fibrosis (NSP) is rendered. The histology of this reaction has not been well described including a pattern of B cell lymphoid hyperplasia described as "chronic follicular pleuritis (CFP)". Thirty-two cases of NSP were studied, of which 13 (41%) corresponded to CFP with the remainder displaying a fibrinous and organizing pleuritis with varying degrees of collagenization. CFP had similar etiologies as NSP with long term follow-up, including cardiac disease, pericarditis, asbestos exposure, and occult malignancy. The importance of recognizing a previously undescribed B cell/plasma cell pleural inflammatory response in reactive pleural disease is discussed.

The encaged lung: rapidly progressive idiopathic pleurisy

A 56-year-old, non-smoker male with no exposure, presented with right chest pain and a huge loss in forced vital capacity due to right lung volume reduction with consensual pleural thickening on high-resolution computed tomography. All serological and microbiological tests were negative. The surgical lung biopsy showed fibrinous pleurisy while the search for neoplastic cells resulted negative. Because of symptoms worsening he started low dose steroids without benefits until he died 3 months later for cardiac ischemic attack. We reviewed the literature to identify possible etiologies and a rapidly progressive idiopathic pleurisy revealed to be the most probable diagnosis.

Feasibility and Safety of Pleuroscopic Cryobiopsy of the Pleura: A Prospective Study

Background

The aim of this study was thus to evaluate the feasibility and safety of taking biopsy specimens by cryoprobe from the parietal pleura during semirigid pleuroscope.

Methods

In a single-center, observational, prospective study, patients with exudative pleural effusion (EPE) were evaluated with a semirigid pleuroscope between January 2015 and July 2017. Each patient underwent pleural biopsy using flexible forceps and flexible cryoprobe through pleuroscope following diagnostic thoracentesis and closed pleural biopsy (CPB).

Results

A total of 92 patients (median age 64 years) were included in the study, most of whom were men (65.2%). Cytological cell block (CCB) and CPB made definitive diagnoses in 32/92 (34.8%) and 25/92 (27.5%), respectively; flexible forceps biopsy (FFB) and cryoprobe biopsy (CB) established definitive diagnoses in 84/92 (91.3%) and 91/92 (98.9%), respectively. The sample obtained by CB (9.4 ± 4.9 mm) was significantly larger than the other two methods: FFB (4.2 ± 2.3 mm) or CPB (1.9 ± 1.0 mm) (P < 0.0001). The immunohistochemical (IHC) staining was more easily performed with CB (98.9%) compared to either FFB (87.0%) or CPB (13.0%). There were no significant complications or procedure-related deaths.

Conclusions

Based on these results, CB during semirigid pleuroscope has a high diagnostic yield, differentiating EPE of unknown etiology with satisfactory effectiveness and safety.

Association of immunoglobulin G4 and free light chain with idiopathic pleural effusion

The cause of pleural effusion remains uncertain in approximately 15% of patients despite exhaustive evaluation. As recently described immunoglobulin (Ig)G4-related disease is a fibroinflammatory disorder that can affect various organs, including the lungs, we investigate whether idiopathic pleural effusion includes IgG4-associated etiology. Between 2000 and 2012, we collected 830 pleural fluid samples and reviewed 35 patients with pleural effusions undiagnosed after pleural biopsy at Yamaguchi-Ube Medical Center. Importantly, IgG4 immunostaining revealed infiltration of IgG4-positive plasma cells in the pleura of 12 patients (34%, IgG4⁺ group). The median effusion IgG4 level was 41 mg/dl in the IgG4⁺ group and 27 mg/dl in the IgG4^- group (P < 0·01). The light and heavy chains of effusion IgG4 antibodies of patients in the IgG4⁺ group were heterogeneous by two-dimensional electrophoresis, indicating the absence of clonality of the IgG4 antibodies. Interestingly, the κ light chains were more heterogeneous than the λ light chains. The measurement of the κ and λ free light chain (FLC) levels in the pleural fluids showed significantly different κ FLC levels (median: 28·0 versus 9·1 mg/dl, P < 0·01) and κ/λ ratios (median: 2·0 versus 1·2, P < 0·001) between the IgG4⁺ and IgG4^- groups. Furthermore, the κ/λ ratios were correlated with the IgG4⁺ /IgG⁺ plasma cell ratios in the pleura of the IgG4⁺ group. Taken together, these results demonstrate the involvement of IgG4 in certain idiopathic pleural effusions and provide insights into the diagnosis, pathogenesis and therapeutic opportunities of IgG4-associated pleural effusion.

