Images of the month 1: 'Soy sauce' pleural effusion: what causes black pleural fluid?

We present a case of black pleural fluid following thoracic trauma. The unusual dark colour most strikingly resembled soy sauce as independently commented upon by multiple treating physicians. The black colouration could not be fully accounted for by haemothorax or cholethorax, so other differential diagnoses were investigated, including Aspergillus niger infection and malignant melanoma. The cause, however, was thought to be due to staining of the fluid with carbon deposited in the pleural space from the non-volatilised impurities from smoking crack cocaine. A novel use of a point-of-care urine toxicology assay confirmed the presence of cocaine in the pleural fluid. Considering a broad range of differential diagnoses is needed to avoid missing important causes of unusual pleural effusions.

The quality of medical care during an acute exacerbations of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a significant cause of global morbidity and mortality, with a substantial economic impact. Acute exacerbations of COPD (AECOPD) represent a dramatic event in the course of the disease; is an important cause of morbidity and the fourth cause of mortality worldwide. During the hospitalization for AECOPD mortality is 10%. AECOPD are also associated with a significant reduction of functional capacity and health-related quality of life. Despite these alarming evidence-based data the response of the healthcare system globally is not adequate to the gravity of the situation. A recently published study done in a Canadian hospital reveals that the treatment of the AECOPD is sub-optimal. The management of the COPD exacerbations prior, during and after the hospitalization showed inadequate adherence of the physicians (respirologists, internists and hospitalists) to the current guidelines. This review outlines the worrisome findings of this study and the proposed measures suggested by the authors in order to optimize the management of AECOPD.