Pleural effusion differential diagnosis: Difference between revisions
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==Overview== | ==Overview== | ||
Evaluation of a patient with a pleural effusion requires a thorough clinical history and physical examination in conjunction with pertinent laboratory tests and imaging studies. According to the British Thoracic Society Pleural Disease Guideline 2010, thoracentesis should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. Pleural fluid should always be sent for protein, [[lactate dehydrogenase]], Gram stain, cytology and microbiological culture.<ref name="pmid20696692">{{cite journal | author = Hooper C, Lee YC, Maskell N | title = Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010 | journal = Thorax | volume = 65 Suppl 2 | issue = | pages = ii4–17 | year = 2010| month = August | pmid = 20696692 | doi = 10.1136/thx.2010.136978 | url = | issn = }}</ref> Additional studies which may be indicated in selected cases include pH, [[glucose]], acid-fast bacilli and tuberculosis culture, [[triglyceride]], [[cholesterol]], [[amylase]], and [[hematocrit]]. Light's criteria is applied to distinguish the fluid between transudative or exudative.<ref name="pmid4642731">{{cite journal | author = Light RW, Macgregor MI, Luchsinger PC, Ball WC | title = Pleural effusions: the diagnostic separation of transudates and exudates | journal = Ann. Intern. Med. | volume = 77 | issue = 4 | pages = 507–13 | year = 1972 | month = October | pmid = 4642731 | doi = | url = | issn = }}</ref> A broad array of underlying conditions result in exudative effusions, while a limited number of disorders are assoicated with transudative effusions, which include congestive heart failure, cirrhosis, nephrotic syndrome, peritoneal dialysis, hypoalbuminemia, urinothorax, atelectasis, constrictive pericarditis, trapped lung, superior vena | Evaluation of a patient with a pleural effusion requires a thorough clinical history and physical examination in conjunction with pertinent laboratory tests and imaging studies. According to the British Thoracic Society Pleural Disease Guideline 2010, [[thoracentesis]] should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. Pleural fluid should always be sent for protein, [[lactate dehydrogenase]], [[Gram stain]], [[cytology]] and microbiological culture.<ref name="pmid20696692">{{cite journal | author = Hooper C, Lee YC, Maskell N | title = Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010 | journal = Thorax | volume = 65 Suppl 2 | issue = | pages = ii4–17 | year = 2010| month = August | pmid = 20696692 | doi = 10.1136/thx.2010.136978 | url = | issn = }}</ref> Additional studies which may be indicated in selected cases include pH, [[glucose]], acid-fast bacilli and [[tuberculosis]] culture, [[triglyceride]], [[cholesterol]], [[amylase]], and [[hematocrit]]. Light's criteria is applied to distinguish the fluid between transudative or exudative.<ref name="pmid4642731">{{cite journal | author = Light RW, Macgregor MI, Luchsinger PC, Ball WC | title = Pleural effusions: the diagnostic separation of transudates and exudates | journal = Ann. Intern. Med. | volume = 77 | issue = 4 | pages = 507–13 | year = 1972 | month = October | pmid = 4642731 | doi = | url = | issn = }}</ref> A broad array of underlying conditions result in exudative effusions, while a limited number of disorders are assoicated with transudative effusions, which include [[congestive heart failure]], [[cirrhosis]], [[nephrotic syndrome]], [[peritoneal dialysis]], [[hypoalbuminemia]], [[urinothorax]], [[atelectasis]], [[constrictive pericarditis]], [[trapped lung]], [[superior vena cava obstruction]], and duropleural fistula. | ||
==Differentiating Pleural Effusion from other Diseases== | ==Differentiating Pleural Effusion from other Diseases== | ||
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|- | |- | ||
| Infectious | | Infectious | ||
| Bacterial pneumonia, tuberculous effusion, fungal disease, atypical | | Bacterial [[pneumonia]], tuberculous effusion, fungal disease, atypical pneumonia, [[nocardia]], [[actinomyces]], [[subphrenic abscess]], [[hepatic abscess]], [[splenic abscess]], [[hepatitis]], parasites | ||
|- | |- | ||
| Iatrogenic | | Iatrogenic | ||
| Drug-induced, esophageal perforation, esophageal sclerotherapy, central venous catheter misplacement or migration, enteral feeding tube in pleural space | | Drug-induced, [[esophageal perforation]], esophageal sclerotherapy, central venous catheter misplacement or migration, enteral feeding tube in pleural space | ||
|- | |- | ||
| Vasculitis | | Vasculitis | ||
| Wegener granulomatosis, Churg–Strauss syndrome, familial Mediterranean fever | | [[Wegener's granulomatosis|Wegener granulomatosis]], Churg–Strauss syndrome, [[familial Mediterranean fever]] | ||
|- | |- | ||
| Malignancy | | Malignancy | ||