Long-term outcome of patients with nonspecific pleurisy at medical thoracoscopy

BACKGROUND

Medical thoracoscopy is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. But there are still a part of patients with pleural effusions were diagnosed as nonspecific pleurisy when no specific biopsy results were found after undergoing thoracoscopic biopsy. The long-term outcome of these patients is unclear, and anxieties about undiagnosed malignancy persist.

METHODS

Between July 2005 and June 2014, medical thoracoscopy using the semi-rigid instrument was performed and pleural biopsy was taken in 833 patients with pleural effusions. Fifty-two patients diagnosed with nonspecific pleurisy with available follow-up data were included in the present study and their medical records were reviewed.

RESULTS

Fifty-two patients (31 men and 21 women) were included. Mean follow up was 35.5 ± 40.9 months (range, 1-143 months). No specific diagnosis was established in 21 (40.4%) of the patients. Eight of 52 patients with nonspecific pleurisy (15.4%) were subsequently diagnosed with pleural malignancies. 23 of 52 patients (44.2%) were diagnosed as benign diseases. The recurrence of pleural effusion during followed-up and pleural nodules or plaques found in medical thoracoscopy was associated with malignant disease.

CONCLUSION

Patients with nonspecific pleurisy after medical thoracoscopy should be closely monitored, especially in those patients with the recurrence of pleural effusion during followed-up, pleural nodules or plaques found in medical thoracoscopy. One year of clinical follow-up for patients found to have nonspecific pleurisy is likely sufficient.

A potential role for VEGF in the diagnostic approach of pleural effusions

BACKGROUND

Vascular endothelial growth factor (VEGF) may play a role in pleural fluid formation, as it represents a potent inducer of capillary permeability. We aimed to investigate the diagnostic utility of VEGF levels in pleural fluid and serum in patients with pleural effusions with initially negative diagnostic work up.

METHODS

Seventy-one patients with exudative lymphocytic pleural effusions undiagnosed after initial diagnostic work up were enrolled in this prospective study and their clinical course was followed up to 24 months. VEGF levels were measured in serum and pleural fluid by using immunoenzymometric assay.

RESULTS

During the follow up period, in 43 patients the pleural effusion was eventually attributed to malignancy while in the rest 28 patients it was due to non-malignant causes (benign and unknown origin). Patients with malignancy had significantly higher VEGF levels in pleural fluid compared to patients with non-malignant effusions (1,506 vs. 588 pg/dL, P=0.0001), while no statistically significant difference was found in the VEGF serum levels between the two groups.

CONCLUSIONS

Pleural VEGF levels may be helpful in identifying malignant pleural effusion (MPE) in patients with negative diagnostic work up at the initial assessment and help in selecting patients for more invasive procedures.

The diagnosis of pleural effusions

Pleural effusions arise from a variety of systemic, inflammatory, infectious and malignant conditions. Their precise etiological diagnosis depends on a combination of medical history, physical examination, imaging tests and pertinent pleural fluid analyses; including specific biomarkers (e.g., natriuretic peptides for heart failure, adenosine deaminase for tuberculosis, or mesothelin for mesothelioma). Invasive procedures, such as pleuroscopic biopsies, may be required for persistently symptomatic effusions which remain undiagnosed after the analysis of one or more pleural fluid samples. However, whenever parietal pleural nodularity or thickening exist, image-guided biopsies should first be attempted. This review addresses the current diagnostic approach to pleural effusions secondary to heart failure, pneumonia, cancer, tuberculosis and other less frequent conditions.

