Relationship of pleural and serum cholesterol and lipoprotein levels in exudative and transudative effusions

This study aimed to assess whether total cholesterol [CHOL], low-density lipoprotein cholesterol [LDL], and high-density lipoprotein [HDL] are sensitive markers for discriminating between transudative and exudative pleural effusions [PE]. In this study CHOL, LDL, HDL, TG, protein and LDH were analyzed in PE and serums of 119 patients with pleural effusion out of which 49 had transudative and 70 had exudative pleural effusion. Sensitivity, specificity, and area under the curve [AUC] of CHOL, LDL and HDL were measured by receiver operating characteristic curve [ROC]. Pleural fluid CHOL, LDL and HDL levels were significantly lower in the transudate group compared to the exudate [29.6 +/- 16.3 mg/dl versus 65.24 +/- 25.9 mg/dl, p < 0.001; 17 +/- 14.8 mg/dl versus 43.94 +/- 21.6 mg/dl, p < 0.001; and 9.2 +/- 4.8 mg/dl versus14.9 +/- 6.3 mg/dl, p<0.001, respectively]. Sixty-seven percent of cases with pleural transudates were secondary to heart failure, while 41% and 39% of those with pleural exudates were of parapneumonic effusion and neoplastic origin, respectively. Pleural fluid CHOL, LDL and HDL levels were significantly higher in malignant pleural effusion [71.5 +/- 18.6, 48.1 +/- 17.4 and 16.1 +/- 6.6mg/dl, respectively], and in parapneumonic effusion [70.7 +/- 28.5, 49.4 +/- 22.4 and 14.7 +/- 6.4 mg/dl, respectively] than in heart failure [30.6 +/- 11.9, 17.5 +/- 10.4 and 9.6 +/- 5.4 mg/dl, respectively]. The optimum cut-off value for pleural fluid CHOL level of >/= 38 mg/dL had a sensitivity of 87% and 80% specificity, for LDL pleural fluid level a cut-off value of >/= 22.5 mg/dl had a sensitivity of 87% and 78% specificity, and for HDL pleural fluid a cut-off value of >/= 10.5 mg/dl had a sensitivity of 70% and 69% specificity. AUC values were 0.906, 0.883, and 0.783, for CHOL, LDL, and HDL of pleural fluid, respectively. We conclude that pleural fluid CHOL, LDL and HDL are significantly increased in exudative effusions compared to the transudative ones. Measurement of CHOL, LDL and HDL concentrations in pleural effusions is useful in distinguishing exudates from transudates

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.

Role of cancer antigen-125 from pleural & ascitic fluid samples in non malignant conditions.

BACKGROUND & OBJECTIVE: CA-125, an ovarian tumor marker is known to increase in non malignant conditions such as tubercular and non tubercular pleuritis and ascites. We undertook this study to evaluate non-specific rise in CA-125 levels in conditions associated with pleural effusion and ascites and also to understand the mechanism of its secretion. METHODS: CA-125 levels in 38 pleural and 46 ascitic fluid samples from non malignant cases and 10 blood samples from pulmonary tuberculosis cases were estimated by ELISA. The ascitic fluid samples were collected from cases of bacterial peritonitis, tuberculosis, hepatitis, cirrhosis of other aetiology and pleural fluid samples were from cases of tubercular, pyogenic, cardiomegaly and other conditions. RESULTS: Both ascitic and pleural fluid samples (transudative and exudative) showed elevated CA- 125 levels. The CA-125 levels were significantly higher in ascitic fluid samples than in pleural fluid samples. INTERPRETATION & CONCLUSION: Our findings showed that elevated levels of CA-125 in pleural and ascitic fluid could be because of varied aetiologies which need to be ruled out before considering malignancy. Peritoneum has a greater capacity to secrete CA-125 than the pleural epithelium and the secretion occurs following inflammation or mechanical distress. Pulmonary tuberculosis as a closed lesion without involvement of pleural epithelium does not evoke high CA-125 release.

Malignant mesothelioma: a study of sixty-six cases

This study was conducted to review the epidemiology, and biochemical data of pleural fluid to assess the potential contribution to occupational risk of patients with malignant mesothelioma [MM] in Iran. Hospital files of patients with MM of the pleura in Masih Daneshvari Hospital were reviewed between 1997 and 2004 and were evaluated in a cross-sectional study. 66 patients [49 men and 17 women] with a mean age of 53.8 +/- 4.2 yrs were selected. Probable or known occupational contacts were detected in 8 [12.1%] patients. The diagnosis was confirmed by closed pleural biopsy in 26[39.4%] cases. Statistical analysis showed significant cut-off for LDH and glucose level in pleural fluid analysis. Detailed occupational history must not overemphasize blind biopsy as the first diagnostic approach for MM of pleura and pleural fluid glucose as well as LDH had characteristic levels respectively

Scoring system for empyema thoracis and help in management.

OBJECTIVE: To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS) vs early elective VATS. METHODS: A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children's hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38 degrees C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE). RESULTS: Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS. CONCLUSION: A pleural pH < 7.1 and a newly designed clinical severity score of empyema 4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

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.

