VETERANS MEMORIAL MEDICAL

CENTER
Department of Pediatrics

PLEURAL EFFUSION
FARICA ARMANE E. AQUINO MD
Objectives

 To present a case of Pleural Effusion

 To delineate the most likely causes of Pleural effusion
 To differentiate exudate and transudate
 To describe the diagnostic radiographic and laboratory
examinations for pleural effusions
 Describe the management of Tuberculous Pleural effusion
GENERAL DATA

 EJ
 18 year old
 Male
 Filipino
 Roman Catholic
 Born on December 30, 1998
 Cabuyao Laguna
 Admitted for the first time on February 8, 2017
CHIEF COMPLAINT

Dyspnea
SOURCE and RELIABILITY

 Source of information: Patient and Parents

 Reliability: 95%
HISTORY OF PRESENT ILLNESS
MATERNAL and BIRTH HISTORY

 Born to a 45-year old G10 P10 (100010) mother

 Non-smoker, non-alcoholic beverage drinker
 Regular prenatal check up at a tertiary hospital
 Regular intake of multivitamins and ferrous sulfate
 No maternal illness
 No exposure to radiation, teratogens or toxic chemicals
MATERNAL and BIRTH HISTORY

 Delivered full term via normal spontaneous delivery at a tertiary

hospital in Laguna assisted by an obstetrician
 Good cry and activity
 Amniotic fluid was not meconium stained
 No cord coil
NUTRITIONAL HISTORY

 The patient was given mixed milk feeding with 1:1

dilution from birth to six months
 Started complimentary feeding at 6 months
 Usual diet
 1 and ½ cup of rice, meat vegetables 3x a day
 1-2 snacks in between (bread, junk food, juice, carbonated
beverages)
PAST MEDICAL HISTORY

 No history of mumps, measles, chicken pox

 No history of previous hospitalization
 No history of allergies to food and drugs
 No history of bronchial asthma
 No history of blood transfusion
 No history of surgical operation
BCG
IMMUNIZATION HISTORY
1 dose
Hepatitis B 3 doses
DPT 3 doses
OPV 3 doses
Measles 1 dose
MMR 1 dose
Rotavirus None
Pneumococcal None
Typhoid None
Hib None
Varicella None
Hepa A None
HPV None
Dengue None
DEVELOPMENTAL MILESTONES
GROSS FINE LANGUAGE SOCIAL
1 month Head lag
2 months Raises head Social smile
3 months Coos
4 months Grasp objects Babbles
5 months Roll over
6 months Sat aided Reaches
objects
7 months Crawls
9 months
12 months First word
15 months Walks alone
24 months Runs well
HEEADSSS

 Home: The patient lives with his parents and six siblings. He has a
good relationship with his parents and siblings.
 Education: He is currently in 1st year of college taking up Hotel and
Restaurant Management, with average performance. The patient
dreams of working at a hotel someday. He is in good terms with his
classmates. He has not encountered any form of bullying in school.
 Eating Behavior: The patient prefers to eat meat dishes. His usual
diet is 1 cup of rice, meat and vegetables 3x a day. He also prefers
bread, junk foods, juice and carbonated beverages.
 Activity: He spends most of his time studying, plays with computer
and basketball. He enjoys watching animated shows.
 Drugs: Patient denies any alcohol intake, cigarette smoking or drug
use. He does not know anyone who uses prohibited drugs
 Safety: The patient does not experience any form of bullying.
He can safely walk to school alone. The patient has not
experienced physical nor sexual abuse
 Suicide: Patient denied having recurrent feelings of sadness
and hopelessness. He was optimistic of his condition that he
would be sent home and be well again
 Sexuality: The patient is pleased with his physical
development. Patient has no girlfriend or boyfriend but admits
to have a female crush in school
SOCIOECONOMIC HISTORY

 Well-lit and well-ventilated two-storey concrete house

 With eight household members
 Drinking water is from refilling station
 Garbage collected twice a week
 Father – breadwinner
 No exposure to second hand smoke
FAMILY HISTORY

HTN
HTN
DM
REVIEW OF SYSTEMS

 General: no weakness, no weight loss

 Skin: no pallor, no easy bruisability, no rashes
 HEENT: no headache, no epistaxis, no dysphagia, no sore
throat, no visual changes
 Respiratory: no dyspnea, no hemoptysis
 Cardiovascular: no palpitations, no cyanosis
 Gastrointestinal: no vomiting, no abdominal pain, no diarrhea,
no constipation
REVIEW OF SYSTEMS

