Idiopathic pleuritis: Truth or myth?
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Objective: To determine the presence or not of idiopathic pleuritis in patients that underwent medical thoracoscopy(MT) Materials and methods: Retrospective study of 750 patients (1998-2011) that underwent MT under conscious and local sedation. Assessment of clinicopathological status/results and clinical follow up in the thoracic outpatients clinic. Results: Thirty two patients were excluded from the group of patients with undiagnosed pleural effusion (histology report:systemic disease or parapneumonic effusion).152/770 patients(20.2%)were classified as idiopathic pleuritis (sinister and any other underlying pathology was excluded) and underwent long term surveillance. Mean surveillance was 4.1 years(2months–9years). During that time 2/152 was diagnosed with lung cancer. 3/152 presented pleural effusion recurrence without any signs of malignancy/systemic disease and underwent talc pleurodesis. Conclusions: Undiagnosed pleural effusions constitute a large group among the pleural effusion patients. This group is associated with favourable patient outcome and encouraging prognosis especially when the diagnosis is set by MT under conscious sedation.Keywords:
Thoracoscopy
Parapneumonic effusion
Pleurodesis
Pleurisy
Pleural disease
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Background: A pleural effusion represents the disruption of the normal mechanisms of formation and drainage of fluid from the pleural space. Pleural effusions are associated with diseases of varied etiologies and often carry a grave prognosis.Objective: To evaluate the common cause of pleural effusion in developing country and also to compare to that of developed countries.Methods: This is a prospective observational study. Fifty four patients, diagnosed with pleural effusion on admission were randomly selected from I April 2016 to 30 September 2016 in Medicine ward of Khulna medical college hospital. Etiologic diagnosis was established by sequential clinical history and findings on physical examination, laboratory tests, chest radiograph, CT Scan of chest and pleural fluid analysis. Patients who remained undiagnosed were subjected to fibre-optic bronchoscopy, thoracoscopic pleural biopsy, and histopathology.Results : Etiologic diagnosis of pleural effusion was established in 50 (92.59%); tuberculosis 25 (46.29%), parapneumonia 10 (18.52%) malignancy 7 (12.96%) nephrotic syndrome 3 (5.55%),cirrhosis of liver disease 2 (3.71%) congestive cardiac failure 2 (3.71%), systemic lupus erythematosus I (1.85%). 4 patients (7.41%) remain undiagnosed. Among subjects, exudative pleural effusion was 43 (79.63%) and transudative 11 (21 57%). Among exudative pleural effusion sputum for AFB positive 15 (34.88%), FNAC 10 (23%), fibreoptic bronchoscopy was positive 2 (4.6%), gene expart test for tuberculosis positive in 5 (11.62%).Conclusions: Most of the pleural effusion cases are diagnosed as tuberculosis, Early and adequate treatment results in complete recovery of the patient.Bang Med J (Khulna) 2016; 49 : 27-30
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Pleuroscopy is the test of choice for patients with suspected malignant pleural effusion and negative cytology. Biopsies negative for malignancy are frequently attributed to non-specific pleuritis, which poses a dilemma in patients with a known active malignancy, raising concern for a false-negative result. Our primary objective was to determine the outcomes of patients with active malignancy who had a non-malignant diagnosis on pleuroscopy.Retrospective review of all pleuroscopy cases from January 2005 to January 2015 at our institution was conducted. Biopsies were categorized by histopathology as malignant, eosinophilic or non-specific pleuritis. Malignant histopathology was considered a true positive. Eosinophilic or non-specific pleuritis was categorized as malignant, if malignancy was later identified during follow-up, or chemotherapy induced, possible radiation induced, other paramalignant, other benign or idiopathic.Of the 199 pleuroscopy cases reviewed, 172 (86%) had a history of active malignancy. On histopathology, 73 (42%) had malignancy, 9 (5%) had eosinophilic pleuritis and 90 (52%) had non-specific pleuritis. Three patients with non-specific pleuritis were diagnosed with malignancy at follow-up. Pleuritis in 24 patients was chemotherapy induced, 27 were possibly radiation induced, 11 were other paramalignant and 3 were other benign. Idiopathic pleuritis was diagnosed in 31 patients. Patients were monitored for a mean of 23 ± 11 months.The prevalence of malignant pleural disease was lower than expected for our patient population. Patients with no malignancy on histopathology were most likely to have non-specific pleuritis, a cause for which was identified in a majority of patients after clinical review.