Tuberculous Pleural Effusion

When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult.

Is There a Role for a Needle Thoracoscopic Pleural Biopsy under Local Anesthesia for Pleural Effusions?

Background

A closed pleural biopsy is commonly performed for diagnosing patients exhibiting pleural effusion if prior thoracentesis is not diagnostic. However, the diagnostic yield of such biopsies is unsatisfactory. Instead, a thoracoscopic pleural biopsy is more useful and less painful.

Methods

We compared the diagnostic yield of needle thoracoscopic pleural biopsy performed under local anesthesia with that of closed pleural biopsy. Sixty-seven patients with pleural effusion were randomized into groups A and B. Group A patients were subjected to closed pleural biopsies, and group B patients were subjected to pleural biopsies performed using needle thoracoscopy under local anesthesia.

Results

The diagnostic yields and complication rates of the two groups were compared. The diagnostic yield was 55.6% in group A and 93.5% in group B (p<0.05). Procedure-related complications developed in seven group A patients but not in any group B patients. Of the seven complications, five were pneumothorax and two were vasovagal syncope.

Conclusion

Needle thoracoscopic pleural biopsy under local anesthesia is a simple and safe procedure that has a high diagnostic yield. This procedure is recommended as a useful diagnostic modality if prior thoracentesis is non-diagnostic.

Tuberculous pleural effusion

Tuberculous pleural effusion (TBPE) is the most common form of extrapulmonary tuberculosis (TB) in Spain, and is one of the most frequent causes of pleural effusion. Although the incidence has steadily declined (4.8 cases/100,000population in 2009), the percentage of TBPE remains steady with respect to the total number of TB cases (14.3%-19.3%). Almost two thirds are men, more than 60% are aged between 15-44years, and it is more common in patients with human immunodeficiency virus. The pathogenesis is usually a delayed hypersensitivity reaction. Symptoms vary depending on the population (more acute in young people and more prolonged in the elderly). The effusion is almost invariably a unilateral exudate (according to Light's criteria), more often on the right side, and the tuberculin test is negative in one third of cases. There are limitations in making a definitive diagnosis, so various pleural fluid biomarkers have been used for this. The combination of adenosine deaminase and lymphocyte percentage may be useful in this respect. Treatment is the same as for any TB. The addition of corticosteroids is not advisable, and chest drainage could help to improve symptoms more rapidly in large effusions.

Nonspecific pleuritis: optimal duration of follow-up

BACKGROUND

Nonspecific pleuritis (NSP) is a frequent diagnosis after parietal pleural biopsy, but the clinical significance of this finding and need for further follow-up have not been firmly established. Previous reports suggest that 5% to 25% of patients with NSP are subsequently diagnosed with pleural malignancy.

METHODS

Our pathology database was queried for patients with histologic evidence of NSP from January 01, 2001, to December 31, 2012 (n = 413). Patients with less than 1 year of follow-up after biopsy, diagnosis of empyema, tuberculous pleuritis, active systemic connective tissue disease or vasculitis, or active malignancy were excluded (n = 327). The remaining patients were included and their medical records were reviewed.

RESULTS

Eighty-six patients were included. Mean follow up was 1,824 ± 1,032 days (range, 409 to 4,599 days). Three of the 86 patients with NSP (3.5%) were subsequently diagnosed with pleural malignancy. All 3 patients were found to have mesothelioma with a mean time from biopsies to diagnosis of 205 ± 126 days (range, 64 to 306 days). Twenty-two of 86 patients (25.5%) had a possible identifiable cause of pleural inflammation (benign disease). After exclusion of these 22 patients, the incidence of malignancy was 3 of 64 (4.7%).

