Both nonmalignant and malignant causes of effusion can be identified by the relatively noninvasive technique of pleural fluid cytology. Pleural effusion is the most common manifestation of pleural disease and a common presentation of other conditions such as heart failure or kidney failure. Pleural effusion in adultsetiology, diagnosis, and treatment. When a pleural effusion is large and unilateral, concern for an underlying abnormality should be raised. There are currently no firm recommendations on whether it is sufficient to perform a puncture on a single side or whether it is necessary to routinely perform bilateral diagnostic thoracentesis. Differential diagnosis of tuberculous and malignant pleural. The presence of mpe usually indicates advanced stage cancer, thus prognosis of patients with mpe is poor. Reeder and felsons gamuts in radiology, comprehensive lists of roentgen differential diagnosis. Differential diagnosis of tuberculous and malignant. Diffuse nodules and opacification in right lung with compressive atelectasis. What is the process for differential diagnosis of pleural. Pleural effusion has a wide differential diagnosis. It is reasonable to order the following pleural fluid tests when considering malignancy. Diagnostic approach to pleural effusion in adults request pdf.
Dec 11, 2015 pleural effusion is common in various diseases and especially malignant effusions can have rapid onset symptoms such as dyspnea, chest pain, and coughing. Pleural effusion differential diagnoses medscape reference. Analysis of the relevant clinical history, physical examination, chest radiography and diagnostic thoracentesis is useful in. The history and physical examination are critical in guiding the evaluation of pleural effusion signs and symptoms of an effusion vary depending on the underlying disease, but dyspnea, cough, and pleuritic chest pain are common.
Tpe was confirmed in 54 patients and malignant effusion in 67 patients. The diagnostic yield of biopsies is low, and invasive procedures are often required to achieve diagnosis. The differential diagnosis for bilateral pleural effusions is narrower and includes causes of. Definition pleural effusion is the accumulation of fluid in the pleural space. Moderate right pleural effusion, some fluid in nondependent portions suggestive of loculation. Bilateral pleural effusion is commonly seen in heart failure. Minimal pericardial effusion without echocardiographic evidence of tamponade. A pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption or both.
Pdf differential diagnosis of pleural effusion by lactate. Its most common causes are congestive heart failure, cancer, pneumonia, and pulmonary embolism. No related items previous abstract next abstract 25 broadway. The pleural fluid was aspirated and examined for total cell count, differential cell count, protein, sugar, ada and pcr for mtb. The differential for a single pleural mass is essentially the same as that for multiple pleural masses with the addition of a few entities. If the patient has an exudative effusion, attempts should be made to define the etiology.
Pneumonia, cancer, tuberculosis, and pulmonary embolism account for most exudative effusions. Pleural effusion pleural effusion more evident on lateral view pleural effusion is bilateral in 70% of cases of chf. Diagnostic value of pleural effusion linkedin slideshare. The differential diagnosis of pleural masses is limited. Appearance and studies radiologic appearance class type treatment 3 bordeline complicated pleural effusion ph 7. No shift of mediastinum as evident by shift of trachea on palpation 2.
The most important aspect of forming a differential diagnosis of pleural effusion is performing a thoracentesis and obtaining a sample of the pleural fluid. This article discusses the causes and treatment of pleural effusions, referencing guidelines produced by the british thoracic society. Large unilateral pleural effusion radiology reference. A pleural effusion is defined as an abnormal collection of fluid between the thin layers of tissue lining the lung and the wall of the chest cavity.
For bilateral effusion with a normal heart size, the differential diagnosis should include malignancy and, less commonly, lupus pleuritis and constrictive pericarditis3. The diagnostic significance of the cytologic study of the fluid may be attributable to the fact that the cell population present in the sediment is representative of a. Ct in differential diagnosis of benign and malignant pleural disease. Specific differential diagnosis problems generated by pleural nodules, where the main concern is establishing if the complementary ct scan is needed. A ct thorax was done in all the 106 patients of pleural effusion and. Common pleural effusions in children sciencedirect. Detection of a pleural effusion, either by physical exam or radiograph, necessitates an investigation into the cause of the effusion. A diagnosis of pleural effusion may be sug gested by characteristic symptoms e. An interesting case of undiagnosed pleural effusion. In exudative effusions accompanying inflammatory reactions in pneumonia are the most common reasons.
Systemic lupus erythematosus presenting with recurrent. Jun 20, 2019 minimal pericardial effusion without echocardiographic evidence of tamponade. With this basis the present study on cytology of pleural fluids was taken up. The aim was to determine the cutoff value for adenosine deaminase ada and the sensitivity and specificity of ada and evaluate pleural fluid cytology and pleural biopsy in the differential diagnosis of malignant and tuberculous pleurisy. It is the most common manifestation of pleural disease, with etiologies ranging from cardiopulmonary disorders to symptomatic inflammatory or malignant diseases requiring urgent evaluation and trea. A pleural effusion is an excessive accumulation of fluid in the pleural space.
Evaluation of a patient with a pleural effusion requires a thorough clinical history and physical examination in conjunction with pertinent laboratory tests and imaging studies. It is seen in about 20% of the hospitalized patients with pneumonia 12 and approximately 1 million patients develop ppes annually in the united states us. A delayed etiological diagnosis can be associated with markedly higher morbidity and mortality, e. A study by our group has shown that the cause of the bpe is the same. Pleural lesions that require differential diagnosis with mediastinal diseases, especially tumors cap.