Role of pleural fluid cholesterol in differentiating transudative from exudative pleural effusion.

BACKGROUND: Pleural fluid cholesterol has been reported to be useful in distinguishing between transudative and exudative pleural effusion. However, the difference in lipid profile between tubercular and non-tubercular pleural effusion has not been studied. METHODS: The lipid profile of pleural fluid in 50 patients with exudative (25 tubercular and 25 non-tubercular) and 25 with transudative effusion was studied. The diagnosis was based on clinical criteria and/or a positive diagnosis from another site. RESULTS: The criteria that best identified an exudative pleural effusion were pleural fluid cholesterol > or = 60 mg/dl, pleural fluid to serum cholesterol ratio > or = 0.4, pleural fluid triglyceride > or = 40 mg/dl and pleural fluid to serum triglyceride ratio > or = 0.3. Pleural fluid cholesterol had a sensitivity of 88% and a specificity of 100% for exudates with an accuracy of 92%. Pleural fluid to serum cholesterol ratio had a sensitivity of 98% and a specificity of 84%. These results were superior to the criteria proposed by Light et al. (sensitivity 98% and specificity 80%). CONCLUSION: Pleural fluid cholesterol estimation is an effective and cost-efficient method of differentiating exudative from transudative pleural effusion. The lipid profile does not help in diagnosing tubercular effusion.

Utilidad del pH del líquido pleural en derrames pleurales neoplásicos / Usefulness of pleural fluid pH in neoplastic effusions

Con el objeto de evaluar la utilidad del pH pleural en pleuresías neoplásicas, se estudiaron retrospectivamente 16 casos hospitalizados en el Servicio de Medicina del Hospital Regional de Concepción. Se encontró pH plural normal (>7,30) en nueve enfermos y en 7 pH pleural bajo (< 7,30). Los casos con pH pleural bajo, resultaron con valores significativamente menores de glucosa pleural (p < 0,001), y con valores significativamente elevados de LDH pleural (p< 0,001). En relación a procedimientos diagnósticos, el rendimiento de la citología en líquido pleural para células neoplásticas fue mayor (71 por ciento), en los pacientes con pH pleural bajo. Los enfermos con ph pleural normal, fueron sometidos a pleurodesis con hidróxido de sodio y tuvieron mejor sobrevida (50 por ciento) a dos meses de observación que los no sometidos a este procedimiento (20 por ciento). En resumen, el estudio del pH pleural en derrames pleurales neoplásicos, presta utilidad como índice pronóstico, siendo al mismo tiempo indicativo para decidir una pleurodesis como terapia paliativa, puesto que la pleurodesis tiene una pobre relación costo/efecto si el pH del líquido pleural es menor de 7,30

Urinothorax: a case report.

A case of right sided transudative pleural effusion associated with right sided renal calculi and moderate hydronephrosis is reported. The diagnosis of urinothorax was confirmed by demonstrating a pleural fluid to serum creatinine ratio of greater than one. The relief of obstructive uropathy by surgical treatment of renal calculi resulted in resolution of the pleural effusion.

Criterios diagnosticos para diferenciar trasudados de exudados en liquido pleural / Differential diagnosis between exudate and transudate in pleural effusion

El objetivo fue determinar la utilidad de diferentes critérios para el diagnóstico diferencial entre exudados y trasudados en el líquido pieural. Se realizo la evaluación de todos los pacientes ingresados desde el 15 de enero hasta el 15 de agosto de 1994 con derrame pleural en forma consecutiva. Se obtuvieron las características clínicas y el diagnóstico etiológico de los pacientes (gold standard), y se midieron en líquido pleural y en suero los niveles de proteínas totales, lácticodeshidrogenasa (LDH), albúmina y colesterol. De los 112 pacientes evaluados fueron excluídos 7 por no llegar al diagnóstico final. En base ai diagnóstico etiológico, 47 pacientes (44,8 por ciento) con una edad promedio de 69,6 + 12,07 fueron definidos como trasudados y 58 (52,2 por ciento) con una edad promedio de 66,5 ñ 14,26 como exudados. El 66 por ciento de los trasudados fue secundaria a insuficiencia cardíaca, mientras que el 40 por ciento de los exudados fueron neoplásicos. Utilizando los critérios de Light obtuvimos una exactitud diagnostica (ED) del 82,7 (IC 95 por ciento 73,190,0) por ciento. Sin embargo, cuando se modificaron los valores de corte según Valdés y se agregó al colesterol en líquido pleural y su relación con el suero la ED se elevo al 90,2 (83,296,0) por ciento.(p < O,05); prueba de proporciones. Entre los exudados la relación del colesterol en el líquido pleural/suero > O,3 presentó una sensibilidad del 100 (85,1-100) por ciento para derrames neoplásicos, en tanto que para los exudados no neoplásicos, la sensibilidad fue del 89 (73,2-96,8) por ciento. El test, no obstante, mostró una especificidad de tan sólo 17,4 (6,5633,6) por ciento. El gradiente de albúmina entre el plasma y el líquido pleural no se modificó en pacientes con trasudados que recibían tratamiento diurético, permitiendo definir correctamente un 93 por ciento de los casos. Sin embargo, en los pacientes con trasudados que recibían diuréticos, los critérios clásicos de índice de proteínas definieron correctamente un 66 por ciento (p < O,05). Por lo expresado concluimos que el agregado del dosaje del colesterol en líquido pleural y su relación con el colesterol del suero, sumados a la modificación de los valores de corte establecidos por Light, permitieron mejorar la exactitud diagnostica, siendo el mejor método para segregar trasudado de exudado. La relación de colesterol mostró una muy baja especificidad para diferenciar derrames pleurales exudativos de causa neoplásica. A diferencia de lo que ocurre con el índice de proteínas líquido pleural/suero, el gradiente de albúmina permitió definir correctamente a trasudados, incluso en aquellos pacientes bajo tratamiento diurético.