CONCLUSIONS

The incidence of subsequent pleural malignancy (mesothelioma) among patients found to have NSP based on pleural biopsy was 3.5%. Occult mesothelioma in patients with NSP will most likely be diagnosed within 1 year of the initial pleural biopsy; therefore, these patients should be followed for a minimum of 1 year to allow for timely detection of occult pleural malignancy.

Role of common investigations in aetiological evaluation of exudative pleural effusions

BACKGROUND

Pleural effusion is a common problem encountered in daily practice. To Establish aetiology of exudative effusions is a diagnostic challenge to general practitioners and even to pulmonologists especially in resource poor government hospitals with lack of investigations like thoracoscopy. Some recent studies had shown that around 2% of patients remained undiagnosed even after these investigations.

AIMS AND OBJECTIVE

To evaluate the role of the commonly available investigations such as pleural fluid study, blind pleural biopsy, sputum examination, CT scan thorax, bronchoscopy in the aetiological evaluation of exudative effusions and to ascertain the proportion of cases which remain undiagnosed after all the above investigations.

MATERIAL AND METHODS

This was a prospective single-centred cross-sectional study carried out at the NRS Medical College, Kolkata, India from February 2008 to February 2013 which included 568 patients of exudative pleural effusions. We performed commonly available procedures like pleural fluid study, blind pleural biopsy, sputum examination, CT scan thorax, bronchoscopic procedures to the diagnosis.

RESULTS

Total number of patients studied were 568. Tuberculosis was the most common cause (54.57%) followed by malignancy (28.17%), empyema (10.56%), parapneumonic effusion (5.28%) and others. Carcinoma of the lung was the commonest cause of malignant effusions and bronchoscopic biopsy was given the highest yield of histological diagnosis (84.6%) followed by CT guided FNAC (77.6%) and pleural fluid cytology (55%). Highest yield to diagnose tubercular effusion was found in lymph node FNAC (81.5%) followed by pleural biopsy (62%). Sputum smear for AFB was positive in only 27.4% cases. Bleeding followed by pneumothorax were the most common complications. Complications are very less (1.3% and 0.9% respectively). 2 patients (0.34%) remained undiagnosed even after these all above said investigations.

CONCLUSION

Above mentioned commonly available investigations can ascertain diagnosis in most of the cases in the aetiological evaluation of exudative effusions and they are relatively safe procedures.

Combining clinical and analytical parameters improves prediction of malignant pleural effusion

PURPOSE

The usefulness of a panel of tumour markers and clinical-radiological criteria for diagnosing malignant pleural effusion (MPE) is not clearly stated. Our purpose was to assess the performance of those parameters in the diagnosis of MPE.

METHODS

Consecutive patients with exudative PE were enrolled and divided into two groups: MPE and non-MPE. Logistic regression analysis was used to estimate the probability of MPE. Four prognostic models were considered: (1) clinical-radiological variables; (2) analytical variables; (3) combination of clinical and analytical variables; and (4) simpler model removing some analytical variables. Calibration and discrimination (receiver operating characteristics curves and AUC) were performed.

RESULTS

A total of 491 pleural exudates were included: tuberculous (n = 72), malignant (n = 211), parapneumonic (n = 115), empyemas (n = 32), or miscellaneous (n = 61). The AUC obtained with Model 1 (absence of chest pain and fever and radiological images compatible with malignancy), Model 2 (CEA, NSE, CYFRA 21-1, and TPS), Model 3 (sum of the variables of models 1 and 2), and Model 4 (the variables of model 1 plus CEA) were 0.918, 0.832, 0.952 (all with a P < 0.05), and 0.939 (P < 0.01 compared to models 1 and 2), respectively. The correct classification rate for Models 1, 2, 3, and 4, was 87.2, 79.5, 88.4, and 87.6 %, respectively.