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Characteristics of malignant pleural effusions. Review of one-year data from a large tertiary centre
Introduction: Malignant pleural effusion is a common finding in patients presenting late with stage IV lung cancer. It is associated with variable survival and high morbidity. Our study aimed to review the diagnostic tools, pathology and outcomes of the patients with malignant effusions. Methods: We retrospectively collected data of patients presenting with pleural effusion at the large tertiary centre over 1-year. Consecutive patients were selected from the multidisciplinary meeting and data was analysed. Results: 110 patients with effusion were selected and 70 had malignant pathology. The median age of patients was 75 (range 31-93) and 39 (55%) were male. Forty-three (61%) had right pleural effusion and 9 (13%) had bilateral effusions. Diagnostic aspiration was performed in 39 (55%) patients with positive cytology in 32 with sensitivity of 85%. Forty percent of patients had video-assisted thoracoscopy and pathological diagnosis was achieved in 65. Blind pleural biopsy was not utilised and 8% of patients had radiological diagnosis. Pleurodesis was performed in 22 (31%) and 18% of them has complications. Median survival was better in patients with mesothelioma at 325 days compared to lung cancer. Conclusion: Our data shows the variable prognosis in patients with malignant effusion. Better survival was seen in patients with mesothelioma, therefore early effective strategies are required for diagnosis and management.
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The accurate diagnosis of pleural effusion is challenging because even after thoracocentesis and/or closed pleural biopsy, 25–40% of pleural effusion remains undiagnosed. Thoracoscopy is now considered the approach of choice for diagnosis of certain kinds of pleural diseases such as pleural mass, malignant pleural effusion with negative pleural fluid cytology, and in the diagnosis of pleural tuberculosis. To evaluate the diagnostic utility and safety of medical thoracoscopy in patients with undiagnosed exudative pleural effusion and pulmonary parenchyma lesions. This study was conducted on 44 patients, 21 males and 23 females with age ranging between 32 and 74 years (mean age 57.59 ± 7.1 years). There were 38 patients with undiagnosed exudative pleural effusion, 3 patients with multiloculated pleural effusion, 1 patient with undiagnosed pulmonary nodules and 2 patients with undiagnosed pulmonary parenchyma ground glass appearance and reticulation. There were 21 patients with co morbidities and 23 patients without co morbidities. Forty four patients with undiagnosed pleural and pulmonary lesions underwent medical thoracoscopy, multiple pleural nodules were found in 24 out of 44 patients (54.54%). Pleural mass was found in 6 patients (13.63%) and pleural thickness was found in 8 patients (18.2%). Pleura loculation and adhesion was found in 3 patients (6.8%). Pulmonary nodules were found in 1 patient (2.3%). Normal thoracoscopy was found in 2 patients (4.54%) and lung biopsy was taken. As regards histopathology there were 16 patients (36.36%) diagnosed as epithelial mesothelioma, 3 patients (6.81%) diagnosed as metastatic squamous cell carcinoma, 1 patient (2.27%) diagnosed as non Hodgkin lymphoma, and 4 patients diagnosed as tuberculosis. In patients with pleural mass 3 patients (6.81%) diagnosed as sarcomatous mesothelioma and 3 patients (6.81%) diagnosed as non Hodgkin lymphoma. In 8 patients with pleural thickness, 6 patients (13.63%) diagnosed as non specific pleurisy and 2 patients (4.54%) diagnosed as tuberculosis. In 3 patients with pleural loculation they diagnosed as pleural fibrosis. One patient with pulmonary nodules (2.27%) diagnosed as small cell carcinoma. In 2 patients with normal thoracoscopy lung biopsy showed desquamative interstitial pneumonia in 1 patient (2.27%) and usual interstitial pneumonia in 1 patient (2.27%). The diagnostic yield of medical thoracoscopy was 86.4% (38 patients with definite histopathological diagnosis and 6 patients 13.6% diagnosed as non specific pleurisy). As regards thoracoscopic complications bleeding needed blood transfusion occurred in 1 patient (2.27%) with malignant mesothelioma, surgical emphysema occurred in 3 patients (1 with metastatic squamous cell carcinoma, 1 with tuberculous pleural effusion and 1 with loculated empyema), hypotension occurred in 1 patient underwent lung biopsy (desquamative interstitial pneumonia), the total thoracoscopic complications were 11.36% which was mild and statistically non significant. Medical thoracoscopy is safe and effective for the diagnosis of benign and malignant pleural disease and pulmonary nodules.
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To assess the diagnostic value of video-assisted thoracoscopic surgery in exudative pleural effusions, and to evaluated the frequency of malignancy development with long term follow-up of patients defined as nonspecific pleuritis after surgery. .The retrospective study was conducted at Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey, and comprised data of patients with undiagnosed exudative pleural effusions seen between January 2008 and December 2013. Data related to clinical, radiological, thoracoscopical, histopathological and follow-up periods were obtained from the hospital records. SPSS 15 was used for data analysis.Of the 229 patients, 145(63.3%) were males and 84(36.7%) were females. The overall mean age was 54.5 }15.1 years. Malignancy was found in 84 (36.6%) patients, and tuberculosis in 26(11.4%). The remaining 119(52%) patients had nonspecific pleuritis and their mean follow-up period was 29.2}27.1 months (range: 1-103 months). Video-assisted thoracoscopic surgery was repeated in 3(2.52%) patients in the 1st, 4th and 16th months of followup period due to the recurrence of pleural effusion. Tuberculosis and mesothelioma were diagnosed in 1(0.8%) and 2(1.7%) cases, respectively.Video-assisted thoracoscopic surgery was found to be a valuable diagnostic procedure in patients with undiagnosed exudative pleural effusion.
