Role of the Neutrophil-Lymphocyte Ratio in the Differential Diagnosis of Exudative Pleural Effusion

OBJECTIVES: Pleural effusion is a common diagnostic and clinical problem. The differential diagnosis of pleural effusion may be difficult and may require several procedures, including invasive ones. Certain studies have investigated biochemical parameters to facilitate the diagnosis of exudative pleural effusion; however, it remains a challenging problem in clinical practice. We aimed to investigate the potential role of the neutrophil-lymphocyte ratio, which can be easily obtained by determining the cell count of the pleural fluid, in the differential diagnosis of exudative pleural effusion. METHODS: Records from patients who underwent thoracentesis and pleural fluid analysis between May 1, 2013, and March 1, 2015, were obtained from the electronic database of our hospital. The patients who met the inclusion criteria were divided into five groups according to their diagnosis: malignant pleural effusion, para-malignant pleural effusion, para-pneumonic effusion, tuberculosis-related effusion or other. The neutrophil-lymphocyte ratio value was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. The patient groups were compared according to the given parameter. RESULTS: A total of 465 patients who met the inclusion criteria among 1616 patients with exudative pleural effusion were included in the study. The mean neutrophil-lymphocyte ratio value was significantly lower in tuberculosis-related pleural effusion compared to malignant, para-pneumonic and para-malignant effusions (p=0.001, p=0.001, p=0.012, respectively). The areas under the curve for tuberculosis pleurisy compared to malignant, para-pneumonic and para-malignant effusions were 0.38, 0.36, and 0.37, respectively. Lower cut-off values had higher sensitivity but lower specificity for tuberculosis pleurisy, while higher cut-off values had higher specificity but lower sensitivity for this condition. CONCLUSION: The pleural fluid neutrophil-lymphocyte ratio, which is an inexpensive, reproducible, and easily calculated hematological parameter, may facilitate the differential diagnosis of pleural effusion.

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.

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

Serum Vascular Endothelial Growth Factor in Pediatric Patients with Community-Acquired Pneumonia and Pleural Effusion

This study investigated the serum vascular endothelial growth factor (VEGF) levels in children with community-acquired pneumonia. Serum VEGF levels were measured in patients with pneumonia (n=29) and in control subjects (n=27) by a sandwich enzyme-linked immunosorbent assay. The pneumonia group was classified into bronchopneumonia with pleural effusion (n=1), bronchopneumonia without pleural effusion (n=15), lobar pneumonia with pleural effusion (n=4), and lobar pneumonia without pleural effusion (n=9) groups based on the findings of chest radiographs. We also measured serum IL-6 levels and the other acute inflammatory parameters. Serum levels of VEGF in children with pneumonia were significantly higher than those in control subjects (p<0.01). Children with lobar pneumonia with or without effusion showed significantly higher levels of serum VEGF than children with bronchopneumonia. For lobar pneumonia, children with pleural effusion showed higher levels of VEGF than those without pleural effusion. Children with a positive urinary S. pneumonia antigen test also showed higher levels of VEGF than those with a negative result. Serum IL-6 levels did not show significant differences between children with pneumonia and control subjects. Serum levels of VEGF showed a positive correlation with the erythrocyte sedimentation rate in the children with pneumonia. In conclusion, VEGF may be one of the key mediators that lead to lobar pneumonia and parapneumonic effusion.

Derrame Pelural / It spills Pelural

Nota del Editor: la diferenciación entre exudados y transudados constituye el primer paso en el diagnóstico diferencial de los derrames pleurales, desde 1972 el Doctor Richard W. Light propuso unos parámetros como guía para tal diferenciación.Medicina & Laboratorio ha recibido la autorización del propio autor, para la traducción del texto con el fin de que sea una herramienta de consulta en el manejo del ®derrame pleural¼, de vital importancia para la comunidad médica.

Estudos reológicos realizados no líquido pleural com elevada concentraçäo de hémacias / Rheological studies of pleural secretion with high red cell concentration

O líquido pleural procedente de pacientes portadores de determinadas patologias apresenta uma concentraçäo elevada de hemácias, com valortes superiores a 5.000-6.000 hemácias/ml, valores mínimos necessários para obter uma coloraçäo sanguinolenta da soluçäo extraída. Esta causa obrigará posteriores realizaçöes, neste caso de tipo viscosimétrico, sobre amostras adicionadas de anticoagulante. Por causa disto, é necessário a análise cuidadosa das modificaçöes que o anticoagulante (heparina) exerce sobre os valores obtidos dos parâmetros definitórios do modelo de comportamento reológico do líquido pleural. Procedeu-se, pois, a caracterizaçäo reológica das amostras com elevada concentraçäo hemática, passando, a partir dos valores experimentais obtidos, a realizaçäo do teste estimativo de Darmois, comparativo de populaçöes de médias normais conhecidas