 GUT: no dysuria, no oliguria, no hematuria, (-) incontinence

 Endocrine: no polyuria, polydipsia, polyphagia
 Musculoskeletal: no joint pains
 Neurologic: no headache, seizures, numbness
PHYSICAL EXAMINATION

 General appearance: conscious, coherent, not in

cardiorespiratory distress
 Vital signs:
 : BP: 110/70 CR: 87bpm RR: 23cpm Temp: 37C
 Anthropometrics:
 Weight: 53 kg IBW: 60.5kg Height: 170.5cm
 BMI for age: 18.2 (z score below -1 normal)
 Height for age: above -1 (Normal)
PHYSICAL EXAMINATION

 General appearance: conscious, coherent, not in

cardiorespiratory distress
 Vital signs:
 : BP: 110/70 CR: 87bpm RR: 23cpm Temp: 37C
 Anthropometrics:
 Weight: 53 kg IBW: 60.5kg Height: 170.5cm
 BMI for age: 18.2 (z score below -1 normal)
 Height for age: above -1 (Normal)
PHYSICAL EXAMINATION

 Head: normocephalic head with well distributed hair, no lesions

 Eyes: pink palpebral conjunctiva, anicteric sclerae, pupils 2-3mm
equally reactive to light
 Ears: no tragal tenderness, non-hyperemic external auditory canal
AU, intact tympanic membrane AU
 Nose: nasal septum midline, no nasal discharge, pink turbinates,
no discharge
 Mouth/Throat: moist lips and buccal mucosa, non-hyperemic
posterior hyperemic pharyngeal wall
 Neck: supple, non-tender cervical lymphadenopathies
PHYSICAL EXAMINATION

 Chest/Lungs: with chest lagging on the right, decrease tactile

fremitus on the right at the level of T6, dullness to percussion, right
at the level of T6 decrease breath sounds on the right t6-T7 below
posteriorly
 Heart: Adynamic precordium, normal rate regular rhythm, PMI at the
5th intercostal space midclavicular line, no murmur
 Abdomen: flat abdomen, normoactive bowel sounds, soft, non-
tender
 Genitourinary: Grossly male
 Extremities: No gross deformities, full and equal pulses, CRT <2
seconds, no cyanosis, no edema
Sexual Maturity Rating
NEUROLOGIC EXAMINATION

Cerebellum Conscious, coherent, not in respiratory distress

CN I intact
CN II 2-3mm equally reactive to light
CN III, IV, VI Intact EOM
CN V Can clench teeth
CN VII No facial asymmetry
CN VIII Intact gross hearing
CN IX, X (+) gag reflex
CN XI Turns head from side to side
CN XII Tongue at midline
SALIENT FEATURES

 18 year old  Asymmetrical chest

 Male expansion
 Dsypnea  Decrease tactile fremitus,
T7
 Fever
 Dullness to percussion, T7
 Productive cough
 Decrease breath sounds,
 Chest pain
Right T7
 Weight loss

 Chest X-ray: Pleural

effusion, Right, PTB not
DIFFERENTIAL DIAGNOSIS

Non-infectious

Infectious
 INFECTIOUS

NON INFECTIOUS

Pleural Effusions in the Pediatric Population

Ori Efrati, MD,*
Asher Barak, MD*
18 year old, Male
• Productive cough
• Dsypnea
• Chest pain
• Weight loss
• Asymmetrical chest
expansion
• Decrease tactile fremitus,
T7
• Dullness to percussion, T7
• Decrease breath sounds,
Right T7
• Chest X-ray: Pleural
effusion, Right, PTB not
ruled out, Pneumonia,
Right lung
Cardiovascular disease
• Congestive Heart Failure
• Swelling of the feet
• Orthopnea
• Paroxysmal Nocturnal
Dyspnea
Gastrointestinal Disease
• Liver Cirrhosis
• Dyspnea
• Non productive Cough
• Tachypnea
• Right Pleural Effusion
• Common in older age
group
• Cyanosis
• Ascites
• Clubbing
• Peripheral edema
• Jugular venous distention
Collagen Disease
• Rheumatoid Arthritis
• Fever and Pleuritic chest
pain
• Only 3-5% symptomatic
• Older age group (>35 years)
• Absent cough
Collagen disease
• Systemic Lupus
Erythematosus
• Fever
• Chest pain
• Abdominal pain,
peritoneal signs
• Laryngeal involvement is
uncommon – dyspnea or
hoarseness
18 year old, Male
• Productive cough Nephrotic Syndrome
• Dsypnea • Presence of EDEMA
• Chest pain • Dyspnea
• Weight loss