| Carcinoma, lymphoma, mesothelioma, leukemia, chylothorax | | [[Carcinoma]], [[lymphoma]], [[mesothelioma]], [[leukemia]], [[chylothorax]] | ||
|- | |- | ||
| Inflammatory | | Inflammatory | ||
| Pancreatitis, benign asbestos pleural effusion (BAPE), pulmonary infarction, radiation therapy, sarcoidosis, post-cardiac injury syndrome (PCIS), hemothorax, acute respiratory distress syndrome (ARDS), cholesterol effusion | | [[Pancreatitis]], benign [[asbestos]] pleural effusion (BAPE), [[pulmonary infarction]], [[radiation therapy]], [[sarcoidosis]], post-cardiac injury syndrome (PCIS), [[hemothorax]], [[acute respiratory distress syndrome]] (ARDS), cholesterol effusion | ||
|- | |- | ||
| Increased negative intrapleural pressure | | Increased negative intrapleural pressure | ||
| Atelectasis, trapped lung | | [[Atelectasis]], [[trapped lung]] | ||
|- | |- | ||
| Connective tissue disease | | Connective tissue disease | ||
| Lupus pleuritis, rheumatoid | | Lupus pleuritis, [[rheumatoid pleuritis]], mixed connective tissue disease, [[Sjögren's syndrome|Sjögren syndrome]] | ||
|- | |- | ||
| Endocrine dysfunction | | Endocrine dysfunction | ||
| Hypothyroidism, ovarian hyperstimulation syndrome | | [[Hypothyroidism]], [[ovarian hyperstimulation syndrome]] | ||
|- | |- | ||
| Lymphatic abnormalities | | Lymphatic abnormalities | ||
| Chylothorax, yellow nail syndrome, lymphangiomyomatosis, lymphangiectasis | | [[Chylothorax]], [[yellow nail syndrome]], [[lymphangiomyomatosis]], [[lymphangiectasis]] | ||
|- | |- | ||
| Movement of fluid from abdomen to pleural space | | Movement of fluid from abdomen to pleural space | ||
| Acute pancreatitis, pancreatic pseudocyst, Meigs syndrome, chylous ascites | | Acute pancreatitis, pancreatic pseudocyst, [[Meigs syndrome]], [[chylous ascites]] | ||
|- | |- | ||
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Revision as of 15:48, 6 April 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]
Overview
Evaluation of a patient with a pleural effusion requires a thorough clinical history and physical examination in conjunction with pertinent laboratory tests and imaging studies. According to the British Thoracic Society Pleural Disease Guideline 2010, thoracentesis should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. Pleural fluid should always be sent for protein, lactate dehydrogenase, Gram stain, cytology and microbiological culture.[1] Additional studies which may be indicated in selected cases include pH, glucose, acid-fast bacilli and tuberculosis culture, triglyceride, cholesterol, amylase, and hematocrit. Light's criteria is applied to distinguish the fluid between transudative or exudative.[2] A broad array of underlying conditions result in exudative effusions, while a limited number of disorders are assoicated with transudative effusions, which include congestive heart failure, cirrhosis, nephrotic syndrome, peritoneal dialysis, hypoalbuminemia, urinothorax, atelectasis, constrictive pericarditis, trapped lung, superior vena cava obstruction, and duropleural fistula.
Differentiating Pleural Effusion from other Diseases
Exudative Pleural Effusions
| Etiology | Underlying conditions |
| Infectious | Bacterial pneumonia, tuberculous effusion, fungal disease, atypical pneumonia, nocardia, actinomyces, subphrenic abscess, hepatic abscess, splenic abscess, hepatitis, parasites |
| Iatrogenic | Drug-induced, esophageal perforation, esophageal sclerotherapy, central venous catheter misplacement or migration, enteral feeding tube in pleural space |
| Vasculitis | Wegener granulomatosis, Churg–Strauss syndrome, familial Mediterranean fever |
| Malignancy | Carcinoma, lymphoma, mesothelioma, leukemia, chylothorax |
| Inflammatory | Pancreatitis, benign asbestos pleural effusion (BAPE), pulmonary infarction, radiation therapy, sarcoidosis, post-cardiac injury syndrome (PCIS), hemothorax, acute respiratory distress syndrome (ARDS), cholesterol effusion |
| Increased negative intrapleural pressure | Atelectasis, trapped lung |
| Connective tissue disease | Lupus pleuritis, rheumatoid pleuritis, mixed connective tissue disease, Sjögren syndrome |
| Endocrine dysfunction | Hypothyroidism, ovarian hyperstimulation syndrome |
| Lymphatic abnormalities | Chylothorax, yellow nail syndrome, lymphangiomyomatosis, lymphangiectasis |
| Movement of fluid from abdomen to pleural space | Acute pancreatitis, pancreatic pseudocyst, Meigs syndrome, chylous ascites |
References
- ↑ Hooper C, Lee YC, Maskell N (2010). "Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii4–17. doi:10.1136/thx.2010.136978. PMID 20696692. Unknown parameter
|month=ignored (help) - ↑ Light RW, Macgregor MI, Luchsinger PC, Ball WC (1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Ann. Intern. Med. 77 (4): 507–13. PMID 4642731. Unknown parameter
|month=ignored (help)