Role of interleukin-6, gamma interferon and adenosine deaminase markers in management of pleural effusion patients / Papel de la interleucina-6, el interferón gamma, y la adenosina desaminasa como marcadores en el tratamiento de pacientes con derrame pleural

OBJECTIVE: Pleural effusion is a common diagnostic and clinical problem. Neoplasms and tuberculosis are the most frequent diagnostic causes of such effusions. Conventional laboratory methods for diagnosis of such effusion are inefficient because tubercle bacilli are rarely seen in direct examinations of pleural fluid. The present study evaluates interleukin-6 (IL-6), gamma interferon (IFN-γ) and adenosine deaminase (ADA) as diagnostic tools in pleural effusion. METHODS: Interleukin-6, IFN-γ and ADA were measured in pleural fluid from the patients, with exudative pleural effusion from tuberculous, malignant and postpneumonic origin and transudative pleural effusion ofsystemic origin in order to evaluate the diagnostic utility ofthese. RESULTS: The three markers were detectable in all effusions with significantly high levels in exudative as compared to transudative effusions. There was a statically significant difference noticed in tuberculous as compared to malignant andpostpneumonic origin and transudative pleural effusion. CONCLUSION: We concluded that IL-6, IFN-γ and ADA levels in pleural effusion are sensitive parameters to differentiate an exudate from a transudate and they can also differentiate exudates of different aetiology. Finally, the results suggest that there is a remarkable difference in production of these three markers in exudative pleural effusions as compared to transudative pleural effusions.

OBJETIVO: El derrame pleural es un problema diagnóstico y clínico común. Las neoplasias y la tuberculosis son las causas más frecuentes en los diagnósticos de tales derrames. Los métodos de laboratorio convencionales para el diagnóstico de tales derrames son ineficientes, porque los bacilos de la tuberculosis raramente se ven en los exámenes directos del líquido pleural. El presente estudio evalúa la interleucina-6, el interferón gamma (IFN-γ) y la adenosina desaminasa (ADA) como herramientas de diagnóstico en el derrame pleural. MÉTODOS: La interleucina-6, el IFN-γ, y la ADA fueron medidos en el líquido pleural de los pacientes con derrame pleural exudativo de origen tuberculoso, maligno y post-pneumónico, y el derrame pleural trasudativo de origen sistémico, con el fin de evaluar la utilidad diagnóstica de éstos. RESULTADOS: Los tres marcadores eran observables en todos los derrames, con niveles significativamente altos en los exudativos en comparación con los trasudativos. Se notó una diferencia estadísticamente significativa en los derrames de origen tuberculoso en comparación con los de origen maligno y postpneumónico, y los derrames pleurales trasudativos. CONCLUSIÓN: Llegamos a la conclusión de que los niveles de IL-6, IFN-Correspondence: Dr M Marie, College of Applied Medical Sciences, Clinical Laboratory Department, King Saud University, PO Box 10219, Riyadh 11433, Kingdom of Saudi Arabia. E-mail: drmmarie.2000@ gmail.com *Equally contributed to the manuscript YADA en el derrame pleural, son parámetros sensibles para diferenciar un derrame pleural exudado de uno trasudado, pudiendo por otra parte ayudar también a distinguir exudados de diferentes etiologías. Finalmente, los resultados sugieren que existe una diferencia notable en la forma en que se producen estos tres marcadores en los derrames efusiones pleurales exudativos en comparación con los derrames pleurales trasudativos.

Pleural tuberculosis: is radiological evidence of pulmonary-associated disease related to the exacerbation of the inflammatory response?