• Asymmetrical chest
expansion
• Decrease tactile fremitus,
T7
• Dullness to percussion, T7
• Decrease breath sounds,
Right T7 Malignant tumors
• Often bloody
• Positive cytology
• Chest X-ray: Pleural • Result from primary cancer
effusion, Right, PTB not of the lungs, pleural
ruled out, Pneumonia, Right mesothelioma, leukemia,
lung lymphoma
• Unilateral or bilateral
18 year old, Male
• Dyspnea
• Fever 38-39C
• Productive cough
• Chest pain
• Weight loss

• Asymmetrical chest
expansion
• Decrease tactile fremitus,
I D
U
T6
VS
• Dullness to percussion, T6
• Decrease breath sounds,
F L
Right T6-T7
A L
U R I S
• Chest X-ray: Pleural

L E YS
L
effusion, Right, PTB not
P A
ruled out, Pneumonia, Right

N
lung
COURSE IN THE
WARD
 Upon admission
S O A P
Productive VS: BP 110/70 CR: 87bpm PLEURAL D5NM at HS
cough EFFUSION
Dyspnea RR: 25cpm Temp: secondary to DAT
Chest pain 37 PTB vs CBC PC
Afebrile Parapneumonic Chest X-ray
Non-tender cervical process Sputum AFB
lymphadenopathies Serum RBS, , LDH,
Asymmetrical chest Total protein,
expansion Albumin, Globulin,
Decrease tactile fremitus T7 A/G ratio
Dullness to percussion T7
Decrease breath sounds T7 Paracetamol
500mg/tab
Ceftriaxone 1g IV
BID
Pleural Effusion
INTRODUCTION

 Pediatrics pleural effusion is an abnormality

frequently develops from the collection of fluids in the
pleural space commonly caused by a primary
phenomenon or secondary to variety of disorders
such as an infection
 This accumulated fluid can be originated from
excessive filtration or defective absorption

Pleural Effusion in Children: A Review Article and Literature Review

Shahla Afsharpaiman*1, Morteza Izadi1, Reza Ajudani2, Mohammad Hossein Khosravi2
EPIDEMIOLOGY

 Pediatrics pleural effusion is more common in boys

than in girls and also in younger children in
comparison with older ones
 The incidence of pleural effusion in children is directly
depended on the type of underlying disease
 Tuberculous pleural effusion commonly occurs in
adolescents and is uncommon in the preschool-aged
child
ETIOLOGY

 The etiological mechanisms of pleural effusion is considerably different in

childhood and adulthood that the effusion secondary to pleural infections is the
most common cause of this abnormality in children
 Among bacterial causes of pleural effusion, Streptococcus pneumoniae is the
most common germ for this abnormality
 Another cause of pleural effusion in children is pulmonary tuberculosis that was
widely reported in 2 to 38%

Pleural Effusion in Children: A Review Article and Literature Review

Shahla Afsharpaiman*1, Morteza Izadi1, Reza Ajudani2, Mohammad Hossein Khosravi2
 Pathophysiology
Pleural Effusion

Transudate Exudate

Increase
Decrease Decrease Increased Increase
capillary
oncotic hydrostatic oncotic capillary
hydrostatic
pressure pressure pressure permeability
pressure

Pleural Effusions in the Pediatric Population

Ori Efrati, MD,*
Asher Barak, MD*
Clinical Manifestations

 When the underlying cause is pneumonia, the

predominant symptoms
 cough, fever, chills, and dyspnea
 If the effusion is not associated with pneumonia, the
child may be asymptomatic until the effusion becomes
sufficiently large to cause dyspnea or orthopnea
 Older children may complain of a sharp pleuritic pain
 Dullness to percussion and decreased breath sounds
over the affected area almost always are present