Left pleural effusion with high density material at the posterior costophrenic angle. Differential diagnosis consolidation of right lung final diagnosis consolidation of right lung discussion a common clinical scenario of lung consolidation is uniform opacification on the chest. Pcwp in leftsided heart failure ultrasound ultrasound of pleural cavities. A case study of a patient with a pleural effusion is presented, as well as a brief description of the signs and symptoms, pathophysiology, and management of this disease process. Pleural effusion is defined as the presence of excessive fluid in the pleural cavity resulting from transudation or exudation from the pleural surfaces. Diagnosis and management of patients with pleural effusions. Pseudomeigs syndrome with metastasis of breast cancer to both ovaries was diagnosed.
Analysis of pleural effusions in acute pulmonary embolism. The diagnosis and the treatment approaches require several pleural techniques and knowledge about concomitant disease. A 62year old white male presents with a history of increasing dyspnea and mild temperature elevation. An effusion is exudative if it meets any of the following three criteria. The final diagnosis explaining the pleural effusion and the diagnostic study or procedure that eventually established the cause are shown in table 1. In normal conditions, the pleural space contains a limited amount of fluid. Asbestosrelated disease and invasive bronchogenic carcinoma make up the majority of cases. The differential diagnosis for unilateral pleural effusion includes parapneumonic effusion, neoplasms such as mesothelioma, primary lung cancer, pleural metastases, lymphoma, other entities such as cirrhosis, pancreatitis, and trauma. Conditions to consider in the differential diagnosis of exudative pleural effusion include the following. Dullness to percussion left posterior chest to level of sixth ic space, distant bronchovesicular breath sounds in same area, increased whispered voice sounds in same area, tympanic percussive note immediately above sixth ic space, spoken voice.
The use of certain pleural fluid tests such as leukocyte count and differential, glucose, ph and, when indicated, pleural fluid amylase determinations, helps to narrow the differential diagnosis of an exudative pleural effusion. Common types of pleural effusions, their management and disposal a tubercular pleural effusion. Bilateral pleural effusion bpe is not an uncommon finding in clinical practice. Pleural disease is, therefore, often a secondary effect of another disease process.
This image shows that the echogenicity of the consolidated lung is similar to that of the liver and hence the terminology hepatization of the lung. A wedge shaped area of the lung appears solid and uniformly hypoechoic, suggestive of consolidation of the lung. The morbidity and mortality rates of patients with pneumonia associated with pleural effusion are greater than in patients with pneumonia alone. Nov 28, 2018 pericardial effusion is the presence of an abnormal amount of andor an abnormal character to fluid in the pericardial space. Pleural effusions can be easily identified on chest radiography, physical examination findings include dullness to percussion, decreased tactile fremitus and decreased or absent breath sounds. Classification of and therapies for parapneumonic effusion and empyema cont. Differential diagnosis of nonsegmental consolidations. Dec 19, 2014 clinical features in the diagnosis of pleural effusions and identifying etiology. Diagnosis and management lymphocytic pleural effusions and significance levels of adenosine deaminase ada in pleural fluid abstract send to citation mgr. The differential diagnosis of exudate poses a more difficult challenge for clinicians. It can be caused by a variety of local and systemic disorders, or it may be idiopathic.
Pericardial effusion is the presence of an abnormal amount of andor an abnormal character to fluid in the pericardial space. Mar 21, 2008 the aim was to determine the cutoff value for adenosine deaminase ada and the sensitivity and specificity of ada and evaluate pleural fluid cytology and pleural biopsy in the differential diagnosis of malignant and tuberculous pleurisy. Differential diagnosis of pleural effusions jmaj 49910. Diagnostic approach to pleural effusion in adults american. Differential diagnosis issues of atypical pleural lesions. Cells in pleural fluid and their value in differential. Many pleural fluid tests are useful in the differential diagnosis of exudative effusions.
Parapneumonic pleural effusion ppe refers to a pe associated with a focus of infection in the lungs, which can be bacterial pneumonia, a pulmonary abscess, or infected bronchiectasis. Jun 30, 2016 a pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption or both. The pleural effusion morbidity and mortality are directly related to its causes, the stage of the disease at the time of the diagnosis, and to the pleural fluid biochemical finding. Pleural effusions are commonly encountered in the clinical practise of both respiratory and nonrespiratory specialists. It is estimated that a million americans develop a pleural effusion each year 1. Pleural effusion in cats vetlexicon felis from vetstream. The primary diagnosis of the cause for the pleural effusion was consistent between reporting consultants k0. The patient must be placed on standard chemotherapy as follows. In our case the patient presented with recurrent exudative pleural effusion, initially which was unilateral and latter bilateral.
The presence of pleural effusion enables a physician to obtain a specimen of a body cavity fluid easily. Clinical features in the diagnosis of pleural effusions and identifying etiology. Unilateral pleural effusion differential diagnosis. The role of ultrasound in the assessment of pleural effusion. A pleural effusion is present when there is an excess quantity of fluid in the pleural space. For a unilateral pleural effusion evident on chest radiographs, the differential diagnosis is extensive table 1. With a systematic analysis of the pleural fluid, in conjunction with the clinical features and ancillary laboratory data, a clinician should be able to arrive at either a presumptive or. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to. The pleural space lies between the lung and chest wall and normally contains a very thin layer of fluid, which serves as a coupling system. Multiple etiologies for a pleural effusion one cause was identi. A diagnosis of pleural effusion may be suggested by characteristic symptoms e.
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