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Top 3 causes of exudative pleural effusions?
- Pneumonia (parapneumonic)
- Pulmonary Embolism
How often does light's criteria misidentify a transudative effusion as exudative? What protein gradient should suggest true exudative?
What BNP level?
- 25% are misclassified.
- >3.1 gm/dL
- NT-BNP >1300 pg/mL
Pleural effusion protein above 5 g/dL is suggestive of what?
LDH indicates what in a pleural effusion
- LDH is an intracellular enzyme. Indicates degree of cell turnover and inflammation.
- If on repeated thoracenteses LDH increases, suggests that inflammation increases
What are the causes of a lower pleural fluid glucose?
- 1. Parapneumonic effusion (below 40, place chest tube)
- 2. Malignant effusion (if low glucose, cytology likely positive)
- 3. TB effusion
- 4. Rheumatoid effusion (expect below 30)
- 5. Hemothorax
- 6. Paragonimiasis
- 7. Churg-strauss syndrome
Cell types in acute inflammation?
In chronic inflammation?
- Acute: PMN's
- Chronic: Mononuclear cells
Pleural fluid eosinophilia: >/=10%
- Most common: Air/blood in pleural space (may see on repeat thoracentesis)
- Other causes: Once above excluded
- Idiopathic 40%
- Malignancy 17%
- Parapneumonic 13%
- TB 6%
- PE 4%
- Transudates 8%
- Other causes: 13%
Cytology positive on for malignancy on first tap? By third tap?
- 60% on first tap
- 90% by third tap
- Also depends on tumor type
10 causes of pH under 7.2
- 1. Complicated parapneumonic effusion
- 2. Esophageal rupture
- 3. Rheumatoid pleuritis
- 4. TB pleuritis
- 5. Malignant pleural disease
- 6. Hemothorax
- 7. Systemic acidosis
- 8. paragonimiasis
- 9. lupus plueritis
- 10. urinothorax
What percentage of patients with SLE will have a pleural effusion?
What percentage of people with SLE will have negative ANA if pleural effusion?
- Essentially none. Very high negative predictive value.
What percentage of patients with RA will have an effusion
- 5% at some point in disease.
- If pleural fluid rheumatoid factor titer >1:320, clinches dx of RA
1. Bilateral in what percentage? Which side more?
2. What percentage with unilateral right sided?
3. What percentage with unilateral left sided?
- 1. 73% with bilateral, slightly larger on the right.
- 2. 19% with right sided.
- 3. 9% with left sided.
What is a protein discordant effusion?
When diuresis of a heart failure transudate concentrates the fluid to an apparent exudate. It should be only very slightly exudative. Some things to look for: Pleural fluid protein level >3.1 gm/dL. Or NT-BNP >1300 pg/mL. (not regular BNP)
What 7 factors indicate need for more invasive strategy in a parapneumonic effusion?
- 1. Pus in pleural space
- 2. Positive pleural fluid gram stain
- 3. Pleural fluid glucose <60 mg/dL
- 4. Pleural fluid pH <7.2
- 5. Positive pleural fluid culture
- 6. Pleural fluid LDH >3x upper limit of serum nml.
- 7. Loculated pleural effusion
What is the significance of a tuberculous pleural effusion?
Most will resolve spontaneously, and do not need a chest tube. However, if not treated with anti-TB meds, ~50% likelihood of developing active TB in the next 5 yrs.
Of the 5 most common endemic fungi, which are the most likely to cause a pleural effusion?
- 1. Primary coccidioidomycosis-- ~15% with effusions (can also occur through ruptured coccidiodal cavity-- hydropneumothorax
- 2. Blastomycosis-- 10% with pleural effusion; 40% + with pleural thickening
- 3. Aspergillosis-- as complication to lobectomy, pneumonectomy in BP fistula. Previously in articifical PTX for TB therapy
- 4. Cryptococcus-- from rupture of sub pleural foci.
- 5. Histoplasmosis-- rare, 1/259 in 1 series.
- 6. Rare in P.Jirovecii (case reports)
Esophageal perforation is a complication of what 3 procedures mainly?
Which side does it occur on most frequently?
What are the notable characteristics?
- Esophagoscopy, during foreign body removal or esophageal stricture dilation. Also with Blakemore placement. Also seen with TEE, esophageal cancer, gastric intubation, chest trauma or vomiting.
- Typically right sided.
- Expect low pH (often below 7), elevated amylase. Often polymicrobial.
What percentage of patients develop pleural effusions after liver transplant
~70%. Only about 10% will require intervention though.
Characteristics of a rheumatoid pleural effusion?
- Male predominant. 5%, usually in those with sub pleural nodules. Glucose <30, pH <7.2, elevated rheumatoid factor titer >1:320.
- Develops several years after arthritis typically.