Pleural Effusions in the Pediatric Population

Ori Efrati, MD,*
Asher Barak, MD*
DIAGNOSTIC APPROACH
Chest radiography

 Chest posteroanterior and lateral view: The chest

posteroanterior (PA) view is the abnormal blunting of sharp lateral
costophrenic angle when pleural fluid is over 200 mL
 Anteroposterior radiograph: The anteroposterior (AP) chest
radiography is abnormal when pleural fluid is over 300 mL. The
earliest sign is blunting of the costophrenic angle.
 Lateral decubitus view: In the lateral decubitus view, pleural
effusion is easily detected by free pleural fluids shifting between
the dependent chest wall and the lower border of the lung.
 Diagnostic thoracentesis is safe when the distance of shifting is
more than 10 mm
Diagnostic Tools of Pleural Effusion
Moon Jun Na, M.D., Ph.D
A posteroanterior and lateral chest radiograph of pleural effusion
blunting of the posterior costophrenic angle
Ultrasonography

 Thoracic ultrasonography (TUS) will detect the presence of as little

as 5−50 mL of pleural fluids
 It is 100% sensitive for effusions
 Ultrasonography can be used under several different situations
 determining the presence of pleural fluid
 identification of the appropriate locations for an attempted thoracentesis, pleural
biopsy, or chest tube placement
 identification of pleural fluid loculations
 distinction of pleural fluids from thickening
 differentiation of a pyopneumothorax from a lung abscess
Diagnostic Tools of Pleural Effu
Moon Jun Na, M.D., Ph.D
Computed tomography (CT)

 For differentiation of pleural collections or masses, detection of loculated fluid

collections
 demonstration of abnormalities in lung parenchyma
 distinguishing empyema with air-fluid levels from lung abscess
 identification of pleural thickening
 evaluation of major and minor fissures, and distinguishing benign and malignant
effusions

 Magnetic resonance imaging has no advantage over CT in evaluating

pleural disorders

Pleural Effusions in the Pediatric Population

Ori Efrati, MD,*
Asher Barak, MD*
Thoracentesis

 Evaluation of liquid by thoracentesis may confirm the

clinical and radiological diagnosis of effusion
 Thoracentesis is a simple bedside procedure with imaging
guidance that permits fluid to be rapidly sampled,
visualized, examined microscopically, and quantified for
chemical and cellular content

Diagnostic Tools of Pleural Effusion

Moon Jun Na, M.D., Ph.D.
Analysis of Pleural Fluid

 Preparation of Pleural Fluid sample

 20−40 mL of aspirated fluid
 Tubes:
 Biochemistry
 Microbiology
 Cytology
 pH measurement
 Differentiation of Exudates and Transudates

Diagnostic Tools of Pleural Effusion

Moon Jun Na, M.D., Ph.D.
Differentiation of Transudate and
Exudate
 The characteristic of pleural fluid differ according to the
underlying pathological condition
 It can be classified into two categories
 Transudate
 Exudate
 Light’s diagnostic criteria are most commonly used to
differentiate between transudative and exudative effusion

Differenital Diagnosis of Pleural Effusion

Tetsuo Sato
Complications

 With appropriate treatment, fluid usually disappears relatively

rapidly
 It persists somewhat longer if a result of tuberculosis or a
connective tissue disease
 adhesions often develop between the 2 layers of the pleura, as the
effusion is absorbed
 Pleural thickening may persist for months, but the process usually
disappears, leaving no residua

Nelson’s Textbook of Pediatric 20th edition

Treatment

 Therapy should address the underlying disease

 With a large effusion, draining the fluid makes the patient more
comfortable
 When a diagnostic thoracentesis is performed, as much fluid as
possible should be removed for therapeutic purposes

 If the underlying disease is adequately treated, further drainage is

usually unnecessary
 Chest tube drainage – if fluid reaccumulates

Nelson’s Textbook of Pediatric 20th edition

 Most pediatric patients who have uncomplicated
parapneumonic effusion respond well to appropriate
antibiotic therapy
 The initial treatment is administration of antibiotics
directed at the underlying infection and drainage of
infected fluid by thoracentesis or by closed thoracostomy
tube
 Antibiotics should be selected to cover the most common
pathogens for pneumonia for the child’s age group

Pleural Effusions in the Pediatric Population

Ori Efrati, MD,*
Treatment

 Tube thoracostomy is considered necessary if the pleural

fluid pH is <7.20 or the pleural fluid glucose level is <50 mg/dL
 tube drainage with thrombolytic therapy or VATS is indicated
if the fluid is clearly purulent
Prognosis

