Pleural Effusion - Long Case With Questions And Answers

Case History

Presenting Complaints: 

• Cough with slight expectoration for … weeks
• Breathlessness for … days
• Fever for … days
• Weight loss for … days.

History Of Presenting Complaints: According to the statement of the patient, he was alright … weeks back. Since then, he has been suffering from frequent cough, which is present throughout day and night. The cough is usually dry with occasional slight expectoration of mucoid sputum, but no hemoptysis. He is also complaining of breathlessness, which is more marked during moderate to severe exertion, but there is no history of orthopnea or paroxysmal nocturnal dyspnea. The patient also complains of low grade continued fever for … days, more marked in the evening and associated with night sweats. During this period, he lost about 15 kg of body weight. There is no history of chest pain, joint pain or swelling, skin rash or any contact with patient with pulmonary TB. His bowel and bladder habits are normal.

General Physical Examination: 

• The patient is ill-looking and emaciated
• Mildly anemic
• No jaundice, cyanosis, clubbing, edema, koilonychia or leukonychia
• No lymphadenopathy or thyromegaly

Vitals:

• Pulse: 100/min
• BP: 130/75 mm Hg
• Temperature: 100º F
• Respiratory rate: 24/min.

Respiratory system: (supposing right sided effusion)

Inspection:

Movement is restricted on lower part of right side of the chest with fullness of intercostal spaces

 (Mention, if any puncture mark, gauze and tape indicating aspiration of pleural fluid).

Palpation:

Trachea is shifted to the left side

Apex is shifted to the left (in 6th intercostal space in the anterior axillary line), normal in character

Vocal fremitus is reduced in right lower chest up to … ICS (tell where)

Chest expansion is restricted over the right lower chest.

Percussion:

There is stony dullness in the right lower chest up to … ICS (tell where).

Auscultation:

Breath sound—diminished (or absent) in the right lower chest

Vocal resonance—diminished (or absent) in the right lower part of chest

No added sound.

Note:  Just above the upper level of effusion, the following findings may be present (mention, if any)

¯¯ Bronchial sound

¯¯ Increased vocal resonance

¯¯ Whispering pectoriloquy

¯¯ Pleural rub.

Examination of the other systems reveals no abnormalities.

Provisional Diagnosis: My diagnosis is right sided pleural effusion.

Questions Likely To Be Asked By The Examiner: 

Q. What is the likely cause of pleural effusion?

A. This is more likely to be tubercular, because:

• In the history, there is low grade fever with evening rise and night sweating
• Marked weight loss
• Cough with slight mucoid sputum.

Q. What may be the other causes in this case?

A. This may be due to:

• Post-pneumonic
• Lymphoma
• SLE (in female).

Q. Why not bronchial carcinoma? 

A. The patient is young, bronchial carcinoma is less common (but he is a heavy smoker for 15 years,

so carcinoma should be excluded.)

Q. Why not thickened pleura?

A. In this case, there is history of breathlessness, weight loss and fever which are not present in

thickened pleura. Also, on examination, there is mediastinal shifting with stony dullness on the

affected side. These are not found in thickened pleura.

Q. Why not consolidation?

A. There is stony dullness and reduced breath sound and vocal resonance in the affected area along

with mediastinal shifting. These are against consolidation (In consolidation, there is woody dullness,

bronchial breath sound, increased vocal resonance and no shifting of the mediastinum).

Q. Why not collapse?

A. In case of collapse, the apex beat and trachea will be shifted to the same side. In addition, if there

is collapse with patent bronchus, there will be bronchial breath sound and increased vocal resonance.

Q. Why not pneumothorax?

A. In pneumothorax, there is hyper-resonance on percussion.

Q. What investigations do you suggest?

A. As follows:

1. X-ray chest P/A view

2. Hb%, TC, DC, ESR (high ESR in TB, leukocytosis in pneumonia)

3. Mantoux test (MT)

4. Aspiration of pleural fluid for analysisxx

• Physical appearance (straw colored, serous, hemorrhagic, chylous)
• Gram-staining, cytology (routine) and exfoliative cytology (malignant cells)
• Biochemistry (protein and sugar), also a simultaneous blood sugar, protein and lactate dehydrogenase (LDH) may be done
• ADA (high in tuberculosis)
• Culture and sensitivity (C/S)
• AFB and mycobacterial C/S

