Pleural Effusions

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Separation of exudates from transudates

One of the main reasons to do a thoracentesis in a patient with an undiagnosed pleural effusion is to determine whether the patient has a transudative or an exudative pleural effusion. The reason to make this differentiation is that the existence of a transudative pleural effusion indicates that systemic factors such as heart failure or cirrhosis are responsible for the effusion, whereas the existence of an exudative effusion indicates that local factors are responsible for the effusion. If the

Diseases that most commonly cause pleural effusion

In the sections that follow, the diseases that most commonly cause pleural effusions are discussed.

Malignant pleural effusion

Malignant pleural effusions are the second most common exudative pleural effusion (see Table 1). Pleural effusions associated with neoplasms arise through at least 5 different mechanisms: (1) the pleural surfaces may be involved by the tumor, which leads to increased permeability of the pleural membranes, possibly because of vascular endothelial growth factor38; (2) the neoplasm may obstruct the lymphatics or veins draining the pleural space, leading to the accumulation of pleural fluid; (3) an

Pleural effusion caused by pulmonary embolism

Pulmonary embolism is the fourth leading cause of pleural effusions. Approximately 20% to 40% of patients with pulmonary embolism have a pleural effusion.47 The presence of pleuritic chest pain in a patient with a pleural effusion is suggestive of pulmonary embolus. More than 75% of patients with pleural effusions secondary to pulmonary emboli have pleuritic chest pain.47

The pleural effusions secondary to pulmonary emboli are usually unilateral and occupy less than one-third of the hemithorax.48

Pleural effusions caused by viral diseases

It is estimated that viral infections are responsible for 100,000 pleural effusions annually in the United States (see Table 1). However, the diagnosis of a viral pleural effusion is rarely established because it depends on showing an increase in antibodies to the virus. The importance of viral pleural effusions is that they are self-limited. Accordingly, if a patient with an undiagnosed exudative effusion is improving, no additional diagnostic procedures are indicated.

Pleural effusions caused by tuberculosis

In some parts of the world, tuberculous pleural effusions are the most common pleural effusions, but they are relatively uncommon in the United States (see Table 1). However, if a patient has tuberculous pleuritis, it is important to establish the diagnosis because if the patient is not treated, the effusion spontaneously resolves, but the patient has a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis.50

The diagnosis of tuberculous pleuritis should be

Pleural effusions after CABG

Almost all patients after CABG develop a pleural effusion, and approximately 10% develop a pleural effusion that occupies more than 25% of the hemithorax.51 The primary symptom of patients with pleural effusions after CABG is dyspnea. Chest pain and fever are distinctly uncommon. The pleural effusions that occur after CABG can be divided into those that occur within the first 30 days and those that occur after the first 30 days.52 The pleural fluid in both instances is an exudate. The early

Pleural effusions caused by systemic lupus erythematosus

Pleural effusions occur in approximately 40% of patients with systemic lupus erythematosus.1 The effusions are frequently bilateral but may be unilateral and change from 1 side to the other. Pericardial effusions are frequently present concomitantly with the pleural effusion. The pleural fluid is typically a serous exudate with normal pH and glucose levels and an LDH level less than 2 times the upper limit of normal.54 The diagnosis of lupus pleuritis is established by using the diagnostic

Pleural effusions caused by rheumatoid disease

Pleural effusions occur in approximately 4% of patients with rheumatoid pleuritis. Most rheumatoid pleural effusions occur in men and most patients have subcutaneous rheumatoid nodules. The effusion is usually small to moderate in size and only occasionally produces symptoms. The pleural fluid with rheumatoid pleuritis is distinctive, with a glucose level less than 30 mg/dL, an LDH level more than 2 times the upper limit of normal, and a pH level less than 7.20.54 It is not clear that any

Pleural effusions caused by gastrointestinal disease

Many different gastrointestinal diseases can have an associated pleural effusion, and it is beyond the scope of this article to discuss them all in detail. Patients with acute pancreatitis frequently have an associated pleural effusion, and at times chest symptoms dominate the clinical picture. The diagnosis is established by showing a high pleural fluid amylase level. Patients with pancreatic pseudocysts may have a large pleural effusion caused by a sinus tract from the pseudocyst into the

Pleural effusions caused by drug reactions

The possibility that an undiagnosed pleural effusion is caused by a drug reaction should be considered. The primary drugs responsible for pleural effusions include nitrofurantoin, dantrolene, ergot alkaloids, amiodarone, interleukin 2, procarbazine, methotrexate, and clozapine. The pleural effusions associated with the administration of drugs are frequently eosinophilic.

Chylothorax and pseudochylothorax

When pleural fluid is found to be milky or opaque, the patient either has a high lipid pleural effusion or an empyema. If the fluid is centrifuged, the supernatant remains milky or opaque only if the patient has a high lipid pleural effusion. Chylothorax and pseudochylothorax are the 2 effusions with high lipid levels. A chylothorax occurs when the thoracic duct is disrupted and chyle accumulates in the pleural space. With chylothorax, the pleural fluid triglyceride levels usually exceed 110

Other causes of pleural effusions

There are many other causes of pleural effusions (see Box 1), which are not discussed in this article because of space considerations. The reader is referred to Refs1, 58 for additional information.

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