Resolution of Pleural Effusions

doi:10.1378/chest.119.5.1547

Chest

Volume 119, Issue 5, May 2001, Pages 1547-1562

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Parapneumonic Pleural Effusions

The annual incidence of bacterial pneumonia in the United States is estimated at 4 million.¹ Parapneumonic effusions develop in 36 to 66% of hospitalized patients with bacterial pneumonia.²³⁴⁵ When both ambulatory and hospitalized patients are studied, the incidence decreases to 9% (168 of 1,906).⁶ The vast majority of parapneumonic effusions resolve with antibiotic therapy alone, with only a small percentage of patients requiring operative intervention for resolution. The following paragraphs

Coccidioides immitis

C immitis is endemic in southwestern United States, northern Mexico, and certain areas of Central and South America. Pleural effusions may occur during either acute primary or chronic progressive disease,⁵³ with the reported incidence ranging from 7 to 19%.⁵⁴⁵⁵⁵⁶ Effusions tend to develop within a week after the onset of symptoms. The effusions are usually small, but occasionally may be massive. The natural history of acute coccidioidal effusions is self-limited, with radiographic resolution in

Viral Infections

Viral lower-respiratory-tract infections have been associated with pleural effusion. The incidence of pleural effusions in viral pneumonia is reported to be 2% (2 of 123)⁶⁴ to 9% (2 of 23)¹² of cases. When pleural effusions are specifically targeted with lateral decubitus chest views, 18% (2 of 11) with viral pneumonia revealed an effusion.¹³ A variety of viral infections, including influenza,¹³⁶⁴parainfluenza,⁶⁴ respiratory syncytial virus,⁶⁴⁶⁵⁶⁶ herpes simplex virus,⁶⁷cytomegalovirus,⁶⁸⁶⁹ and

Tuberculosis

Eight million people developed tuberculosis in 1990 worldwide, with 95% occurring in underdeveloped countries.⁷³ The frequency of pleural effusion in tuberculosis varies from country to country. In the United States, tuberculous pleural effusions represent 4% (905 of 22,764) of all cases of tuberculosis⁷⁴; in Spain, it affects 23% (146 of 637).⁷⁵

Radiographs typically show small-to-moderate, unilateral effusions, although massive effusions are seen in 14 to 29% of those with primary disease.⁷⁶⁷⁷

AIDS

The incidence of pleural effusion in patients with AIDS varies in different populations and geographic areas. In a large series of 4,511 HIV-positive patients admitted to a New York hospital, pleural effusions were seen in only 1.7% of cases; however, the stage of these cases is not commented on in this abstract.⁹² In a series from South Carolina,⁹³ the prevalence of pleural effusion was 17% in 350 HIV-positive hospitalized patients, but there was a significant difference in CD4 counts in those

Congestive Heart Failure

Congestive heart failure (CHF) is the most common cause of a transudative pleural effusion, and is probably the most common cause of all pleural effusions. Defining the precise incidence of pleural effusion with CHF is problematic, because there is variance between techniques used to detect the effusion and the stage and degree of heart failure at the time of the evaluation. Earlier literature reports an incidence of 38% (136 of 356) clinically and radiographically,¹⁰⁵ and as high as 72% (290

Postcardiac Injury Syndrome

The postcardiac injury syndrome (PCIS) occurs days, weeks, or months after a variety of myocardial or pericardial injuries. The syndrome has been described after cardiac surgery (postpericardiotomy syndrome),¹¹⁶¹¹⁷¹¹⁸¹¹⁹¹²⁰¹²¹ myocardial infarction (postmyocardial infarction or Dressler's syndrome),¹²²¹²³¹²⁴¹²⁵ blunt chest trauma,¹²⁶¹²⁷ pacemaker implantation (postpericardial trauma syndrome),¹²⁸¹²⁹¹³⁰¹³¹ and angioplasty.¹³²¹³³ This autoimmune syndrome is manifested by pericarditis, with

After Coronary Artery Bypass Surgery

Pleural effusions are common after coronary artery bypass graft surgery. The reported incidence ranges from 40 to 90%, depending on the diagnostic modality used to detect the presence of PF.¹³⁵¹³⁶¹³⁷¹³⁸¹³⁹ The majority of pleural effusions are small and usually left sided; however, large and bilateral effusions have been reported.

