Recurrent pleural effusion as a rare manifestation after prolonged PD1 inhibitor (camrelizumab)-based immunotherapy: A case report.

Immune-related adverse events (irAEs) pose a significant challenge for the widespread adoption of immuno-oncology therapies, but their symptoms can vary widely. In particular, the relationship between irAEs and pleural effusion (PE) in patients with advanced non-small cell lung cancer (NSCLC) remains unclear. In this report, we present the case of an advanced NSCLC patient who developed persistent PE despite receiving camrelizumab (an anti-programmed death receptor 1 [PD-1] antibody) and chemotherapy as first-line treatment. While the patient's tumor biomarkers decreased after multiple cycles of treatment, the PE persisted despite negative findings on cytology and pleural biopsy. Additionally, the use of anti-angiogenic drugs failed to alleviate the PE. Screening for rheumatic connective tissue markers and tuberculosis yielded negative results, but intrathoracic dexamethasone injections in two doses resulted in a significant reduction of the PE. This case suggests that PE may represent a rare type of irAE that should be monitored for during prolonged immuno-oncology therapy.

A multidisciplinary approach for the diagnosis of benign asbestos pleural effusion: a single-center experience.

BACKGROUND: There is little detailed information regarding benign asbestos pleural effusion (BAPE). It is frequently misdiagnosed because of lack of a standardized diagnostic approach and criteria. The present study aimed to better characterize BAPE and outline a diagnostic approach for this disease. METHODS: Complete clinical data of 11 consecutive patients with BAPE were prospectively collected and analysed. A multidisciplinary team (MDT) was involved in discussing the suspected cases of BAPE. The team was comprised of thoracic physicians, radiologists and pathologists. A multidisciplinary practical diagnostic approach for BAPE was introduced. RESULTS: Six patients had respiratory symptoms, but another 5 were asymptomatic. All the patients had an asbestos exposure and the median duration was 23.9 years (rang, 12-36 years). The median level of lactate dehydrogenase (LDH), adenosine deaminase (ADA), proteins and carcinoembryonic antigen (CEA) in the pleural fluid (PF) were 221.4 U/L (range, 189.8-11,325 U/L), 21 U/L (rang, 14-247 U/L), 48.3 g/dL (range, 35.2-53.2 g/dL) and 3.46 mg/mL (range, 0.84-4.54 mg/mL), respectively. Five patients had pleural plaques, 2 had diffuse pleural thickening (DPT), 1 had asbestosis, and 1 had round atelectasis. The pleural biopsy specimens showed a benign fibrotic pleura in all case. The symptoms and pleural pulmonary radiologic findings remained stable during the follow-up. CONCLUSIONS: BAPE is diagnosed by exclusion. A suspected diagnosis of BAPE with an asbestos exposure should be considered, especially with the presence of pleural plaques, and/or DPT, and rounded atelectasis. The MDT-based diagnostic approach may reduce misdiagnosis.

Diagnostic procedure for idiopathic eosinophilic pleural effusion: a single-center experience.

BACKGROUND: Eosinophilic pleural effusion (EPE) is attributed to several well-recognised causes. However, some patients remain idiopathic, even after thorough clinical work-up. The present study aimed to better characterize idiopathic EPE (IEPE) and to outline the diagnostic procedure for this disease. METHODS: Complete clinical data of 11 consecutive patients with IEPE were prospectively collected and analysed. Preliminary diagnostic procedure of IEPE in our hospital was performed. RESULTS: All the 11 patients had respiratory symptoms and unilateral pleural effusion (PE) occurred in 4 patients. The mean percentage of eosinophils in PE was 22.4% (range, 12.4-50.5%). Lactate dehydrogenase, adenosine deaminase, proteins and carcinoembryonic antigen in PE were 246.0 U/L (range, 89.8-421.9 U/L), 13.8 U/L (range, 1.8-24.0 U/L), 42.6 g/dl (range, 32.8-52.6 g/dl) and 2.17 mg/mL (range, 0.46-4.31 mg/mL), respectively. Parasite-specific IgG antibody in blood and parasite eggs in stool were both negative. No evidence of tuberculosis or malignancy was observed in pleural biopsy. Symptoms and abnormal pulmonary imaging were eliminated after glucocorticoid use. CONCLUSIONS: IEPE is a diagnosis of exclusion. Patients with EPE without a clear cause should be asked to provided complete medical, surgical and drug-related histories. A thorough work-up is essential. Moreover, we recommend follow-up after the use of glucocorticoid until effusion resolves. TRIAL REGISTRATION: GYFYY. Registration No: GYFYY20150901221. Registered time: 1 September 2015. Date of enrolment of the first participant to the trial: 22 January 2016.