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.

Importancia del PH del derrame pleural maligno en el pronóstico de la pleurodesis química con bleomycina / Importance of the pH in the pleural effussion

Con el objeto de averiguar si el PH en líquido pleural del paciente con derrame pleural maligno (DPM) altera la eficiencia de la pleurodesis química con Bleomycina, entre los meses de Febrero de 1991 y Enero de 1993 se realizó este procedimiento (Con dosis de un Mg/Kg) a 33 pacientes del hospital Santa Clara de Bogotá con diagnóstico de DPM, comprobado histológicamente en todos los casos mediante biopsia obtenida de tejido pleural. Para ingresar al estudio los pacientes debían cumplir los siguientes requisitos: 1) No haber recibido tratamiento previo para su enfermedad neoplásica (radio, quimioterapia, drenajes previos, etc).2) Reexpansión completa del pulmón y drenaje total del derrame pleural post-toracostomía cerrada. 3) Score de Karnofsky mayor de 60. 4) Medición del PH del líquido pleural. Posteriormente, se hizo control clínico y radiológico de los pacientes, a los 30 días de realizada la pleurodesis química. Tres pacientes no ingresaron a este análisis: Uno por fallecer antes del plazo descrito y dos por haber presentado como complicación empiema. Se comparó la efectividad de la Pleurodesis con Bleomycina en los pacientes que tenían PH del líquido pleural menor a 7,3 con el grupo de pacientes que tenía cifras mayores o iguales, se encontró que la efectividad del procedimiento era de 30 por ciento en el primer grupo y del 85 por ciento en el segundo. Considerando la "respuesta parcial" como efectividad en ambos grupos. Así se sugiere por primera vez en la literatura disponible, que la efectividad de la pleurodesis con Bleomycina, del mismo modo que ocurre con la Tetraciclina, varía de acuerdo al pH previo del líquido pleural del paciente

Exudative pleural effusions in patients over forty years of age--an analysis of seventy-six patients.

A prospective study of 76 consecutive patients over the age of 40 years, with exudative pleural effusion, was undertaken to determine the common causes of such a clinical condition. Malignant pleural effusions were the most common in this series, found in 49 patients (64.47%), all but one being metastatic from elsewhere. Forty were secondary to a carcinoma of the bronchus, 3 from carcinoma of the breast, 1 each from carcinoma of the ovary, oesophagus, and larynx; lymphoma accounted for the remaining 2. Infective causes accounted for 24 of the effusions (31.57%). Of the infections, tuberculosis was the most common, accounting for 17 of the 24. Other infective causes included bacterial empyemas in 4, ruptured amoebic liver abscess in 2, and actinomycosis in 1. Pancreatitis, pulmonary thromboembolism, and a post-cardiotomy syndrome were diagnosed in 1 patient each, while the diagnosis remained unknown in the remaining 5 patients. In 2 patients the diagnosis was made on autopsy.

Pleurologia: líquido pleural e seu manejo diagnóstico / Pleurology: pleural effusion and its diagnostic management

Fora, estudados, retrospectivamente, 249 pacientes com derrame pleural de diversas etiologias, atendidos, de 1979 a a993, no Hospital Universitário Lauro Wanderley e no Serviço de Tórax do Hospital Napoleäo Laureano, sendo realizada revisäo da literatura acerca do assunto. Valoriza-se a contribuiçäo da análise do líquido pleural nos seus aspectos bioquímicos, citológicos e bacteriológicos no diagnostico diferencial dos derrames pleurais, comentando-se inovaçöes em termos de técnicas propedêuticas complementares, e, por fim, discutindo-se sobre a interpretaçäo dos parâmetros mais importantes na análise do líquido pleural como um quadro sinóptico

Estudio derrame pleural / Pleural effusion

En cuarenta pacientes estudiados con base en los criterios de Light, gradiente de albúmina y relación de colesterol el líquido pleural y suero, se encontró una sesibilidad del 100 por ciento para los criterios de Light, 95 por ciento para el gradiente de albúminas y un 69 por ciento para la relación de colesterol, así mismo, la especificidad fue de 57 por ciento y 65 por ciento respectivamente