Pleural Effusion in an Asymptomatic Patient: DISCUSSION part 2

Diagnostic Evaluation of Asymptomatic Effusions

Our proposed diagnostic work-up of APE is shown in Figure 1. In general, the work-up is similar to that of symptomatic effusion. However, several points de­serve emphasis.

Since there is no radiographic appearance that is diagnostic, once PE is detected in the asymptomatic patient, careful evaluation of the history and clinical circumstances is required. As outlined in tables 3 and 4 multiple causes of PE may be asymptomatic at the time of presentation. Patients with APE following uncomplicated abdominal or thoracic surgery or re­cent vaginal childbirth can be observed closely. Patients with findings of left ventricular failure (in­creased cardiac shadow, infiltrates in butterfly pattern, or vascular redistribution, S3 gallop) can also be observed during diuresis. All others should have a diagnostic thoracentesis if the fluid is accessible since clinically useful information will be obtained in over 90 percent of cases.

When the cause of APE is unclear following thora­centesis, the next diagnostic step is that of closed pleural biopsy. In experienced hands, the diagnostic yield is increased in cases of suspected tuberculous pleurisy or malignant pleuritis by combining multiple closed pleural biopsies with repeat thoracentesis for culture or cytology. The most common complications are pneumothorax and pain. viagra 50 mg

FIGURE 1. Diagnostic algorithm

FIGURE 1. Diagnostic algorithm for evaluation of asymptomatic pleural eflusion.

Than 95 percent. Ninety-seven percent of cases of malignancy or tuberculosis had at least one of these criteria. When all of these were absent, there was a 94 percent chance that the pleural disease was non­specific pleuritis. This was supported by an average of 33 months of follow-up. If pleural biopsy is nondiagnos­tic and none of the above criteria is present, patients can be followed clinically unless there is a parenchymal abnormality on chest radiograph.

Computed tomography (CT) of the chest and upper abdomen should be part of the evaluation of APE when thoracentesis and initial closed pleural biopsy have been nondiagnostic, when uremic effusions do not clear with dialysis, and before accepting a diagnosis of BAE. Detection of loculation, radiographically inapparent parenchymal lesions, or subdiaphragmatic pathology by CT can help focus the subsequent evaluation. We have recently seen a young man with an asymptomatic left PE and positive result of PPD test. After a nondiagnostic thoracentesis and pleural biopsy, CT scan of the chest and upper abdomen demonstrated a previously unsuspected subcapsular splenic hematoma, the result of trauma several years earlier (Fig 2). On the basis of this study, the eflusion was considered to be sympathetic and resolved com­pletely following splenectomy. buy antibiotics canada

FIGURE 2. Posteroanterior chest roentgen

FIGURE 2. Posteroanterior chest roentgenogram. (A, left). Left sided pleural eflusion (see text). Computed tomography of the upper abdomen. (B, right). Large subcapsular splenic hematoma. The efiusion resolved completely following splenectomy.

Fiberoptic bronchoscopy has been useful in evalu­ating PE in the presence of hemoptysis or associated roentgenographs abnormality. However, the diag­nostic yield of bronchoscopy in the absence of these associated findings is low.

Rigid or fiberoptic thoracoscope examination of the pleura allows direct visualization for biopsy and its sensitivity in the diagnosis of tuberculosis and malig­nancy approaches 100 percent in some series. How­ever, it does require hospitalization overnight and its advantage over conventional means of diagnosis is unclear.

We re<£mmend thoracotomy in only a small minor­ity of patients undiagnosed after closed pleural biopsy since the procedure does not guarantee the diagno­sis. A definitive diagnosis is made in only 52 percent of cases. Furthermore, Ryan et al found that in approximately 61 percent of patients with nonspecific pleuritis at thoracotomy, the course was entirely be­nign without recurrence of eflusion or development of a specific etiology. The same finding has been noted by others. Those who remain asymptomatic and whose effusions are stable can be observed. Patients who develop symptoms or whose effusions reaccu- mulate or increase in size are referred for open biopsy.

In conclusion, we found the frequency of APE to be 16 percent in our series of patients undergoing thoracentesis. When compared to symptomatic pa­tients, the spectrum of causes was similar, with malig­nancy, CHF, pneumonia and recent surgery the major contributors. Review of the literature revealed asbestos exposure, recent childbirth, tuberculosis and uremia as other conditions commonly associated with APE. When the clinical setting indicates need for diagnostic evaluation, the approach is similar to that for SPE. eriacta 100 mg

Leslie and Kinasewitz have defined a group of patients with non-diagnostic pleural biopsies who do not require further evaluation. They classified patients on the basis of pleural biopsy specimens into three groups: granulomatous pleuritis, malignant pleuritis, and nonspecific pleuritis. Repeat pleural biopsy had a diagnostic yield of 55 percent. Five criteria were predictive of an eventual diagnosis of granulomatous or malignant pleuritis: weight loss greater than 4.5 kg; fever greater than 38°C; positive skin test for tuber­culosis; eflusion occupying greater than one-half the hemithorax; and pleural fluid lymphocytosis of greater


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