Cell types in acute inflammation?
In chronic inflammation?
Chronic: Mononuclear cells
Pleural fluid eosinophilia: >/=10%
Most common: Air/blood in pleural space (may see on repeat thoracentesis)
Other causes: Once above excluded
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
7. Systemic acidosis
9. lupus plueritis
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.