CONCLUSIONS

All models analysed had a good diagnostic yield for MPE, being greater in those that combined radiological and analytical criteria. Although Model 3 obtained a higher yield, the simplest model (Model 4) is very attractive due to its simplicity of use in daily practice.

Coccidioidomycosis: adenosine deaminase levels, serologic parameters, culture results, and polymerase chain reaction testing in pleural fluid

BACKGROUND

In a patient with positive serum serology for coccidioidomycosis, the differential diagnosis of concurrent pleural effusions can be challenging. We, therefore, sought to clarify the performance characteristics of biochemical, serologic, and nucleic-acid-based testing in an attempt to avoid invasive procedures. The utility of adenosine deaminase (ADA), coccidioidal serology, and polymerase chain reaction (PCR) in the evaluation of pleuropulmonary coccidioidomycosis has not been previously reported.

METHODS

Forty consecutive patients evaluated for pleuropulmonary coccidioidomycosis were included. Demographic data, pleural fluid values, culture results, and clinical diagnoses were obtained from patient chart review. ADA testing was performed by ARUP Laboratories, coccidioidal serologic testing was performed by the University of California-Davis coccidioidomycosis serology laboratory, and PCR testing was performed by the Translational Genomics Research Institute using a previously published methodology.

RESULTS

Fifteen patients were diagnosed with pleuropulmonary coccidioidomycosis by European Organization for the Research and Treatment of Cancer/Mycoses Study Group criteria. Pleural fluid ADA concentrations were < 40 IU/L in all patients (range, < 1.0-28.6 IU/L; median, 4.7). The sensitivity and specificity of coccidioidal serologic testing was 100% in this study. The specificity of PCR testing was high (100%), although the overall sensitivity remained low, and was comparable to the experience of others in the clinical use of PCR for coccidioidal diagnostics.

CONCLUSION

Contrary to prior speculation, ADA levels in pleuropulmonary coccidioidomycosis were not elevated in this study. The sensitivity and specificity of coccidioidal serologic testing in nonserum samples remained high, but the clinical usefulness of PCR testing in pleural fluid was disappointing and was comparable to pleural fluid culture.

The Long-term Prognosis of Patients With the Diagnosis of Nonmalignant Pleural Effusions After Pleuroscopy

PURPOSE

Several studies have demonstrated the diagnostic yield of medical thoracoscopy (pleuroscopy) in making the diagnosis of malignant pleural effusion (MPE). No previous studies, however, have reported long-term outcomes for patients undergoing diagnostic pleuroscopy in whom no malignancy was demonstrated either with cytologic examination of pleural fluid or pathologic examination of thoracoscope-guided pleural biopsies. We report the results of long-term follow-up (at least 3 y) of patients with the diagnosis of nonmalignant pleural effusions (NMPEs) after pleuroscopy.

METHODS

One hundred and nineteen patients underwent the procedure between 1994 and 2003 at Lahey Clinic. We report a retrospective review of 25 of those patients diagnosed with NMPE after diagnostic pleuroscopy. All 25 patients underwent thoracoscopic pleural biopsy and cytologic examination of the effusion. Outcomes were assessed using review of the medical records, appointment scheduler, social security death index, and/or telephone conversation with primary care providers.

RESULTS

Mean age±SD was 68 years (range, 34 to 87 y). Median survival time was estimated at 114 months. Concomitant illness was also evaluated: 40% (n=10) diabetes, 64% (n=16) coronary artery disease, 40% (n=10) congestive heart failure, 20% (n=5) liver disease, 20% (n=5) renal disease, and 36% (n=9) pulmonary disease. Final diagnoses after pleuroscopy most commonly included chronic pleuritis (n=7) and pleural plaques (n=5). Survival was found at 1 year to be 88% (22/25), 3 years 80% (20/25), and 5 years 74.7% (19/25). None of the 25 patients developed subsequent MPE.

