causes
2. Pleural effusion associated with pulmonary embolism can be:
A. An exudate
B. A transudate
C. Bloody
D. All of the above
D : PE account 10 % of exudates effusion 75% > transudate 25% as well as hemorrhagic
A 34 year old male as admitted to our hospital with progressive shortness of breath. A chest X-ray reveals a large right sided unilateral pleural effusion. An ultrasound guided pleural aspirate is undertaken, the results are shown below:
Pleural fluid pH 7.16
Pleural protein 45 g/dl
Serum protein 50 g/dL
Pleural LDH 342 IU/L
Serum LDH ULN 280 IU/L
Gram stain/ microscopy – no organisms or polymorphs seen
Cytology – atypical cells
What is the most correct response with regards to the pleural fluid analysis
(A) Transudate as the pleural protein is less than the serum protein
(B) Transudate as the serum LDH is less than the pleural LDH
(C) Exudate as the pleural pH < 7.2
(D) Exudate as the pleural protein is > two-thirds the serum protein
(E) Exudate as the pleural LDH : serum LDH is >0.6
E: This is clearly an exudate as it fulfils lights criterion (1: pleural protein: serum protein >0.5, 2: pleural LDH: serum LDH >0.6 or 3: pleural fluid LDH >2/3 ULN of serum LDH). Pleural pH is not a part of lights criterion. A pH <7.2 is strongly indicative of a complicated parapneumonic effusion.
Which of the following would result in the classification of a pleural infection as Complicated Parapneumonic?
A. normal glucose & pH >7.2, gram stain neg
B. pH < 7.2, gram stain/culture +, glucose < 60 , no pus
C. pH < 7.2, gram stain/culture +, frank pus
B , IF there is pus called empyma
what are the drug that induced PE ? MENTION 3
Nitrofurantioin , bromocriptine , amidronre
60 years old male patient , reveals 15 pack year smoking history, recent "flu" that resulting in cough with purulent sputum and fevers. Poor dentition but no swallowing difficulties, positive risk factor for HIV, but most recent testing several years ago was negative. No recent travel, no TB contacts known. No joint pains, rashes, mouth ulcers, alopecia. No history of heart, kidney, liver disease. No risks for PE. On examination, he is febrile at 39.9, RR 28, O2 sat on room air 84, HR 128, BP 108/78. He appears toxic. Dull percussion on lower 1/2 L hemithorax, decreased breath sounds and tactile fremitus lower 1/2 L hemithorax but with bronchial breathing above. Egophony and increased tactile fremitus above level of effusion. No evidence of JVP, pedal edema and normal S1 and S2 without adventitious sounds. Remainder of exam unremarkable. Pleural fluid frankly purulent and foul smelling, pH 6.9, glucose 1.1, LDH 780, TP 48, serum LDH 122, TP 80, glucose 5.1. Many neutrophils and gram stain positive G+ cocci in pairs. What should be done first to manage this patient?
A. Surgical management
B. Broad-spectrum antibiotics
C. Drained and a catheter left in place
EXUDATIVE EMPYMA - C : Drained and a catheter left in place
According to the diagnostic/therapeutic algorithm, the patient should be drained and a catheter left in place. He should be empirically treated with broad spectrum antibiotics awaiting microbiology results. These infections are often poly-microbial. Here you would ensure coverage for Strep. pneumonia based on the initial gram stain. He will require prolonged drainage and antibiotics (at least 6 weeks or until resolution). If he fails to improve he may be considered for surgical management.
A 78 year old patient with metastatic gastric adenocarcinoma is admitted with progressive dyspnoea with super-imposed type 2 respiratory failure. On examination he has stony dullness to both bases, greatest on the right side with bronchial breathing above this area. CT of his chest confirms a large pleural effusion bilaterally. He has both sides drained. The initial analysis shows an exudative effusion and cytology shows atypical cells without any malignant cells seen.
What is the most CORRECT answer ?
(A) Malignancy is the most common cause of an exudative pleural effusion
(B) Transudative causes are more common than exudative causes of pleural effusion
(C) Talc pleurodesis would be preferred over insertion of an indwelling catheter for the management of his effusion
(D) Pleural fluid cytology has at best a sensitivity of 60%, therefore cannot rule out malignancy as a cause
(E) Type 2 respiratory failure is not associated with large pleural effusions
D: The sensitivity of cytology is at best 60%. However it is highly specific. Talc pleurodesis obliterates the pleural space in 80% of cases. In the TIME-2 trial, patients with malignant pleural effusions were randomised to receive either standard talc pleurodesis or an indwelling pleural catheter, and the study found no difference between the two arms in the primary end point of patient reported dyspnoea at six weeks. Exudates account for 57% of all pleural effusions according to the BMJ review, and of these lung parenchymal infections 25% are more common than malignancy 15%. Type 2 respiratory failure may occur due to a failure of ventilation, given decreased tidal volume not overcome by increased respiratory rate.