 Children who have uncomplicated parapneumonic effusion respond well to

conservative management with no apparent residual lung damage
 Viral and mycoplasmal pleural disease generally resolve spontaneously
 Patients who have empyema have more prolonged and complicated
hospital courses
 In contrast to adults, infants and children have a
remarkableability to resolve pleural thickening with
no effect onsubsequent lung growth and lung
function
 1st Hospital Day
S O A P
Productive VS: BP 100/60 CR: 75 PLEURAL D5NM at HS
cough RR: 21 Temp: 36.8 EFFUSION
Dyspnea secondary to DAT
No Chest pain Non-tender cervical PTB vs
Afebrile lymphadenopathies Parapneumonic PPD was done
Asymmetrical chest process AFB smear No. 1
expansion Serum RBS, , LDH,
Decrease tactile fremitus T6 Total protein,
Dullness to percussion T6 Albumin, Globulin,
Decrease breath sounds T6- A/G ratio
T7
Paracetamol
500mg/tab q4 for
fever
Ceftriaxone 1g IV
1st Hospital Day
2/9
WBC 8.8
Segmenters 0.71
Lympocytes 0.27
Monocytes
Eosinophils 0.02
Hemoglobin 142
Hematocrit 0.41
Platelet 482
Lateral decubitus
Free fluid at the level
of 6th – 7th rib

Gravitational shift of
the fluid
1st Hospital Day
2/9 (Serum) 2/9
AFB Smear Negative
RBS 5.4
LDH 266 U/L
Total Protein 70 g/L
Albumin 40 g/L
Globulin 30 g/L
A/G Ratio 1.3

Gram stain Sputum (2/9): Gram positive cocci in clusters, pairs, singly and Gram negative
bacilli
 2nd Hospital Day
S O A P
Productive VS: BP 100/70 CR: 62 PLEURAL D5NM at HS
cough RR: 23 Temp: 36.8 EFFUSION
Dyspnea secondary to DAT
No Chest pain Non-tender cervical PTB vs
Afebrile lymphadenopathies parapneumonic Thoracentesis
Asymmetrical chest process Pleural Fluid Analysis
expansion Chest X-ray
Decrease tactile fremitus T6 s/p
Dullness to percussion T6 thoracentesis Medications:
Decrease breath sounds T6- Paracetamol
T7 500mg/tab q4 for
fever

Ceftriaxone 1g IV
BID Day 1
2nd Hospital Day
2/9 (Serum) 2/10 (Pleural Fluid)

RBS 5.4 5.3

LDH 266 U/L 507 U/L
Total Protein 70 g/L 51 g/L
Albumin 40 g/L 31 g/L
Globulin 30 g/L 20 g/L
A/G Ratio 1.3 1.5

AFB Smear (2/10): Negative

Gram stain Pleural Fluid (2/10): No organism seen

Pleural Fluid Cytology (2/10): Negative for malignant cells
1st X-ray 2nd X-ray
Thoracentesis

 Thoracentesis is a percutaneous procedure during which a

needle is inserted into the pleural space and pleural fluid is
removed either through the needle or a small bore catheter
 "Diagnostic thoracentesis" refers to removal of a small volume
of pleural fluid for analysis
 “Therapeutic thoracentesis" refers to removal of a large volume
of pleural fluid for relief of symptoms
 Thoracentesis can be performed with the patient sitting upright
and leaning over
 The most common complication of thoracentesis is
pneumothorax
How is thoracentesis done?

 Ultrasound is recommended for all bedside

procedures.
 It can be very helpful to:
 Find the area of fluid where the depth to the lung is
the greatest
 If possible, 9-10 cm lateral to the spine (avoid
intercostal arteries by going just above the rib)
 Above the 9th rib to avoid hitting below the diaphragm
 Gauge the distance from skin to fluid
 Patients are usually asked to sit upright during the procedure. It is important
to remain still so that the needle is inserted into the correct place.
 Antibacterial solution will be used to clean the skin around the needle
insertion site. This is usually between the ribs at the back of the chest.
 Local anesthetic is injected into the back to help reduce discomfort.
 A larger needle or catheter is then inserted in the same spot, passing deeper
into the chest wall and into the pleural space. The pleural fluid draining
through the needle will be collected in a bottle to be sent for analysis.
 The needle or catheter will be removed, and a sterile dressing applied over
the insertion site to help prevent infection.
Analysis of Pleural Fluid

 Preparation of Pleural Fluid sample

 20−40 mL of aspirated fluid
 Tubes:
 Biochemistry
 Microbiology
 Cytology
 pH measurement
 Differentiation of Exudates and Transudates

Diagnostic Tools of Pleural Effusion

Differentiation of Transudate and
Exudate
2/9 (Serum) 2/10 (Pleural Fluid)