Retrospective study of pleural parasitic infestations: a practical diagnostic approach.

BACKGROUND: Pleural parasitic infestation (PPI) is a disease prevalent in certain parts of the world. It is frequently misdiagnosed due to its lack of standardized diagnostic criteria. The purpose of this study was to evaluate the clinical characteristics of PPI patients and develop a practical diagnostic approach for PPI. METHODS: A retrospective study was conducted by reviewing the medical records of 11 patients with PPI. A practical diagnostic approach was proposed based on the unique laboratory findings. RESULTS: All patients demonstrated respiratory symptoms, including shortness of breath, cough, fever, chest pain, excessive sputum and hemoptysis. Leukocytosis (> 10,000/µL) and eosinophilia (> 500/µL) of peripheral blood were present in 45.5 and 36.4% patients, respectively. The mean concentrations of pleural effusion lactate dehydrogenase (LDH), adenosine deaminase (ADA), protein and carcinoembryonic antigen (CEA) were 338.2 U/L (range, 61-667 U/L), 11.6 U/L (range, 0.1-28.2 U/L), 43.7 g/dL (range, 21.9-88.1 g/dL), and 1.84 mg/mL (range, 0.28-4.8 mg/mL), respectively. The mean percentage of eosinophils in the pleural effusion was 19.5% (10.5-41%). Blood test was positive for parasite-specific IgG antibody in 9 patients, including 4 for Paragonimus westermani, 3 for Taenia solium, 1 for Clonorchis sinensis and 1 for Echinococcus granulosus. Eggs of Clonorchis sinensis were detected in the stool of two patients. Sparganum was found in the pleural effusion of one patient. Respiratory symptoms and abnormal appearances in pulmonary radiographic examination were disappeared in all patients who received anti-parasitic treatment. CONCLUSIONS: In patients with unexplained pleural effusion, parasite-specific IgG antibody tests should be performed when pleural fluid testing shows eosinophilic pleural effusion. It is preferable to consider the diagnosis of PPI in clinical practice when serum parasite-specific IgG antibody test is positive.

The pleural fluid lactate dehydrogenase/adenosine deaminase ratio differentiates between tuberculous and parapneumonic pleural effusions.

BACKGROUND: Although pleural fluid lactate dehydrogenase (LDH) and adenosine deaminase (ADA) levels are often used to distinguish between tuberculous pleural effusion (TPE) and parapneumonic pleural effusion (PPE), this can be challenging as the LDH level may vary from normal to severely increased in PPE and a significantly elevated ADA is frequently measured in both conditions. In this study, we evaluated use of the pleural fluid LDH/ADA ratio as a new parameter to discriminate TPE from PPE. METHODS: A retrospective study was conducted in patients with pathologically-confirmed TPE (n = 72) and PPE (n = 47) to compare pleural fluid LDH and ADA levels and LDH/ADA ratios between the 2 groups. A receiver operating characteristic (ROC) curve was constructed for identifying TPE. RESULTS: The median pleural fluid LDH and ADA levels and LDH/ADA ratios in the TPE and PPE groups were: 364.5 U/L vs 4037 U/L (P < .001), 33.5 U/L vs 43.3 U/L (P = .249), and 10.88 vs 66.91 (P < .0001), respectively. An area under the ROC curve of 0.9663 was obtained using the LDH/ADA ratio as the indicator for TPE identification, and the sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were, respectively, 93.62%, 93.06%, 13.48, and 0.068 at a cut-off level of 16.20. CONCLUSIONS: The pleural fluid LDH/ADA ratio, which can be determined from routine biochemical analysis, is highly predictive of TPE at a cut-off level of 16.20. Measurement of this parameter may be helpful for clinicians in distinguishing between TPE and PPE.