She is a 40 years old , previously work in the laundry department of a TB hospital. Not known asbestos exposures. 50 pack-year smoking history, past medical history significant for cryptogenic cirrhosis and a diagnosis of lupus. There is no history of heart failure. Physical exam reveals RR 16, afebrile, not in acute distress, trachea not deviated, dull to percussion lower 1/3 R hemithorax, egophony and increased tactile fremitus above level of effusion, no evidence of JVP, pedal edema and normal S1 and S2 without adventitious sounds, and no ascites. Diagnostic Thoracentesis and Pleural Fluid Analysis were performed. Pleural fluid findings: pH 7.32, LDH 302, total proteins 48. Serum LDH 124, total proteins 78. Is this a transudate or exudate?
A. Transudate
B. Exudate
C. Pedal edema
B : Characteristics of TB pleural fluid analysis :
serosang appear / WBC 5-10,000 lymph , RBC < 10,000 , PH & GLU ( N or low ) + AFB & +Ve ADA
this is a 60 years old male patient , reveals 15 pack year smoking history, had recent "flu" that resulting in cough with purulent sputum and fevers. Poor dentition but no swallowing difficulties, positive risk factor for HIV, but most recent testing several years ago was negative. No recent travel, no TB contacts known. No joint pains, rashes, mouth ulcers, alopecia. No history of heart, kidney, liver disease. No risks for PE. On examination, he is febrile at 39.9, RR 28, O2 sat on room air 84, HR 128, BP 108/78. He appears toxic. Dull percussion on lower 1/2 L hemithorax, decreased breath sounds and tactile fremitus lower 1/2 L hemithorax but with bronchial breathing above. Egophony and increased tactile fremitus above level of effusion. No evidence of JVP, pedal edema and normal S1 and S2 without adventitious sounds. Remainder of exam unremarkable. Pleural fluid frankly purulent and foul smelling with pus , pH 6.9, glucose 1.1, LDH 780, TP 48, serum LDH 122, TP 80, glucose 5.1. Many neutrophils and gram stain positive G+ cocci in pairs. What do these results indicate?
A. Exudative empyema
B. complicated parapneumonic
C. Transudative empyema
D. Transudative simple parapneumonic
A
what is meigs' syndrome ?
bening ovarian tumor complicated with ascities & plural effusion
She is A 40 years old female previously work in the laundry department of a TB hospital. No known asbestos exposures. 50 pack-year smoking history, past medical history significant for cryptogenic cirrhosis and a diagnosis of lupus. There is no history of heart failure. Physical exam reveals RR 16, afebrile, not in acute distress, trachea not deviated, dull to percussion lower 1/3 R hemithorax, egophony and increased tactile fremitus above level of effusion, no evidence of JVP, pedal edema and normal S1 and S2 without adventitious sounds, and no ascites. Diagnostic Thoracentesis and Pleural Fluid Analysis were performed. Pleural fluid findings: pH 7.32, LDH 302, total proteins 48. Serum LDH 124, total proteins 78. Culture and sensitivity and AFB- negative, cell count does not suggest infections, cytology negative. ANA 1:160 and remainder of connective tissue work-up negative. LFTs in normal range, no fluid in abdominal imaging and no masses. Pleural biopsy showed non-specific changes. What do you do next?
A. Treat for infection
B. Treat with anti-inflammatories
C. Biopsy liver
D. Thoracoscopy
D : Thoracoscopy-despite standard pleural fluid analysis 25% exudative effusions undiagnosed. pleural fluid cytology alone only 40% sensitive but can increase to 80% with 3 samples blind needle biopsy only 44% sensitive (many false negatives!. thoracoscopy above 90% sensitive for malignancy and tb. the patient went on to thoracoscopy and biopsies of the parietal pleura revealed adenocarcinoma, with special pathology stains indicating that it was suspicious for a gi primary tumour. the cytology from the pleural fluid was sent at the time of thoracoscopy also revealed malignant cells consistent with adenocarcinoma.
mention 5 causes of hemothorax ( hct eff/ hct blood > 50 % ) ?
truma , PE , malignancy , coagulopathy , aortic dissection or aneurysm , pulmonary vascular malformation
A 52 year old male who suffers from chronic alcoholism is seen in emergency after failure to cope. he is hypotensive and tachycardic. his chest X-ray shows a large left sided pleural effusion that causes midline shift. Initial diagnostic thoracocentecis shows an exudative effusion with gram stain showing gram positive rods. His pleural pH is 7.16. he underwent a thoracotomy and drainage. Unfortunately his inflammatory markers continued to rise and he had persistent low grade temperatures. A repeat Chest X-ray showed re-accumulation of the fluid. A chest drain is re-inserted. In addition to the chest drain, what additional step would you take?
(A) TpA (alteplase) + DNAse alpha into drain
(B) TpA alone
(C) DNAse alpha alone
(D) Urokinase alone
(E) Streptokinase and Urokinase
A: Combination of TpA and DNAse alpha is better than either alone according to the MIST-2 trial published in the new england journal of medicine. It improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay compared to single agent therapy