OBJECTIVE: Pleural tuberculosis is the most frequently occurring form of extra pulmonary disease in adults. In up to 40% of cases, the lung parenchyma is concomitantly involved, which can have an epidemiological impact. This study aims to evaluate the pleural and systemic inflammatory response of patients with pleural or pleuropulmonary tuberculosis. METHODS: A prospective study of 39 patients with confirmed pleural tuberculosis. After thoracentesis, a high resolution chest tomography was performed to evaluate the pulmonary involvement. Of the 39 patients, 20 exhibited only pleural effusion, and high resolution chest tomography revealed active associated-pulmonary disease in 19 patients. The total protein, lactic dehydrogenase, adenosine deaminase, vascular endothelial growth factor, interleukin-8, tumor necrosis factor-α, and transforming growth factor-β1 levels were quantified in the patient serum and pleural fluid. RESULTS: All of the effusions were exudates with high levels of adenosine deaminase. The levels of vascular endothelial growth factor and transforming growth factor-β1 were increased in the blood and pleural fluid of all of the patients with pleural tuberculosis, with no differences between the two forms of tuberculosis. The tumor necrosis factor-α levels were significantly higher in the pleural fluid of the patients with the pleuropulmonary form of tuberculosis. The interleukin-8 levels were high in the pleural fluid of all of the patients, without any differences between the forms of tuberculosis. CONCLUSION: Tumor necrosis factor-α was the single cytokine that significantly increased in the pleural fluid of the patients with pulmonary involvement. However, an overlap in the results does not permit us to suggest that cytokine is a biological marker of concomitant parenchymal involvement. Although high resolution chest tomography can be useful in identifying these patients, the investigation of fast acid bacilli and cultures for M. tuberculosis in the sputum is recommended for all patients who are diagnosed with pleural tuberculosis.

Does the evaluation of coagulation factors contribute to etiological diagnosis of pleural effusions?

OBJECTIVE: The aim of this study was to identify the participation of the coagulation system in the differential diagnosis of pleural effusions. INTRODUCTION: Imbalance between immunologic and metabolic factors triggers a sequence of events resulting in pleural reactions and accumulation of fluid. The coagulation system, which is fundamental for the maintenance of homeostasis, contributes to the inflammatory process responsible for pleural effusions, and participates in cellular proliferation and migration as well as in the synthesis of inflammatory mediators. METHODS: We evaluated the laboratory profile of coagulation and fibrinolysis in 54 pleural fluids (15 transudates and 39 exudates). RESULTS: The coagulation system acts according to the pathophysiologic mechanisms involved in the development of pleural effusions. In inflammatory effusions (exudates), there is activation of coagulation with increased levels of fragment 1+2 and thrombin-antithrombin complex in addition to reduction of fibrinogen levels due to fibrinolysis and fibrin tissue incorporation. As a consequence, there is activation of the fibrinolytic system with increased levels of fibrin degradation products, including the D-dimer. These changes are not sufficient for differentiation of different subgroups of exudates. In transudates, these events were observed to a lesser degree. CONCLUSION: The coagulation system plays an important role in the development of pleural diseases. Coagulation tests show differences between transudates and exudates but not among exudate subgroups. Understanding the physiopathological mechanisms of pleural disorders may help to define new diagnostic and therapeutic approaches.

Pleural fluid analysis with traditional and additional parameters.

36 patients with pleural effusion were studied clinically with pertinent investigations and pleural fluid analysis. The pleural fluid analysis was done with routine protocol including study of traditional parameters like protein and cell count and additional parameters like pleural LDH, GOT(AST) and their ratio with serum LDH and GOT respectively. The utility of these parameters was studied critically. Amongst the isolated parameters cell count enjoyed highest (100%) specificity and positive predictive value. LDH ratio had highest (79.1%) sensitivity. Pleural LDH showed highest (52.6%) negative predictive value and diagnostic accuracy (69.4%). Amongst the combination of two parameters protein with LDH ratio had highest (87.5%) sensitivity, cell count with LDH ratio showed highest specificity (100%), positive predictive value (75%) and diagnostic accuracy (88.9%). Amongst the combination of three parameters pleural protein and cell count with LDH ratio and GOT ratio respectively enjoyed best sensitivity (87.5%), specificity and positive predictive value (100%), negative predictive value (80%) and diagnostic accuracy (90.6%). Similarly competent were the combinations offour parameters namely p rotein and cell count with LDH and its ratio and GOT and its ratio respectively. Combination of all parameters exhibited similar degree of utility.

