VA morning report 7.17.17 – Pleural effusion, empyema and EtoH complications

Case Summary
Thank you to Annelys for presenting an interesting case of a 53M with EtOH use disorder who presented with pleuritic chest pain and cough found to have an empyema – likely from strep pneumo

Top pearls
  • The details of the occupational history matter! Try to get as much detail from your patient as possible
    • e.g carpenter
      • Works with wood —>  ?organic duct exposure
      • Concrete exposure —> ? silica exposure
  • Chronic alcohol use is an immunosuppressive condition with patients more vulnerable to a variety of infections – see below for details
  • An empyema is an exudative pleural effusion with any one of these features
    • Glucose < 60
    • pH < 7.2
    • positive gram stain
    • pus on thoracentesis

 


Complications of EtOH use

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Exudative pleural effusions

Remember that light’s criteria is very sensitive and will occasionally label truly transudative effusions as exudative. This is particularly true for chronic transudative effusions (e.g. heart failure)

Exudative effusions

The DDx of exudative effusions is extensive. Big categories to consider include

  • Infection
    • Bacterial: usually neutrophilic
    • Atypical bacterial: use lymphocytic
    • Fungal: usually lymphocytic
    • Parasitic: may be eosinophilic
  • Autoimmune
    • RA and SLE in particular
  • Malignancy
    • Lung cancer: this represents metastatic disease
    • Others to consider include
      • Breast cancer
      • Ovarian cancer
      • Lymphomas
      • Mesothelioma
  • Drug-induced
    • Common offenders include
      • PTU/MMZ
      • Minoxidil
      • Amiodarone
      • Nitrofurantoin
  • Vascular
    • PE
    • SVC syndrome
    • Brachiocephalic vein stenosis (chronic indwelling catheter)
  • Intra-abdominal source
    • Pancreatic: high amylase
    • Urinothorax: high creatinine
    • Ovarian
      • Meig’s syndrome: benign fibroma
      • Ovarian cancer
    • Endometriosis
      • Usually right-sided
  • Other
    • Cholesterol effusion
    • Chylothorax

Empyema

There is a movement to merge the terms “complicated parapneumonic effusion” and empyema. For practical purposes, both these terms imply a need for a chest tube.

While suspicion of an empyema can be high based on imaging (loculated, pleural enhancement/thickening), it is defined when one of these variables is present:

  • Glucose < 60
  • pH < 7.2
  • positive gram stain
  • pus on thoracentesis.

Pleural studies clues

The first pass work up for an exudative effusion (cell count, glucose, cytology etc) is usually diagnostic. In challenging causes, clues can be gleaned from a closer look at pleural studies

  • LDH
    • A very high LDH in the setting of normal pleural protein is suggestive of cell turnover –> malignancy
  • Total protein
    • If total protein ratio is close to 1 or pleural protein > 5, strongly consider Tb.
    • Low protein ratio (<0.15), consider fluids with low protein
      • Urinothorax
      • CSF
      • Central line in pleural space.
  • Eosinophilia > 10%
    • Air in the pleural space: pneumothorax/recent thorax
    • Blood in pleural space: hemothorax, PE
    • Drug induced
      • Including asbestos related
    • Autoimmune
      • Eosinophilic pneumonia
      • eGPA
  • Pleural  glucose < 20
    • Bacterial empyema
    • Rheumatoid effusion
  • Cells
    • Reactive mesothelial cells reduce the likelihood of Tb.

 

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