These effusions have multiple causes. They could be related to CHF, PCIS, atelectasis, chest tubes, pleural lymphatic injury from the pleurotomy, injury to the

Rheumatoid Pleurisy

Pleural involvement appears to be the most common intrathoracic manifestation of rheumatoid arthritis (RA), occurring in approximately 5% of patients.¹⁴⁴¹⁴⁵ However, based on autopsy findings, clinical presence of pleural effusion and pleurisy significantly underestimates pleural involvement in RA patients. Postmortem series¹⁴⁶ report a 40 to 70% incidence of pleuritis; this clinicopathology discrepancy suggests that many patients are asymptomatic or that anti-inflammatory drugs mask minimal

Systemic Lupus Erythematosus

Pleurisy (pleural inflammation), a common feature of systemic lupus erythematosus (SLE), is usually associated with chest pain with or without pleural effusion, and occurs in 45 to 56% of patients during the course of the disease.¹⁶⁶¹⁶⁷ Radiographic evidence of pleural effusion is less common, with an incidence of 16 to 37%.¹⁶⁶¹⁶⁷¹⁶⁸ Pleural effusions occur more frequently in female patients and usually are a late manifestation of the disease but may be the presenting feature in 5% of cases.¹⁶⁶

Sarcoidosis

Although the lung is affected in > 90% of patients with sarcoidosis, pleural involvement is an uncommon manifestation. The incidence of pleural effusion with sarcoidosis ranges from 0 to 5%¹⁸²¹⁸³¹⁸⁴ but has been reported to be as high as 7.5%.¹⁸⁵ Patients with sarcoid pleural effusion usually have extensive parenchymal disease (stage 2 or stage 3) and frequently have extrathoracic sarcoidosis.¹⁸²¹⁸³¹⁸⁴¹⁸⁵ Chest radiographs usually show unilateral, small-to-moderate effusions, but bilateral and

Pulmonary Embolism

Pulmonary embolism should be a diagnostic consideration in every patient with an acute, unilateral pleural effusion. Pleural effusion occurs in 10 to 50% of patients with pulmonary embolism¹⁹⁴¹⁹⁵¹⁹⁶¹⁹⁷¹⁹⁸¹⁹⁹; an associated ipsilateral parenchymal infiltrate is seen on chest radiography in 50% of patients.¹⁹⁵ Effusions secondary to pulmonary embolism generally are small and occupy less than a third of the hemithorax.¹⁹⁵¹⁹⁷¹⁹⁸¹⁹⁹ The effusion tends to be larger if an associated infiltrate is

Benign Asbestos Pleural Effusion

Pleural effusion resulting from asbestos exposure is the most common asbestos-related pleuropulmonary abnormality during the first 20 years after exposure; however, it may occur from 1 to 60 years from initial exposure.²⁰⁰²⁰¹²⁰² Benign asbestos pleural effusion (BAPE) is defined as an effusion that occurs in the setting of asbestos exposure, in the absence of other conditions, and is not followed by the development of a malignancy within 3 years. Using this definition, Epler and coworkers²⁰⁰

Lung and Heart-Lung Transplantation

Pleural effusions are the rule in the early postoperative period. One series²⁰⁶ of heart-lung transplants reported a 100% (10 of 10) incidence of pleural effusions. More parapneumonic effusions have been noted in double-lung transplants than in single-lung transplants (16% [4 of 25] vs 0% [0 of 5]).²⁰⁷ The latter is possibly explained by the greater pretransplant incidence of pulmonary sepsis in double-lung recipients with cystic fibrosis and COPD.