Coleta e preservação do líquido pleural e biópsia pleural / Collection and preservation of the pleural fluid and pleural biopsy

As amostras de líquido pleural obtidas por toracocentese para o diagnóstico de transudatos e exsudatos devem obedecer a uma rotina de coleta e preservação para a realização de uma análise laboratorial adequada. Igualmente, fragmentos de biópsia de pleura obtidos para o diagnóstico diferencial dos exsudatos devem ser coletados de forma sistemática com o objetivo de otimizar o diagnóstico e facilitar a instituição da terapêutica adequada.

The samples of pleural fluid obtained by thoracentesis for the diagnosis of transudates and exudates shall follow a routine of collection and preservation for an appropriate laboratorial analysis. Equally, fragments of pleura biopsy obtained for the differential diagnosis of the exudates should be collected in a systematic way in order to optimize the diagnosis and facilitate the institution of appropriate therapeutics actions.

Derrame pleural de origem indeterminada / Undiagnosed pleural effusion

Apesar do progresso nos métodos diagnósticos, cerca de 20 por cento dos derrames pleurais podem permanecer sem diagnóstico etiológico definido após os exames convencionais. Para tentar determinar a origem destes derrames, métodos não convencionais e procedimentos mais invasivos devem ser utilizados com o objetivo de tentar esclarecer a etiologia do derrame pleural e instituir a terapêutica mais adequada.

In spite of the progress in the diagnostic methods, about 20 percent of the pleural effusions may remain without a proper diagnosis after the use of conventional exams. In order to determine the origin of these effusions, alternative methods and invasive procedures shall be used aiming to determine the etiology of the undiagnosed pleural effusions and institute the most appropriate therapeutics.

Evaluation of cholinesterase to differentiate pleural exudates and transudates.

AIMS AND OBJECTIVES: The present study was undertaken to evaluate the usefulness of pleural fluid cholinesterase (PChE) level in pleural fluid and its ratio to serum cholinesterase (P/SChE) in order to differentiate transudates and exudates and to compare their diagnostic efficacy with the Light's criteria. MATERIAL AND METHODS: A total of 110 patients of pleural effusion of diverse etiology were studied. Eighty patients were of exudative pleural effusion of tubercular, malignant or parapneumonic origin and 30 patients were of transudative effusion. Cholinesterase was estimated in the pleural fluid and serum in all the patients. RESULTS: The mean PChE and P/S ChE were significantly higher in exudates as compared to transudates (p < 0.001). P/S ChE was 0.79 +/- 0.45 and 0.14 +/- 0.11 in exudates and transudates, respectively. When a cut-off value of 469 IU/L for PChE was taken for the diagnosis, it was found that 10% of exudates and 2.5% of transudates were misclassified. However percentage of misclassification decreased to 1.25% in exudates and 3.3% in transudates when the cut-off value of 0.24 for P/S ChE ratio was used. Using Light's criteria, a sensitivity of 91.25% and specificity of 90% with positive predictive value (PPV) of 96.05% and negative predictive value (NPV) of 79.42% was observed. However using P/S ChE, the PPV was 98.75% and NPV was 96.67%. CONCLUSIONS: The estimation of PChE and P/SChE ratio had better discriminatory capacity than Light's criteria. It is cost effective and more specific, therefore its routine estimation is recommended.

Alkaline phosphatase in pleural effusions.