Combined ultrasound-guided cutting-needle biopsy and standard pleural biopsy for diagnosis of malignant pleural effusions.

BACKGROUND: The most efficient approach to diagnose malignant pleural effusions (MPEs) is still controversial and uncertain. This study aimed to evaluate the utility of a combined approach using ultrasound (US)-guided cutting-needle biopsy (CNB) and standard pleural biopsy (SPB) for diagnosing MPE. METHODS: Pleural effusions were collected from 172 patients for biochemical and microbiological analyses. US-guided CNB and SPB were performed in the same operation sequentially to obtain specimens for histological analysis. RESULTS: US-guided CNB and SPB procedures provided adequate material for histological analysis in 90.7 and 93.0% of cases, respectively, while a combination of the 2 techniques was in 96.5% of cases. The sensitivity, specificity, positive-predictive value (PPV), negative-predictive value (NPV) and diagnostic accuracy of US-guided CNB versus SPB were: 51.2 vs 63.4%, 100 vs 100%, 100 vs 100%, 64.9 vs 72.2% and 74.4 vs 81.3%, respectively. When CNB was combined with SPB, the corresponding values were 88.6, 100, 100, 88.6 and 93.9%, respectively. Whereas sensitivity, NPV and diagnostic accuracy were not significantly different between CNB and SPB, the combination of CNB and SPB significantly improved the sensitivity, NPV and diagnostic accuracy versus each technique alone (p < 0.05). Significant pain (eight patients), moderate haemoptysis (two patients) and chest wall haematomas (two patients) were observed following CNB, while syncope (four patients) and a slight pneumothorax (four patients) were observed following SPB. CONCLUSIONS: Use of a combination of US-guided CNB and SPB afforded a high sensitivity to diagnose MPEs, it is a convenient and safe approach.

Utility of contrast-enhanced ultrasound with SonoVue in biopsy of small subpleural nodules.

OBJECTIVES: This study aimed to evaluate the diagnostic accuracy and complication rates of contrast-enhanced ultrasound (CEUS)-guided biopsy of small subpleural nodules with SonoVue. METHODS: CEUS-guided biopsies with SonoVue and conventional ultrasound were performed to determine nodule size, texture and biopsy route. After baseline ultrasonography, all patients received an intravenous injection of 4 mL of SonoVue, followed by 5 mL of saline flush. CEUS was obtained using a convex probe and contrast-specific imaging software. The lesion was observed using a contrast agent. Biopsies were performed during real-time visualisation of the target lesion. RESULTS: A total of 51 patients (34 males and 17 females; average age, 54.8 ± 5.8 years) with subpleural nodules were enrolled. The median nodule size was 1.92 ± 0.75 cm (0.9-2.5 cm). Forty-eight of 51 procedures (94.1%) provided adequate material for histological analysis. Thirty patients (62.5%) were malignant and 18 patients (37.5%) were benign at the definitive diagnosis. The true positive and true negative result were 28 (58.3%) and 18 (37.5%), no false positive result was seen and two (4.2%) provided a false negative result. The sensitivity, specificity, positive and negative predictive values for the malignant diagnosis were 93.3, 100, 100 and 90%, respectively. The diagnostic accuracy was 95.8% (46/48), the standard error and the 95% CI were 2.8% and 86%-99%. An asymptomatic pneumothorax was present in one patient with no chest tube placement required. A small amount of hemoptysis was observed in another patient, which stopped spontaneously without treatment. CONCLUSIONS: CEUS-guided biopsy with SonoVue exhibits high diagnostic accuracy and low complication rates. It is especially advantageous for biopsies of small subpleural nodules.