Most of these pleural effusions are small to

Uremic Pleural Effusions

In 1836, Bright²²¹ reported that only 29% of patients with albuminous urine had healthy pleura at autopsy. Fibrinous pleuritis has been found in 20 to 58% of uremic patients at autopsy.²²²²²³ There are several reasons why pleural disease may be common in patients with renal failure: (1) CHF because of tenuous fluid balance, ischemic heart disease, and dilated cardiomyopathy; (2) increased risk of infection²²⁴²²⁵; (3) diseases associated with renal and pleural manifestations (ie, SLE); (4)

Pleural Effusion in Pancreatitis

Pleuropulmonary complications are commonly associated with pancreatic disease. Pleural effusions are no exception, but the clinical presentation, management, and prognosis for effusions in acute and chronic pancreatitis are different.

Persistent Benign Pleural Effusions

There are only a few causes of persistent benign pleural effusion. These effusions are because of lymphatic abnormalities or a severe inflammatory process. The lymphatic abnormalities include yellow nail syndrome (YNS),²⁵⁷ chylothorax from lymphangioleiomyomatosis²⁵⁸ or Noonan's syndrome, and other causes of lymphangiectasis²⁵⁹²⁶⁰ and trapped lung because of chronic inflammation.

YNS, the triad of yellow, slow-growing nails, lymphedema, and respiratory tract disease, which includes pleural

Conclusion

Knowledge of the spontaneous resolution rates of pleural effusions should be of value to the clinician when diagnosis is problematic. With this information, the differential diagnosis can be limited, possibly avoiding unnecessary diagnostic testing, with its inherent morbidity and economic burden. Although the data presented are derived from case series, most of which are retrospective, effusions can be reliably categorized by resolution times (Table 3) and, thus, be of clinical value in