BACKGROUND: Pleural effusion (PF) is a common clinical presentation in several diseases. Various parameters from pleural fluid have been studied to identify the cause. The diagnostic value of these parameters varies. The present study was carried out to evaluate the value of alkaline phosphatase concentration in the pleural effusions as a diagnostic tool. METHODS: One hundred and one patients with pleural effusion admitted over a period of two years were studied. The diagnosis was confirmed by pleural biopsy and cytology for malignant cells. RESULTS: Pleural fluid alkaline phosphatase levels of more than 75 mg/dl was found in exudative effusions and less than 75 mg/dl in transudative ones. But it did not differentiate tubercular pleural effusions from other exudative ones. CONCLUSION: Pleural fluid alkaline phosphatase of >75 mg/dl is a useful biochemical marker to suggest exudative effusions.

Comparative analysis of the biochemical tests used to differentiate between pleural transudates and exudates

This study aimed to evaluate the diagnostic accuracies for pleural fluid tests that discriminate between transudative and exudative pleural effusion. A prospective evaluation of 78 patients with pleural effusion of different etiologies was done. The criteria showed the best results in this series, four effusions only were misclassified [three transudates and one exudate]. The number of misclassified effusions in other criteria was seven by PF cholinesterase [three transudates and four exudates], six by the P/S cholinesterase [four transudates and two exudates], six by PF cholesterol [one transudate and five exudates] and five by PF/S cholesterol ratio [two transudates and three exudates]. It was concluded that the criteria of Light et al. were the best method for distinguishing exudates from transudates

Manejo de exudados pleurales complicados mediante catéteres angiográficos

Basados en la literatura reciente y para demostrar que el manejo de exudados complicados mediante catéteres angiográficos es una técnica segura y eficiente, que ofrece una alternativa útil, como manejo de primera elección y como tratamiento complementario en casos de falla de tubos de toracostomía diseñamos el presente protocolo. En 28 pacientes con edades promedio de 52.7 años, que tenían evidencia radiográfica de derrame pleural, y que además cumplieron los criterios de Light para exudados pleurales complicados, se realizó drenaje de la colección mediante catéteres angiográficos, guiados ecográficamente. El 85.72 por ciento de los drenajes realizados, se clasificaron como exitosos. El 14.28 por ciento restante presentó liquido pleural luego del drenaje, anotando que ninguno de los drenajes fallidos requirió manejo quirúrgico. El 71.42 por ciento se manejó únicamente con catéteres angiográficos, mientras el 28.57 por ciento se les colocó catéteres luego del manejo con tubo de tórax. El tiempo necesario para el drenaje varió entre 3 y 14 días. No se observaton complicaciones mayores durante el procedimiento ni durante el tiempo de drenaje

Diagnostic value of cholesterol in pleural effusions.

The separation of pleural effusions into transudates and exudates is the first task the physician must solve in evaluating a pleural effusion for management. Many criteria have been established, but without a definite efficacy of any of them. Cholesterol is an easy, effective, relatively cheap determination to differentiate transudates from exudates. In our prospective study of 40 patients, cholesterol best separated transudates from exudates. A pleural fluid cholesterol value of 60 mg/dl or above has sensitivity, specificity, PPV, NPV and efficacy of 100%, 93%, 96%, 92%, and 95.5% respectively. Pleural fluid to serum cholesterol ratio of 0.3 or higher has sensitivity, specificity, PPV, NPV and efficacy of 96%, 93%, 96%, 92%, and 95% respectively. P. CHOL and P/S CHOL ratio has a misclassification rate of 2.5% each. When both were combined all cases are clearly separated into transudates and exudates.