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The aim of this study was to find out the common etiological causes of exudative pleural effusion in patients before starting treatment. Fifty patients, diagnosed with pleural effusion on admission were randomly selected from Medicine and Paediatric wards of Khulna Medical College Hospital during the period from March 2016 to November 2016. Etiological diagnosis was established by sequential clinical history and findings on physical examination, laboratory tests, chest radiograph, CT scan of the chest and pleural fluid analysis. Patients who remained undiagnosed were subjected to fibro-optic bronchoscopy, thoracoscopic pleural biopsy, and histopathology. Among the patients having pleural effusion, there were tuberculosis, pneumonia, malignancy and systemic lupus erythematosus in 27 (54%), 11 (22%), 7 (14%) and 1 (2%), respectively. Despite all investigations, 4 (8%) were remained undiagnosed etiologically. Most of the pleural effusion cases were diagnosed as tuberculosis. Early and adequate treatment resulted in complete recovery of the patients.Mediscope Vol. 4, No. 1: Jan 2017, Page 30-33
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Medical Thoracoscopy for Undiagnosed Exudative Pleural Effusion: A Descriptive Cross-sectional Study
Introduction: Medical thoracoscopy has recently gained renewed interest due to its minimal invasive nature and high yield diagnostic outcome. This study aims to observe diagnostic yield and safety of medical thoracoscopy in undiagnosed exudative pleural effusion.
Methods: This is a descriptive cross-sectional study conducted in two tertiary care hospitals in Chitwan from March 2018 to May 2018. Ethical approval from the Institutional Review Board was obtained. Convenient sampling was done that included all the patients who met criteria for undiagnosed exudative pleural effusion after diagnostic thoracocentesis. Patients having contraindication to procedure and who refused consent were excluded. Statistical analysis was performed using IBM SPSS Statistics 20 and data are presented as mean (±SD) and frequency (percentage).
Results: A total of 14 patients underwent rigid medical thoracoscopy. All 14 patients had unilateral pleural effusion. The overall diagnostic yield was 100%. Malignancy was the most frequent histopathology diagnosis seen in 11 (78.57%) patients, the commonest being metastatic adenocarcinoma in 8 (57.1%). Pleural tuberculosis and acute-on-chronic pleuritis were seen in 2 (14.3%) and 1 (7.1%) patients, respectively. Pleural deposits and hemorrhagic pleural fluid were the two commonest findings, seen in 10 (70.1%) and 9 (64.3%) patients, respectively. Two (14.3%) patients clinically treated as tuberculous pleural effusion was re-diagnosed to have metastatic adenocarcinoma. Common procedure-related minor complications observed were mild to moderate pain and mild bleeding, observed in 3 (21.4%) and 2 (14.3%) patients, respectively.
Conclusions: Medical thoracoscopy is a safe, well-tolerated and high yield procedure in undiagnosed exudative pleural effusion. This art of medicine should be promoted in daily medical practice.
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Introduction: A number of exudative pleural effusions(EPE) are diagnosed as non specific pleuritis(NSP), after investigation with medical thoracoscopy(MT). It remains unclear if this is a specific clinical entity(idiopathic pleuritis). Aim: To assess the long-term outcome of cases with post-MT histological diagnosis of NSP. Methods: All patients with undiagnosed EPE, further investigated with MT, and diagnosed as NSP were enrolled in study. Parapneumonic EPE were excluded. Demographic, laboratory, imaging data and main thoracoscopic findings were recorded. All cases were followed up for 2 years. Patients with persistent/recurrent EPE or suspicious for malignancy findings were further investigated with video assisted thoracoscopic surgery(VATS). Results: 127 patients with EPE, investigated with MT were screened. 57 patients(age mean ±SD 65.3±12.9) diagnosed as NSP were enrolled in the study. Three cases(5.2%) developed malignancy(one metastatic lung and two breast cancers) during the follow-up period. A probable cause was established in 16 cases(pleuropericarditis caused by Rickettsia infection n=3, benign asbestos pleuritis n=3, rheumatoid pleurisy n=3, drug induced n=3, post traumatic n=2, paramalignant n=2). In the remaining cases(n=38) EPE was considered due to true 9idiopathic pleuritis´, since it resolved spontaneously in 89.2± 62.3 days. Among them, 5 patients with suspicious for malignancy MT findings were referred for VATS, without establishing a different diagnosis. Conclusion: The majority of patients with NSP followed a benign course, without identifying a specific cause, implying the clinical diagnosis of idiopathic pleuritis. However, close and long-term follow-up should be undertaken in all cases.
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