CONCLUSIONS

Patients with NMPE after pleuroscopy have a favorable prognosis and are unlikely to be subsequently diagnosed with an MPE.

Mechanisms of pleural involvement in orphan diseases

Over the past 10 years, the widespread clinical applicability of semi-invasive and noninvasive diagnostic tools including medical thoracoscopy and ultrasonography has expanded the occurrence of pleural effusions to include several rare diseases such as granulomatous, connective tissue and autoimmune disorders including sarcoidosis, granulomatosis with polyangiitis (Wegener's), systemic sclerosis, lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome, amyloidosis, Langerhans cell histiocytosis, and others. The purpose of this review is to summarize the current state of the knowledge regarding pathogenetic mechanisms of pleural involvement in rare disease entities and to highlight the need for more efforts to understand the underlying mechanisms for a more effective therapy.

Update on tuberculous pleural effusion

The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of gamma-interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.

Evaluation of serum and pleural levels of the tumor markers CEA, CYFRA21-1 and CA 15-3 in patients with pleural effusion

OBJECTIVE

To determine the levels of the tumor markers carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA21-1) and carbohydrate antigen 15-3 (CA 15-3) in the blood and pleural fluid of patients with benign or malignant pleural effusion, evaluating the sensitivity of each marker in these fluids.

METHODS

We prospectively evaluated 85 patients with pleural effusion. The study of the pleural fluid observed the criteria established in the literature. Levels of the markers were determined using electrochemiluminescence. The sensitivity was determined on the condition that the specificity was > or = 90%.

RESULTS

Of the 85 cases, 36 (42.4%) were malignant, 30 (35.3%) were benign, and the results were inconclusive in 19 (22.3%). In the malignant cases, the CEA and CYFRA21-1 levels were higher in the pleural fluid than in the blood, which was not observed for CA 15-3. In the benign cases, the CYFRA21-1 levels were higher in the pleural fluid than in the blood, whereas the opposite was found for CEA and CA 15-3. There were significant differences between malignant and benign cases for all markers, in pleural fluid and blood. In the pleural fluid, the sensitivity of CEA, CYFRA21-1 and CA 15-3 was 69.4, 69.4 and 66.7%, respectively, and the combined sensitivity was 80.6%. In the blood, the sensitivity was 57.1%, 71.4% and 48.6% for CEA, CYFRA21-1 and CA 15-3, respectively, and the combined sensitivity was 77%.

CONCLUSION

The results suggest that these markers might be useful in the differentiation between malignant and benign pleural effusion.

Diltiazem-induced eosinophilic pleural effusion

A 68-year-old woman developed eosinophilic pleural effusion and systemic eosinophilia 2 months after starting antihypertensive therapy with diltiazem. Several drugs are known to cause this disorder; however, the only other drug the patient had been taking was clonidine, which she had taken for the past 3-4 years. She was evaluated for all other possible causes of eosinophilia and eosinophilic pleural effusion, including malignancy, infection, and autoimmune disorders. Her symptoms resolved after diltiazem was discontinued, and no recurrence was noted on follow-up. To our knowledge, this is the first case report of eosinophilic pleural effusion caused by diltiazem. According to the Naranjo adverse drug reaction probability scale, a probable relationship existed between diltiazem and the patient's eosinophilia and pleural effusion. Although numerous drugs have been associated with eosinophilia and eosinophilic pleural effusion, the spectrum may actually be wider than is commonly thought and may include such unrecognized agents as diltiazem.

Pleural effusion associated with rheumatoid arthritis: what cell predominance to anticipate?