5. Pleural biopsy by Abram’s or Cope’s needle

6. Other investigation of pleural fluid (according to suspicion of cause):

• Cholesterol, LDH and rheumatoid factor (in rheumatoid arthritis)
• Amylase (high in acute pancreatitis, esophageal rupture, malignancy)
• Trigycerides (in chylothorax)

7. Sputum (if present) for Gram staining, C/S, AFB, mycobacterial C/S and malignant cells (exfoliative cytology)

8. If palpable lymph node: FNAC or biopsy (for lymphoma, metastasis)

9. Other investigations according to suspicion of causes include:

• ANF, anti-ds DNA (SLE)
• Liver function tests
• Urine for protein and serum total protein (nephrotic syndrome)
• CT scan in some cases (it helps to clarify pleural abnormalities more readily than chest X-ray and ultrasonogram, and also helps to distinguish between benign and malignant diseases).

Note: 

• In tuberculosis, AFB is positive in pleural fluid in 20% cases and pleural biopsy is positive in 80% cases.
• In malignancy, pleural biopsy is positive in 40% cases (may be up to 60% cases).

Q. What is pleural effusion?

A. Accumulation of excessive amount of fluid in pleural cavity is called pleural effusion.

Q. What are the definitive signs of pleural effusion?

A. Stony dullness on percussion and reduced or absent breath sound (confirmed by aspiration).

Q. How to confirm if there is small effusion? (if not detected by chest X-ray PA view.)

A. By doing:

• X-ray in lateral decubitus position
• Ultrasonogram (USG) of lower part of the chest
• Occasionally, CT scan of chest may be needed.

Q. What are the characteristics of pleuritic chest pain?

A. Pleuritic chest pain is localized, sharp or lancinating in nature, worse on coughing, deep inspiration or movement.

Q. What are the causes of dullness on percussion over lower chest?

A. As follows:

• Pleural effusion (stony dullness)
• Thickened pleura
• Consolidation (woody dullness)
• Collapse of the lung
• Raised right hemidiaphragm (due to hepatomegaly or liver pushed up)
• Mass lesion.

Remember the following points in pleural effusion:

• Pleural fluid normally present: 5 to 15 mL
• At least 500 mL of fluid is necessary to detect clinically
• At least 300 mL of fluid is necessary to detect radiologically in PA view
• At least 100 mL of fluid is necessary to detect radiologically in lateral decubitus position
• Less than 100 mL or small amount of fluid is detected by ultrasonography (even 20 to 25 mL fluid can be detected).

Q. Supposing, clinically it is pleural effusion but no fluid is coming after aspiration. What are the possibilities?

A. As follows:

• Fluid may be thick (empyema)
• Thickened pleura
• Mass lesion.

Q. What are the common causes of pleural effusion?

A. Four common causes are:

• Pulmonary tuberculosis 
• Parapneumonic (also called postpneumonic)
• Bronchial carcinoma
• Pulmonary infarction.

If the patient is young, common causes are

• Pulmonary tuberculosis
• Parapneumonic
• Others—Lymphoma and SLE in female (also pulmonary infarction).

If the patient is middle age or elderly, common causes are:

• Pulmonary tuberculosis
• Parapneumonic
• Bronchial carcinoma.

Q. What are the causes of predominantly right or left sided pleural effusion?

A. As follows:

Causes of right-sided pleural effusion

• Liver abscess
• Meig’s syndrome
• Dengue hemorrhagic fever.

Causes of left-sided pleural effusion

• Acute pancreatitis
• Rheumatoid arthritis
• Dressler’s syndrome
• Esophageal rupture (Boerhaave’s syndrome)
• Dissecting aneurysm.

Q. What are the causes of bilateral effusion?

A. As follows:

• All causes of transudative effusion (CCF, nephrotic syndrome, cirrhosis of liver, malabsorption or malnutrition or hypoproteinemia).
• Collagen diseases (rheumatoid arthritis and SLE).
• Lymphoma.
• Bilateral extensive pulmonary TB.
• Pulmonary infarction.
• Malignancy (usually multiple metastases involving both lungs).

