10/7/16 Intern Morning Report – Pleural Effusion

CC: 3 days of shortness of breath

ID: 82 yo Hispanic male with HTN, DLD, DM, COPD, HFpEF with >50 pack-year smoking history presents with 3 days of shortness of breath.  He was found to have a white out of his R lung and thoracentesis of the pleural effusion was markedly bloody.  Initial pleural fluid studies revealed an exudate with ADA of 21, negative cytology (x3), and subsequently, a normal pleural biopsy.  On further imaging, he was found to have bulky lymphadenopathy and is pending a lymph node biopsy.

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Pearls from morning report:

  • When you have a bloody pleural effusion, make sure to check the pleural fluid hematocrit!  A frank hemothorax is when pleural fluid hematocrit > 50% of peripheral hematocrit.  Otherwise, grossly bloody effusions are associated with trauma, malignancy, or TB.
  • When you have an undiagnosed exudative effusion when TB or malignancy is suspected, get a thoracoscopic pleural biopsy!  The combination of histology and culture of pleural biopsy tissue will establish the diagnosis of TB in up to 90% of patients.
  • > 5% mesothelial cells in pleural fluid makes TB very unlikely

Random trivia:

Dr. Light is still a practicing physician at Vanderbilt!  In his words, here’s how he devised Light’s Criteria.


Want to read more?

Clinical Practice: Pleural Effusions (New England Journal of Medicine)
Diagnostic Approach to Pleural Effusions in Adults (American Family Physician)


References: 

Light RW, Erozan YS, Ball WC. Cells in pleural fluid: their value in differential diagnosis. Arch Intern Med. 1973;132(6):854-860.

Hooper C, Lee YC, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii4-ii17.

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