RBS 5.4 5.3 mmol/L

LDH 266 U/L 507 U/L = 1.9
Total Protein 70 g/L 51 g/L = 0.7
Albumin 40 g/L 31 g/L EXUDATIVE
Globulin 30 g/L 20 g/L PLEURAL
EFFUSION
A/G Ratio 1.3 1.5
Exudative Effusions
 3rd Hospital Day
S O A P
productive VS: BP 110/70 CR: 68bpm PLEURAL D5NM at HS
cough RR: 22cpm EFFUSION
Occasional Temp: 36.8 secondary to DAT
dyspnea PTB
No Chest pain Non-tender cervical
Afebrile lymphadenopathies s/p PPD – Positive 21mm
Asymmetrical chest thoracentesis
expansion Medications:
Decrease tactile fremitus T7 Paracetamol
Dullness to percussion T7 500mg/tab
Decrease breath sounds T7- Ceftriaxone 1g IV
T8 BID Day 3
Quadtab 3 tablets
OD 30 mins before
breakfast
3rd Hospital Day

Gram stain Pleural Fluid (2/10):

No organism seen

Pleural Fluid Cytology (2/10):

Negative for malignant cells

PPD – 21mm
Patient
Pleural Fluid Analysis

2/10 Pleural Fluid Analysis

Specimen Pleural fluid
Color Dark yellow
Transparency Turbid
Volume 10 ml
pH 8.0
Specific gravity 1.015
RBC count 6.95 x10 9/L
WBC count 700 x 10 6/L
Neutrophils 0.02
Lymphocytes 0.98
 TUBERCULOUS PLEURAL EFFUSION
 Pleural effusion is an early complication of primary tuberculosis
 Tuberculous pleural effusion commonly occurs in adolescents and is uncommon in the
preschool-aged child
 Clinical onset – sudden, characterized by low to high fever, shortness of breath, chest pain
and decreased breath sounds
 A positive Mantoux tuberculin test reaction
 The fluid withdrawn is usually an
 Exudate
 Protein level greater than 2-4 g/dL (40 g/L)
 Decreased to normal glucose concentration (60 mg/dL [3.3 and 5.6 mmol/L])
 Elevated LDH levels commonly exceeding 500 IU/L
 Specific gravity 1.012 – 1.025 Pleural Effusions in the Pediatric Popu
Ori Efrati, MD,* Asher Barak, MD*
 Lymphocytic predominance Nelson’s Textbook of Pediatric 20th edi
Patient
Pleural Fluid Analysis
2/9 (Serum) 2/10 (Pleural
 Pleural fluid glucose Fluid)
RBS fluid glucose (<60
 A low pleural 5.4
mg/Dl [between 3.35.3
andmmol/L
5.6 mmol/L]) is
mainly caused by complicated parapneumonic effusion, malignancy,
LDH 266 U/L 507 U/L
Tuberculosis and rheumatoid pleuritis,
Total Protein
 Pleural fluid adenosine 70 g/L
deaminase 51 g/L

 Albumin
In general, elevated effusions 40 g/L than the cutoff31
higher g/L of 40−45 U/L
level
means TB effusion
Globulin 30 g/L 20 g/L

A/G Ratio 1.3 1.5

Diagnostic Tools of Pleural Effusion

Moon Jun Na, M.D., Ph.D.
 Patient
Pleural Fluid Analysis
2/10 Pleural Fluid Analysis
Tuberculous PE
 Pleural fluid white blood cell differentialPleural
Specimen countsfluid
• Exudate
• Protein level
 greater
if with than Color of lymphocytes – seen inDark
predominance acute
yellowTuberculous
2-4 g/dL (40 g/L)
pleural effusion
• Decreased glucose
Transparency, parapneumonic effusion,Turbid
pulmonary embolus, GI disease

concentration
 If(60 mg/dL
with Volumeof mononuclear cells – seen
predominance 10 mlin malignancy, pulmonary
[between 3.3 embolization,
mmol/L and PE following CABG
5.6mmol/L]) pH 8.0
 Pleural fluid pH level
• Elevated LDH levels Specific gravity 1.015
commonly exceeding
 pH levels 500of 7.2 or less in the parapneumonic effusion is related with a poor outcome
IU/L RBC count 6.95 x10 9/L
 A low pleural fluid pH level (≤7.30) in patients with malignant pleural effusions
• Specific gravity 1.012greater
showed – WBC count
cytology positivity 700 x 10 6/L
1.025
• Lymphocytic Neutrophils 0.02
predominance Lymphocytes 0.98
Microbiologic Analysis of Pleural Fluid