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Evaluation of intrapleural fibrinolytic therapy and dosing strategies used for complicated pleural effusions
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Compare the use of Tissue Plasminogen Activator (t-PA) and t-PA + Dornase (DNase) for the management of complicated pleural effusions, and to determine if a dose-response relationship exists for t-PA.
Retrospective cohort study that examined all adult patients at a large academic medical center who received intrapleural t-PA or t-PA + DNase for the management of a complicated pleural effusions. Outcomes were success of therapy [defined as avoidance of secondary interventions (i.e. VATSD or thoracotomy)], chest tube output pre- and post-administration, radiographic findings, t-PA dose and frequency, and bleeding complications.
Thirty-five patients were enrolled: 25 received t-PA and 10 received t-PA + DNase. Successful pharmacologic treatment occurred in 88% of patients receiving t-PA and 100% of patients receiving t-PA + DNase (p = 0.54). In the t-PA group, chest tube output increased from 75 ml/12 h to 538 ml/12 h after administration of t-PA (p = 0.001), and from 103 ml/12 h to 502 ml/12 h (p = 0.001) in the t-PA + DNase group. Radiographic improvement occurred in 84% of t-PA patients and 90% of t-PA + DNase patients (p = 0.99). In the t-PA group, a successful response occurred in 92% of patients receiving a cumulative dose of ≤10 mg (n = 13) and 83% of patients receiving a cumulative dose of >10 mg (n = 12), p = 0.43. Patients who received a single t-PA dose compared to those who received multiple doses also had similar success rates (p = 1). There was one instance of bleeding following drug administration.
Both t-PA and t-PA + DNase were highly effective for reducing a patient's need for surgical intervention. Higher cumulative doses or more frequency administrations did not appear to provide additional benefit.
Pseudochylothorax: An underdiagnosed entity
2019, Human Pathology: Case Reports
Pleuroparenchymal sarcoidosis - A recognised but rare manifestation of disease
2018, Respiratory Medicine Case Reports
Persistent benign pleural effusion
2017, Revista Clinica Espanola
En esta revisión narrativa se describen las principales etiologías, características clínicas y tratamiento de los derrames pleurales de naturaleza benigna que, característicamente, pueden persistir en el tiempo: quilotórax y derrames de colesterol, pulmón no expansible, derrame pleural reumatoide, empiema tuberculoso, derrame pleural asbestósico benigno y síndrome de las uñas amarillas.
In this narrative review we describe the main aetiologies, clinical characteristics and treatment for patients with benign pleural effusion that characteristically persists over time: chylothorax and cholesterol effusions, nonexpansible lung, rheumatoid pleural effusion, tuberculous empyema, benign asbestos pleural effusion and yellow nail syndrome.
Recurrent Brachiocephalic Vein Stenosis as a Cause for Persistent Left-sided Transudative Pleural Effusion in a Hemodialysis Patient
2016, Annals of Vascular Surgery
Citation Excerpt :
In patients receiving long-term hemodialysis, the incidence is reported to be between 16% and 20.2%.2,3 Nonrenal diseases such as congestive heart failure, infections, and neoplasms can also cause effusion in CKD patients.3,4 Transudative effusion can be caused by heart failure, fluid overload, and nephrotic syndrome in chronic hemodialysis patients.
Effusion is common in dialysis patients. The most common causes include fluid overload due to renal failure and nonrenal causes like congestive heart failure and infection. We here report a case of left side transudative effusion due to brachiocephalic venous stenosis.
A 34-year-old female who had chronic kidney disease V during transplant work-up was found to be having left arm swelling and left transudative effusion. Work-up for transudative effusion did not show any cardiac cause or liver problem. Her dialysis duration was optimized from 2 times a week to 3 times a week for 4 hr and her dry weight was adjusted. Despite adequate dialysis for 1 month, effusion on the left side persisted. She had a previous venoplasty for a stenosis in brachiocephalic vein but restenosis occurred again.
Brachiocephalic vein stenting was performed which successfully lead to resolution of left arm swelling and left effusion. She was later on successfully transplanted.
Brachiocephalic stenosis can cause ipsilateral transudative effusion. Venoplasty and stenting of the brachiocephalic vein lead to complete resolution of effusion.
Sarcoid pleural effusion
2014, Medicina Clinica
El derrame pleural (DP) es una manifestación muy poco frecuente en los pacientes con sarcoidosis. Se observa por igual en varones y en mujeres, y puede manifestarse a cualquier edad y en todos los estadios radiológicos, aunque es más frecuente en el i y el ii. Los derrames suelen ser pequeños o de moderado tamaño, y afectan predominantemente al lado derecho. Varios mecanismos pueden estar implicados. El DP será un exudado seroso si se produce un aumento de la permeabilidad capilar por afectación directa de la pleura, un quilotórax si las adenopatías mediastínicas comprimen el conducto torácico y/o el drenaje linfático del espacio pleural, un hemotórax si los granulomas comprimen o invaden los pequeños vasos y capilares pleurales, e incluso un trasudado si existe compresión de la vena cava superior, atelectasia por obstrucción bronquial completa o si la resolución del DP es incompleta con un engrosamiento crónico de la pleura visceral (pulmón atrapado). Bioquímicamente suele manifestarse como un exudado paucicelular de predominio linfocítico, aunque puede ser eosinofílico o de predominio neutrófilo. Las proteínas suelen estar proporcionalmente más elevadas que la lactato deshidrogenasa. La adenosina deaminasa suele ser baja y en las mujeres es posible encontrar valores elevados de CA-125. La prueba de la tuberculina es negativa y las biopsias pulmonar o pleural aportan el diagnóstico al demostrar granulomas no caseificantes. Pueden evolucionar favorablemente de forma espontánea, si bien en la mayoría de los casos se tratan con corticoides y solamente es necesario recurrir a la cirugía en raras ocasiones.
Pleural effusion (PE) is a very uncommon manifestation of sarcoidosis. It is equally observed in men and women, can appear at any age and in all radiologic stages, though it is more common in stages i and ii. Effusions have usually a mild or medium size and mainly involve the right side. Various mechanisms can be implicated. PE will be a serous exudate if there is an increase in the capillary permeability due to direct involvement of the pleural membrane, a chylothorax if mediastinum lymph nodes compress the thoracic duct and/or the lymphatic drainage from the pleural cavity, an hemothorax if granuloma compress or invade pleural small vessels or capillaries, and even a transudate if there is compression of the inferior vena cava, atelectasis due to complete bronchial obstruction or when the resolution of the PE is incomplete with chronic thickening of visceral pleura (trapped lung). It manifests biochemically as a pauci-cellular exudate with a predominance of lymphocytes, though there can be a preponderance of eosinophils or neutrophils. Protein concentrations are usually proportionately higher than lactate dehidrogenase, adenosine deaminase is normally low and it is possible to find increased levels of CA-125 in women. The tuberculin test is negative and pleural or lung biopsies yield the diagnosis by confirming the presence of non-caseating granulomata. These PE can have a favorable self-limited outcome, even though in most cases treatment with corticosteroids is needed, while surgery is required in a few cases.