Esquema terapéutico en la faringoamigdalitis / Therapeutic plan for pharyngoamygdalitis

Con el objetivo de revisar la utilidad de los datos clínicos para el diagnóstico y tratamiento de las faringeoamigdalitis agudas se realizó un estudio que comparó dos grupos: grupo I tratado de acuerdo a esquema terapéutico (esquema tradicional de otorrinolaringología) y grupo II tratado indiscriminadamente con antibióticos. Los resultados de este estudio nos permitió observar que en la práctica diaria, el empleo del criterio clínico es de mayor utilidad. Se propone el esquema de tratamiento clínico para brindar mayor beneficio diagnóstico y evitar el uso indiscriminado de antibióticos

Electrolytes and pH of mammary cyst fluid and their relation to cyst pathology

The relation between intracystic levels of Na+, K+, Na+/K+ ratio, pH and the cytologic appearance of fluid contents and the histopathology of gross mammary cysts was studied in 182 gross mammary cysts. Na+ level was inversely correlated to K+ level [P <0.001]. Two types of cysts were identified: The first group [105 cysts] with Na+/K+ ratio <3 and the lining was mainly metaplastic apocrine epithelium, the second group [77 cysts] Na+/K+ ratio was >3 and the lining was flattened ductal epithelium. Na+K+ was also found to be inversely correlated with the degree of epithelial hyperplasia of the cyst wall [P <0.005]. Poor correlation, however, was found between cytologic appearance of cyst fluid contents and the degree of hyperplasia

Síndrome de ocupación pleural por líquido: estudio y evaluación / Fluid pleural occupation syndrome: study and evaluation

El síndrome de ocupación pleural por líquido es una situación clínica frecuente que precisa de un diagnóstico preciso y oportuno para lograr buenos resultados terapéuticos. En este artículo se revisa algunos aspectos de esta condición incluyendo las manifestaciones clínicas, la fisiología pleural y los elementos clínicos y de laboratorio que se consideran útiles para su estudio y evaluación

study on the cyst fluid in fibrocystic disease of the breast

In the present study, the analysis of the cyst fluid of 20 patients with fibrocystic disease of the breast showed that they can be classified according to their ionic composition, in particular the level of K+, Na+ and Cl-, into two major types [I and II] and one minor less important type. Type I cyst fluid had higher levels of K+ and insignificant high levels of CEA [carcinoembryonic antigen] and alpha-fetoprotein, while type 2 contained higher levels of Na+, C1-, pH and protein. CEA and alpha-fetoprotein showed insignificant low levels in this type. When comparing the histologic findings with the biochemical composition of the cyst fluid, it can be suggested that there may be increased risk for breast cancer in women who had type I cysts. Therefore, patients with this type of fibrocystic disease of the breast should be followed up and checked periodically to detect any signs of malignancy

Derrame pleural tuberculoso: avaliacao clinica e laboratorial / Tuberculous pleural effusion: clinical and laboratory evaluation

Sao apresentados os resultados do estudo de 44 pacientes com diagnostico de derrame pleural tuberculoso. A idade media foi 35 anos. Houve predominio do sexo masculino e da raca branca. As queixas principais foram febre (41/44), dor toracica (41/44) e emagrecimento (34/44), com tempo medio de duracao de sintomas de seis semanas. Em 21 pacientes o derrame foi localizado do lado direito, em 23 no lado esquerdo e em um paciente em ambos os lados. Em 23 por cento dos pacientes foi observado acometimento do parenquima pulmonar ipsilateral. Destes, tres apresentavam cultura de escarro positiva. Foram realizadas 49 biopsias de pleura em 44 pacientes. A primeira biopsia foi diagnostica em 82,5 por cento dos pacientes. A cultura do fragmento de pleura foi positiva em 75,8 por cento e a cultura do liquido pleural em 22,5 por cento. O liquido pleural era um exsudato com uma relacao liquido pleural/sangue maior que 0,5 para proteinas e maior que 0,6 para DHL em todos os casos. O estudo citologico mostrou predominio de linfocitos e escassez de celulas mesoteliais. Os pacientes receberam esquema terapeutico adequado, apresentando boa evolucao. Houve apenas uma falha. Os pacientes apresentaram melhora significativa (p < 0,05) com relacao ao peso, hemoglobina e diminuicao de VHS. Dos 44 pacientes, 23 evoluriam...