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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 3 | Page : 116-120 |
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A clinical study of pleural effusion and its radiological, biochemical, bacteriological, and cytological correlation
Mood Narayan1, Saritha Karre2, Surendra Babu Darivemula3
1 Department of Pulmonary Medicine, ESIC Medical College, Hyderabad, Telangana, India
2 Department of Pathology, Gandhi Medical College, ESIC Medical College, Hyderabad, Telangana, India
3 Department of Community Medicine, ESIC Medical College, Hyderabad, Telangana, India
| Date of Submission | 24-Jun-2021 |
| Date of Decision | 10-Jul-2021 |
| Date of Acceptance | 19-Jul-2021 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Surendra Babu Darivemula
Department of Community Medicine, ESIC Medical College, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/DYPJ.DYPJ_38_21
Background: Pleural effusion refers to excessive or abnormal accumulation of fluid in the pleural space. It is a commonly encountered medical problem caused by a variety of underlying pathological conditions. Collection of fluid in the pleural cavity has varied etiological factors. Because of the various etiologies that can cause pleural effusion, it often presents a diagnostic problem, even after extensive investigations. Materials and Methods: A prospective study was carried out with the aim was to arrive at the etiological diagnosis by analysis of history, clinical presentation, biochemical, radiological, cytological, and bacteriological methods. The inclusion criteria were total 100 patients of adult age and either sex were taken, with age >18 years, and chest X-ray showing evidence of pleural effusion. Already diagnosed with pleural effusion were excluded from the study. Diagnosis was made on clinical examination, radiological examination, and analysis of laboratory data. Results: A total of 106 patients were enrolled with a mean age of 42.8 years and standard deviation of ± 15.1, respectively. Out of 106, the maximum number of cases of pleural effusion were tuberculosis 59 (55.7%) among them more than three-fourth of them were affected on the right side and only 13 (12.2%) were affected on the left side. After tuberculosis, malignancy 17 (16.0%) and congestive heart failure 10 (9.4%) respectively. Most of the cases were affected on the right side 57 (53.7%), followed by 35 (33.1%) and only 14 (13.2%) were affected bilaterally. The most common presenting symptoms are 99 (93.3%) and had shortness of breath, 87 (86.0%). Among the plural effusion cases, majority 90 (84.9%) of them had diagnosed with thoracocentesis. Almost 89 (83.9%) exudative effusions are more common and only 17 (16.1%) transudative effusion. Conclusion: A maximum number of cases of pleural effusion were tuberculosis followed by malignancy. Thoracentesis and pleural fluid analysis were the most common diagnostic technique. Thoracoscopy was required in few cases which are difficult to diagnose cases. Keywords: Malignancy, pleural effusion, tuberculosis
How to cite this article:
Narayan M, Karre S, Darivemula SB. A clinical study of pleural effusion and its radiological, biochemical, bacteriological, and cytological correlation. D Y Patil J Health Sci 2022;10:116-20 |
How to cite this URL:
Narayan M, Karre S, Darivemula SB. A clinical study of pleural effusion and its radiological, biochemical, bacteriological, and cytological correlation. D Y Patil J Health Sci [serial online] 2022 [cited 2023 Mar 23];10:116-20. Available from: http://www.dypatiljhs.com/text.asp?2022/10/3/116/370119 |
| Introduction | |  |
Collection of an abnormal quality and quantity of fluid in the pleural cavity is called pleural effusion.[1] Collection of fluid in the pleural cavity has varied etiological factors.[2] Because of the various etiologies that can cause pleural effusion, it often presents a diagnostic problem, even after extensive investigations. In malignant pleural effusion, 8.33% had polymorphic predominance. It has been shown that predominant polymorphs in TB might be too early or acute stage of illness or due to secondary infection.[3]
Pleural effusion refers to excessive or abnormal accumulation of fluid in the pleural space. It is a commonly encountered medical problem caused by a variety of underlying pathological conditions. It is important to establish an accurate etiological diagnosis so that the patient may be treated in the most appropriate and rational manner. Pleural effusion is commonly encountered by chest physicians accounting for approximately 4% of attendance to chest clinics. However, it often presents a diagnostic dilemma, as no cause may be found in about 19% of cases, in spite of careful evaluation.