Pleural involvement is the most frequent manifestation of rheumatoid arthritis (RA) in the chest. We report here two patients who presented with large exudative pleural effusions and subsequently developed sero-positive RA. In both cases, the differential cell count of the pleural effusion suggested empyema. A literature review identified that RA-associated pleural effusion afflicts more men than women and 95% of the patients have high titers of rheumatoid factor (RF). In 46% of cases, RA-associated pleural effusion is diagnosed in close temporal relationship with the diagnosis of RA. The effusion is an exudate and is characterized by low pH and glucose level, and high lactic dehydrogenase (LDH) and cell count. At diagnosis there is a tendency for predominant neutrophils to occur consistent with an empyema and 7-11 days later, the cells in the pleural effusion are replaced by lymphocytes. Pleural effusion with predominant eosinophilia is rare. RA patients with acidic effusion and low glucose content with neutrophils predominance should be treated with thoracic drainage and antibiotics until an infection is ruled out. The histo-pathologic findings in pleural fluid of tadpole cells and multinucleated giant cells and the replacement of the mesothelial cells on the parietal pleural surface with a palisade of macrophage derived cells are described as pathogonomic for RA. Treatment with systemic steroids and intra-pleural steroids are effective in most cases.

Cell-free DNA concentration in pleural fluid and serum: quantitative approach and potential prognostic factor in patients with cancer and pleural effusions

PURPOSE

The presence of pleural effusions in patients with tumors is often indicative of locally advanced or metastatic disease, and detection of malignancy in effusion samples frequently leads to a disease upstaging. Our purpose was to quantify the DNA in pleural effusion and serum in patients presenting pleural effusion in order to assess the potential prognostic impact.

PATIENTS AND METHODS

The DNA level was determined by amplifying hRNase P in paired samples of serum and pleural fluid in 70 consecutive patients with cancer showing pleural effusion. A group of 30 patients without cancer was included. The correlation between serum and pleural DNA was calculated. Survival curves according to serum and pleural DNA were analyzed.

RESULTS

Median DNA concentrations were greater in patients with neoplasia than in patients without malignancy: 105 ng/mL versus 40 ng/mL (P = 0.001) in serum samples, respectively; 93 ng/mL versus 21 ng/mL (P = 0.001) in pleural fluids, respectively. A positive correlation between serum and pleural levels was confirmed (r = 0.3; P < 0.05). Median survival time for patients with serum DNA < or = 105 ng/mL was 11.03 months in contrast to only 3.63 months for patients with higher values (P = 0.036). Accordingly, median survival time for patients with pleural DNA < or = 93 ng/mL was 12.3 months versus only 4.63 months in case of higher levels (P = 0.027).

CONCLUSION

This study shows that there is a strong correlation between higher levels of free DNA in pleural fluid or serum and malignancy. Survival is worse for patients with higher DNA levels in serum and pleural fluid.

The Undiagnosed Pleural Effusion

The most common causes for undiagnosed transudative effusions are congestive heart failure and hepatic hydrothorax. Pleural fluid N terminal pro-brain natriuretic peptide levels higher than 1500 pg/mL are virtually diagnostic of congestive heart failure. The most common causes for undiagnosed exudative pleural effusions are malignancy, pulmonary embolism, and tuberculosis. Clinical characteristics of patients with a malignant pleural effusion are symptoms for more than 1 month, absence of fever, blood-tinged pleural fluid, and CT findings suggestive of malignancy. Thoracoscopy is useful to establish the diagnosis of malignancy and tuberculosis.

[Inflammation and pleural fibrosis]

Pleural effusions are frequent. There are many etiologies of inflammatory pleural effusions and of pleural fibrosis. Imaging (standard radiography, ultrasound, scanner, MRI) is important for visualization, localization, and assessment of abundance. Exsudative (inflammatory) effusion can sometimes be distinguished from hydrothorax. Imaging signs generally remain nonspecific but can contribute to the etiological diagnosis. In particular, a CT scan of the chest, without and with contrast injection (tissue impregnation) can, in addition to the study of pleural space, enable an visual assessment of the visceral and parietal pleura, the adjacent chest wall, and the adjacent pulmonary parenchyma or vessels, which may provide diagnostic clues. Imaging can also contribute to therapeutic guidance.