 Gram stain
 Culture
 Pleural fluid cultures are positive for less than 40% of
Mycobacterium tuberculosis and smears are virtually always
negative

Gram stain Pleural Fluid (2/10): No organism

seen
Cytological analysis of pleural fluid

 Positive in Malignant Pleural effusion

Pleural Fluid Cytology (2/10): Negative for malignant cells

TUBERCULOUS PLEURAL EFFUSION

 Chest X-ray
 Pleural effusions secondary to TB are largely unilateral with a slight
right-sided predominance, reported to occur in 55% of cases
 Ultrasonography
 The ultrasonographic appearance of pleural effusions secondary to
TB range from anechoic to complex septated or non-septated to
even homogeneously echogenic effusions
 Computed tomography (CT Scan)
 CT of the chest is currently the best imaging modality to visualize
both pleura and lung parenchyma in TB pleural effusions
 DIAGNOSTICS
 Sputum
 Thoracentesis
 Pleural Fluid Analysis
 ADA
 Cell count and cytology
 Additional pleural fluid assays – Interferon gamma
 Pleural biopsy
Treatment of Tuberculous Pleural
Effusion

 The treatment of tuberculous pleural effusion has

three goals:
 to prevent the subsequent development of active TB
 to relieve the symptoms of the patient
 to prevent the development of a fibrothorax
Treatment of Tuberculous Pleural
Effusion

 The medical treatment for TB pleural effusion is the same as for

pulmonary TB, and is consistent with the theory that the majority
of pleural TB cases develop from pulmonary disease
 The expected resolution of TB pleural effusion is variable, and
assuming appropriate therapy,
 Fever usually resolves within 2 weeks with reabsorption of the
pleural fluid within 6 weeks
Treatment of Tuberculous Pleural
Effusion

 Tuberculous pleural effusion usually is reabsorbed

completely with minimal sequelae
 Treatment is the same as for primary pulmonary
tuberculosis, with steroids added to promote fluid
resorption
Chemotherapy

 initial phase of a 6-month regimen should consist of

 2-month period of isoniazid (INH), rifampin and pyrazinamide
 The second phase of the treatment should be INH and rifampin given for 4
months
 Directly observed therapy (DOT) is recommended
 The typical patient becomes afebrile within 2 weeks, but temperature
elevations may persist as long as 2 months
 If a therapeutical thoracentesis is performed at the same time that
antituberculous therapy is initiated, most patients become afebrile within
5 days
Update on tuberculous pleural effusion
RICHARD W. LIGHT
 The mean time for the complete resorption of pleural fluid
is approximately 6 weeks, but it can be as long as 12
weeks.
 There is no reason to keep the patient at bed rest and the
patient needs to be isolated only if their sputum is positive
for mycobacteria
 4th Hospital Day
S O A P
productive VS: BP 110/70 CR: 68bpm PLEURAL D5NM at HS
cough RR: 22cpm EFFUSION
No dyspnea Temp: 36.8 secondary to DAT
No chest pain PTB
Afebrile Non-tender cervical Medications:
Good appetite lymphadenopathies s/p Paracetamol
Asymmetrical chest thoracentesis 500mg/tab
expansion Ceftriaxone 1g IV
Decrease tactile fremitus T7 BID Day 4
Dullness to percussion T7 Quadtab 3 tablets
Decrease breath sounds T7- OD 30 mins before
T8 breakfast
 5th Hospital Day
S O A P
productive VS: BP 110/70 CR: 71bpm PLEURAL D5NM at HS
cough RR: 20-21cpm Temp: EFFUSION
No dyspnea 36.8 secondary to DAT
No chest pain PTB
Afebrile Non-tender cervical Medications:
Good appetite lymphadenopathies s/p Paracetamol
Asymmetrical chest thoracentesis 500mg/tab
expansion Ceftriaxone 1g IV
Decrease tactile fremitus T8 BID Day 5
Dullness to percussion T8 Quadtab 3 tablets
Decrease breath sounds T7- OD 30 mins before
T8 breakfast
Culture of Pleural Fluid (2/13): No growth after 3 days of
incubation