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Chest

ReviewsResolution of Pleural Effusions

Section snippets

Parapneumonic Pleural Effusions

Coccidioides immitis

Viral Infections

Tuberculosis

AIDS

Congestive Heart Failure

Postcardiac Injury Syndrome

After Coronary Artery Bypass Surgery

Rheumatoid Pleurisy

Systemic Lupus Erythematosus

Sarcoidosis

Pulmonary Embolism

Benign Asbestos Pleural Effusion

Lung and Heart-Lung Transplantation

Uremic Pleural Effusions

Pleural Effusion in Pancreatitis

Persistent Benign Pleural Effusions

Conclusion

First page preview

Chest

Am J Med

Respir Med

Am J Med

Diagn Microbiol Infect Dis

Chest

Chest

Clin Radiol

J Pediatr

Chest

J Pediatr

Chest

Tubercle

Chest

Tuberc Lung Dis

Respir Med

Chest

Chest

Chest

Chest

Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy

Am Rev Respir Dis

Anaerobic infections of the lung and pleural space

Am Rev Respir Dis

Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?

Arch Intern Med

The radiographic resolution of Streptococcus pneumoniae pneumonia

N Engl J Med

Adult bacteremic pneumococcal pneumonia in a community teaching hospital, 1992–1996

Arch Intern Med

Comparative radiographic features of community acquired Legionnaires' disease, pneumococcal pneumonia, mycoplasma pneumonia, and psittacosis

Thorax

Pleural effusion in patients infected with the human immunodeficiency virus

Eur J Clin Microbiol Infect Dis

Mycoplasma and adenovirus pneumonias: comparison with other atypical pneumonias in a military population

Ann Intern Med

Frequency of pleural effusions in mycoplasma and viral pneumonias

N Engl J Med

Clinical complications of Mycoplasma pneumoniae disease: other organs

Yale J Biol Med

Mycoplasma pneumoniae pneumonia: experience at a referral center

West J Med

Mycoplasma pneumonia with bilateral pleural effusions

Am Rev Respir Dis

The unusual severity of mycoplasmal pneumonia in children with sickle-cell disease

N Engl J Med

Shedding of Mycoplasma pneumoniae after tetracycline and erythromycin therapy

N Engl J Med

Mycoplasma pneumoniae pneumonia with pleural effusion, with special reference to isolation of Mycoplasma pneumoniae from pleural fluid

Tohoku J Exp Med

The clinical spectrum of Mycoplasma pneumoniae infections

Med Clin North Am

Legionella species community-acquired pneumonia: a review of 56 hospitalized adult patients

Chest

A multicenter, randomized study comparing the efficacy and safety of intravenous and/or oral levofloxacin versus ceftriaxone and/or cefuroxime axetil in treatment of adults with community-acquired pneumonia

Antimicrob Agents Chemother

Multiple pathogens in adult patients admitted with community-acquired pneumonia: a 1-year prospective study of 346 consecutive patients

Thorax

Reviews
Resolution of Pleural Effusions