Q. What are the causes of exudative and transudative pleural effusion?

A. As follows:

1. Exudative (protein >3 g%):

• Pulmonary tuberculosis
• Pneumonia
• Bronchial carcinoma
• Pulmonary infarction
• Collagen disease (SLE, rheumatoid arthritis)
• Lymphoma.
• Dressler’s syndrome (post-myocardial infarction syndrome characterised by pain, pyrexia, pericarditis, pleurisy and pneumonitis).
• Others—acute pancre atitis, subphrenic abscess, liver abscess, pleural mesothelioma, secondaries in the pleura, yellow nail syndrome, etc.

2. Transudative (protein <3 g%):

• Congestive cardiac failure (CCF)
• Nephrotic syndrome
• Cirrhosis of liver
• Malnutrition
• Hypothyroidism
• Meig’s syndrome (ovarian fibroma, ascites and right sided pleural effusion)
• Chronic constrictive pericarditis
• Acute rheumatic fever.

Q. What are the types of pleural effusion according to the color?

A. According to color, pleural effusion may be:

• Serous (hydrothorax)
• Straw
• Purulent (empyema or pyothorax)
• Hemorrhagic (hemothorax)
• Milky or chylous (chylothorax)

Q. What are the causes of hemothorax (blood stained fluid)?

A. As follows:

• Chest injury or trauma
• Bronchial carcinoma
• Pleural mesothelioma
• Pulmonary infarction
• Others – SLE, lymphoma, acute pancreatitis.

Q. What are causes of empyema?

A. As follows:

• Bacterial pneumonia
• Lung abscess (bursting in pleural cavity)
• Bronchiectasis
• Tuberculosis
• Secondary infection after aspiration
• Rupture of subphrenic abscess or liver abscess
• Infected hemothorax.

Q. What are the causes of recurrent pleural effusion? How to treat recurrent pleural effusion?

A. As follows:

• Bronchial carcinoma
• Pleural mesothelioma
• Lymphoma 
• Collagen disease (SLE)
• All causes of transudate (CCF, nephrotic syndrome, cirrhosis of liver).

Treatment of recurrent pleural effusion is done by pleurodesis in the following way:

•  A plain rubber tube is introduced in the intercostal space, and fluid is removed as far as possible.
• Introduce the drug, tetracycline (500 mg) or kaolin or talc through the tube, clamp it and keep for 4 to 8 hours (may be overnight). In malignant pleural effusion, bleomycin 30 to 60 mg is introduced.
• Patients’ posture should be changed 2 hourly to allow the drug to spread in pleural space.
• After 4 to 8 hours, remove any remaining fluid and take out the drainage tube at the height of inspiration.
• The patient usually complains of severe chest pain after pleurodesis. In such case, analgesic should be given.

Q. How can you suspect malignant effusion?

A. As follows:

• Clinically—elderly emaciated or cachexic patient having clubbing with nicotine stain, palpable lymph node, radiation mark on the chest, etc.
• Pleural fluid is hemorrhagic and there is rapid accumulation after aspiration.

Q. What is yellow nail syndrome?

A. It is a congenital disorder characterized by:

• Nails—yellow, thick, onycholysis
• Lymphedema of legs
• Pleural effusion or bronchiectasis.

Q. What are the mechanisms of pleural effusion?

A. Excess pleural fluid accumulation occurs when pleural fluid formation exceeds absorption or

normal pleural fluid formation with reduced absorption. Probable mechanisms are:

• Increased hydrostatic pressure (as in CCF)
• Reduced plasma colloidal osmotic pressure (as in hypoproteinemia)
• Involvement of pleura causing increased permeability (as in TB and tumor)
• Impaired lymphatic drainage of pleural space (as in obstruction of lymphatic system by tumor, TB and radiation)
• Transdiaphragmatic passage of fluid (in liver disease, ascites and acute pancreatitis).

Q. What is the treatment of pleural effusion?

A. Treatment should be according to cause. For example:

• If tuberculosis: Full course antitubercular therapy. Prednisolone 20 to 30 mg daily may be given for 4 to 6 weeks, especially in large effusion.
• If parapneumonic: Aspiration of fluid, may be repeated if necessary. Antibiotic should be given.
• If complicated case, especially empyema, thoracostomy may be done. Sometimes, if all fails, thoracotomy with decortication may be necessary.