Gram stain
Culture
Pleural fluid cultures are positive for less than 40% of Mycobacterium
tuberculosis and smears are virtually always negative
 6th Hospital Day
S O A P
Occasional VS: BP 110/70 CR: 71bpm PLEURAL D5NM at HS
productive RR: 20-21cpm Temp: EFFUSION
cough 36.8 secondary to DAT
No dyspea PTB
No chest pain Non-tender cervical Medications:
Afebrile lymphadenopathies s/p Paracetamol
Good appetite Asymmetrical chest thoracentesis 500mg/tab
expansion Ceftriaxone 1g IV
Decrease tactile fremitus T8 BID Day 6
Dullness to percussion T8 Quadtab 3 tablets
Decrease breath sounds T8- OD 30 mins before
T9 breakfast
 7th Hospital Day
S O A P
Occasional VS: BP 110/70 CR: 65bpm PLEURAL D5NM at HS
productive RR: 20cpm EFFUSION
cough Temp: 36.8 secondary to DAT
No dyspnea PTB Repeat CXR
No chest pain Non-tender cervical
Afebrile lymphadenopathies s/p Medications:
Good appetite Asymmetrical chest thoracentesis Paracetamol
expansion 500mg/tab
Decrease tactile fremitus T9 Ceftriaxone 1g IV
Dullness to percussion T9 BID Day 7
Decrease breath sounds T8- Quadtab 3 tablets
T9 OD 30 mins before
breakfast
Repeat CXR 2/15/17
Pneumonia right parahilar, with regression;
Pleural effusion right, with regression
 8th Hospital Day
S O A P
Occasional non VS: BP 110/70 CR: 68bpm PLEURAL D5NM at HS
productive RR: 20cpm EFFUSION
cough Temp: 36.8 secondary to DAT
No dyspnea PTB Repeat CXR
No chest pain Non-tender cervical
Afebrile lymphadenopathies s/p Medications:
Good appetite Asymmetrical chest thoracentesis Paracetamol
expansion 500mg/tab
Decrease tactile fremitus T9
Dullness to percussion T9 Quadtab 3 tablets
Decrease breath sounds T9 OD 30 mins before
breakfast
 9th Hospital Day
S O A P
Occasional non VS: BP 110/70 CR: 75bpm PLEURAL May go home
productive RR: 20cpm EFFUSION Quadtab 3 3 tablets
cough Temp: 36.8 secondary to 30 minutes before
No dyspnea PTB OD
No chest pain Non-tender cervical For repeat Chest X-
Afebrile lymphadenopathies s/p ray
Good appetite Asymmetrical chest thoracentesis For SGPT, SGOT
expansion For follow up at the
Decrease tactile fremitus T9 OPD after 2 weeks
Dullness to percussion T9
Decrease breath sounds T9
 They investigated the use of early pleural drainage (using pleural
manometer) in addition to standard anti-TB therapy, compared to standard
therapy alone and demonstrated significant differences after 6 months in
lung function
 The drainage group had a forced expiratory volume in the first second
(FEV1) of 87.6% as compared to the control group of 84.9% (P=0.02), with
forced vital capacity (FVC) of 84.5% and 83.3% (P<0.01), respectively
 In unpublished data, we found that patients with confirmed TB pleural
effusions, randomised to therapeutic pleural drainage, showed significantly
superior improvements in several lung function parameters after 3 and 6
months follow-up, despite complete drainage being achieved in less than
half of all patients
 The role of corticosteroids in the treatment of tuberculous pleural
effusion is still controversial
 In two controlled studies in which therapeutical thoracentesis was
performed there were no benefits
 In a third study in which no therapeutical thoracentesis was
performed, the duration of fever and the time required for fluid
resorption were decreased
 A recent Cochrane review concluded that there are insufficient data to
support evidence-based recommendations regarding the use of adjunctive
corticosteroids in people with tuberculous pleurisy

 The recommended approach to the patient with tuberculous pleuritis is as

follows:
 If the patient is more than mildly symptomatic, a therapeutical
thoracentesis is recommended
 If the patient continues to have severe systemic symptoms (fever,
malaise, pleuritic chest pain) after the therapeutical thoracentesis, the
administration of 80 mg of prednisone every other day until the acute
symptoms have subsided is recommended
References

 Nelson Textbook of Pediatrics 20th edition

 Pleural Effusions in the Pediatric Population by Ori Efrati, MD, Asher Barak, MD
 Update on tuberculous pleural effusion by Richard W. Light
 Differenital Diagnosis of Pleural Effusion by Tetsuo Sato
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