The Undiagnosed Pleural Effusion

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Diseases that cause undiagnosed persistent pleural effusions

When a patient with a persistent undiagnosed pleural effusion is encountered, the first step to be considered is the list of the diseases most likely to be associated with a persistent undiagnosed pleural effusion (Box 1). The first question to answer in a patient with a persistent undiagnosed pleural effusion is whether the effusion is a transudate or an exudate. For the past several decades, this differentiation has been made by measuring the levels of protein and lactate dehydrogenase (LDH)

Congestive heart failure

Congestive heart failure is the most common cause of pleural effusion [7]. At times in patients with persistent pleural effusion, it is not obvious that the heart failure is the cause of the effusion. Certainly, symptoms of congestive heart failure, such as dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and nocturia, should be sought when the history is taken. In addition, signs of congestive heart failure, such as basilar rales, S3 gallop, distended neck veins, and pedal edema,

Malignant pleural effusion

There is no doubt that malignancy causes more persistent undiagnosed exudative pleural effusions than any other cause. It should be emphasized that there is no huge hurry to establish this diagnosis, however, because (1) the presence of the effusion indicates that the patient has metastases to the pleura and the malignancy cannot be cured surgically, (2) most malignant pleural effusions are attributable to tumors that cannot be cured with chemotherapy, and (3) there is no evidence that attempts

History

There are certain points in the patient's history that should receive special attention if the patient has a persistent undiagnosed pleural effusion. If a patient has a transudative pleural effusion, particular attention should be paid to symptoms of congestive heart failure, such as dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and nocturia. In addition, historical evidence of cirrhosis, alcoholism, or chronic hepatitis should be sought with the possibility of a hepatic

Summary

When faced with a patient with an undiagnosed pleural effusion, the first question to be answered is whether the patient has a transudate or an exudate. This is most commonly done with Light's criteria. If it seems clinically that the patient has a transudative effusion but Light's exudative criteria are met, the demonstration of a serum pleural fluid protein gradient of greater than 3.1 g/dL indicates that the effusion is transudative. The diagnosis of congestive heart failure is strongly

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