Aims and objectives
The aim of this study was to arrive at the etiological diagnosis by analysis of history, clinical presentation, biochemical, radiological, cytological, and bacteriological methods.
| Materials and Methods | | |
A prospective study was carried out in the Department of Pulmonary Medicine and Pathology in a tertiary care hospital on 106 patients for a period of 1 year in 2020. The inclusion criteria were total 100 patients of adult age and either sex were taken, with age >18 years and chest X-ray showing the evidence of pleural effusion. Those who are already diagnosed with pleural effusion were excluded from the study. Informed consent was obtained from all enrolled patients have to undergo detailed clinical examination and routine laboratory examinations such as blood test for hemoglobin, total white blood cell (WBC) count, differential WBC count, erythrocyte sedimentation rate, random blood sugar, serum proteins, serum lactate dehydrogenase (LDH), urine examination, sputum examination, and tuberculin test were carried out in all patients. A plain chest X-ray PA view was taken before thoracocentesis and another was taken after thoracocentesis to rule out complications. Additional films and ultrasound were done whenever indicated. In case of parapneumonic effusion, thoracocentesis was done for the research purpose with written consent from patient. Ethical clearance was obtained from the institute ethics committee with No. ESICMC/SNR/IEC-F097/04/2019. The pleural fluid was analyzed for cell count, cell type, specific gravity, protein, and sugar content and for the presence of acid-fast bacilli, other bacterial organisms and malignant cells, LDH, and adenosine deaminase (ADA) levels. Additional tests indicated were performed to diagnose the etiology of pleural effusion whenever required. Diagnosis was made on clinical examination, radiological examination, and analysis of laboratory data.
| Results | | |
A total of 106 patients were enrolled in the study, among them in [Table 1], 69 (65.0%) were male and 37 (35.0%) were female with the mean age of 42.8 years and standard deviation of ± 15.1, respectively. Majority of the patients belong to the 31–50 years of age group [Figure 1], and pleural effusion was more common in males compared to females. According to the occupation, majority of them belong to the unskilled workers 65 (61.3%) followed by semiskilled 24 (22.7%) and skilled worker 17 (16.0%). As per the Modified Kuppuswamy scale [Table 2], for the socioeconomic status, more than half of them belong to lower class and one-third of them belong to middle class and only 15 members belong to upper class. [Table 3] suggests that, out of 106, the maximum number of cases of pleural effusion were tuberculosis 59 (55.7%) among them more than three-fourth of them were affected on the right side and only 13 (12.2%) were affected on the left side. Next to tuberculosis, malignancy 17 (16.0%) and congestive heart failure 10 (9.4%), etc. Most of the cases with pleural effusion were affected on the right side 57 (53.7%), followed by 35 (33.1%) and only 14 (13.2%) were affected bilaterally.  | Table 2: Distribution of participants according to the occupation and socioeconomic status
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[Table 4] suggests the distribution of the cases according to various symptoms wise with respect to disease diagnosed. The most common presenting symptoms are 99 (93.3%) had shortness of breath, 87 (86.0%) had cough, 84 (81.1%) had fever, 77 (72.6%) had weight loss, 74 (69.8%) had loss of appetite, 67 (63.2%) had chest pain, and 18 (16.9%) had hemoptysis. According to the grading [Figure 2] of severity, most of them were moderate; 47 (44.3%), mild 31 (29.2%), and 28 (26.4%) were severe. Among the plural effusion cases, majority 90 (84.9%) of them had diagnosed by thoracocentesis [Figure 3] and only 16 (15.1%) cases had undergone thoracoscopy-guided pleural biopsy. [Table 5] suggests that most of the pleural effusion fluid shows elevated levels of protein >3 in 89 (83.9%), glucose >60 were 64 (60.3%), ADA >60 were 55 (51.8%), and LDH >200 were 62 (58.4%) among them majority are having tuberculosis followed by malignancy. [Table 6] suggests that 89 (83.9%) exudative effusions are more common and only 17 (16.1%) transudative effusion. In exudative effusion AFB was present in only two cases, 87 lymphocytes, 11 polymorphs and 8 mesothelial cells [Table 7]. | Table 4: Distribution of cases according to the incidence of various symptoms
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 | Figure 2: Distribution of participants according to size and type of effusion
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 | Figure 3: Distribution of participants according to grading severity and procedures done
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 | Table 6: Distribution of effusion according to transudative and exudative effusion
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| Discussion | | |
In this study, we studied the causative and laboratory profiles of patients with pleural effusion. Tubercular pleural effusion was seen in 59 (55.7%) which is explained by the high prevalence of tuberculosis in India. Three malignant pleural effusions were seen in 17 (16%), congestive heart failure was 10 (9.4%), empyema and hypoproteinemia each were 7 (6.6%), whereas parapneumonic pleural effusion in 6 (5.7%). In patients of age >40 years, malignant effusion was more common; A1 quatrain.[4] Common diagnosis was tubercular (37%) followed by neoplasm (8%), parapneumonic (14%), and congestive cardiac failure (14%); KZ Mamum[5] also showed tubercular and malignancy where the major causes of pleural effusion; Valdés[6] showed tubercular and transudative were most common causes. More than half of the patients 58 (54.8%) in this study belonged to the lower socioeconomic class. This is consistent with the fact that tuberculosis is a disease more commonly seen among people living in crowded unhygienic conditions.
Majority of the patients belonged to 21-50 years of the age and male to female ratio was 2.16:1. Male-to-female ratio is comparable with the studies of Choi (2.13:1), Al-Qorain et al. (2.34:1), and Maldhure et al. (2.53:1).[3.4],[7],[8] Most of the patients had right-sided pleural effusion 57 (53.7%), whereas 35 (33.1%) had left-sided pleural effusion and only 14 (13.2%) had bilateral. In comparison to other studies, Al-Quarain.[4] pleural effusion was more common in the right side (55%) than on the left (32%); in Follador et al.,[9] both right and left side effusion were of equal distribution. In the present study, breathlessness, cough, fever, weight loss, loss of appetite, and chest pain were the common symptoms. Out of 106 patients with pleural effusion, majority 47% had moderate fluid, 31% had mild, and 28% had severe amount of fluid.
The incidence of exudative effusion was 89 (83.9%) which is comparable with other studies [Table 8] of Parikh et al.,[10] Al-Qorain et al.,[4] and Valdés et al.[11] Total 89 (83.9%) of the patients with exudative effusion had protein content >3 g % in pleural fluid, whereas all the transudates had protein content <3 g % in the pleural fluid. Eighty-seven (82.1%) of the patients of pleural effusion had lymphocytic predominance in pleural fluid, 11 (10.3%) had polymorphs, and only 8 (7.5%) were had mesothelial cells. Follador et al.,[9.12],[13]–demonstrated predominance of lymphocytes and scarcity of mesothelial cells in tubercular effusion.[7]
In this study, out of the 59 cases of tuberculous effusion, in eight cases, acid-fast bacilli could be demonstrated in the sputum by Ziehl‐Neelsen staining (13.5%). The detection of AFB in the sputum in the tuberculous depends upon the associated lung parenchymal lesion. In comparison to other study: Kataria and Khurshid[13] 7 of the 62 patients with tuberculous pleural effusion showed sputum positivity for AFB (i.e., 11%).
| Conclusion | | |
Maximum number of cases of pleural effusion were tuberculosis followed by malignancy. Thoracentesis and pleural fluid analysis was the most common diagnostic technique. Thoracoscopy was required in few cases which are difficult to diagnose cases.
Acknowledgment
We would like to thank all the participants in the study and all the authors who contributed for the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Seaton A, Leitch AG Douglas Seaton Crofton and Douglas’s Respiratory Diseases Disease. 5th ed. Wiley-Blackwell; 2008. ISBN: 978-0-470-69524-1, p. 1152-80.  |
| 2. | Harrison’s Principles of Internal Medicine. 16th ed., Vol. 245. 2004. p. 1565-9. Available from: https://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192031615. |
| 3. | Choi H, Chon HR, Kim S, Oh KJ, Jeong SH, Koh WJ Clinical and laboratory differences between lymphocyte and neutrophil-predominant pleural tuberculosis. PLos One 2016;11:e0165428. |
| 4. | Al-Qorain A, Larbi EB, al-Muhanna F, Satti MB, Baloush A, Falha K Pattern of pleural effusion in Eastern Province of Saudi Arabia: A prospective study. East Afr Med J 1994;71:246-9. |
| 5. | Cheng DS, Rodriguez RM, Rogers J, Wagster M, Starnes DL, Light RW Comparison of pleural fluid pH values obtained using blood gas machine, pH meter, and pH indicator strip. Chest 1998;114:1368-72. |
| 6. | Valdés L, Alvarez D, San José E, Penela P, Valle JM, García-Pazos JM, et al. Tuberculous pleurisy: A study of 254 patients. Arch Intern Med 1998;158:2017-21. |
| 7. | Maldhure BR, Bedukar SP, Kulkarni HP, Papinwar SP Pleural biopsy and adenosine deaminase in pleural fluid for the diagnosis of tuberculous pleural effusion. Indian J Tuberc 1994;41:161-5. |
| 8. | Hirsch A, Ruffie P, Nebut M, Bignon J, Chrétien J Pleural effusion: Laboratory tests in 300 cases. Thorax 1979;34:106-12. |
| 9. | Follador EC, Pimentel M, Barbas CS, Takagaki TY, Kairalla RA, Deheinzelin D, et al. Tuberculous pleural effusion: Clinical and laboratory evaluation. Rev Hosp Clin Fac Med Sao Paulo 1991;46:176-9. |
| 10. | Parikh P, Odhwani J, Ganagajalia C Study of 100 cases of pleural effusion with reference to diagnostic approach. Int J Adv Med 2016;3:328-31. |
| 11. | Ram KN, Sing RS Diagnostic value of cholesterol in pleural effusions. J Assoc Physicians India 1995;43:748-50. |
| 12. | Subhakar K, Kotilengani K, Satyasri S ADA activity in pleural effusion. Lung India 1991;9:57-60. |
| 13. | Kataria YP, Khurshid I Adenosine deaminase in the diagnosis of tuberculous pleural effusion. Chest 2001;120:334-6. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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