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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 8-12

A clinical study of pleural effusion and its radiological, biochemical, bacteriological and cytological correlation


1 Resident, Department of Medicine, C.U. Shah Medical College & Hospital, Surendranagar, Gujarat, India
2 Assistant Professor, Department of Pulmonary Medicine, C.U. Shah Medical College & Hospital, Surendranagar, Gujarat, India
3 Associate Professor, Department of Pulmonary Medicine, C.U. Shah Medical College & Hospital, Surendranagar, Gujarat, India

Date of Web Publication30-Aug-2018

Correspondence Address:
P R Gohil
Assistant Professor, Department of Pulmonary Medicine, C.U. Shah Medical College & Hospital, Surendranagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-6486.240228

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  Abstract 


Introduction: 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.
Methodology: An observational study was conducted at a tertiary health care center. The pleural effusion was assessed clinically, radiologically, bacteriologically and cytologically.
Result: Maximum number of cases of pleural effusion were tuberculous (73%) followed by malignant (12%) and parapneumonic effusion (9%). Pleural fluid cytology for malignant cells was positive in 5 (41.67%) patients out of 12 patients of malignant pleural effusion. Chest pain, breathlessness, cough and fever were common symptoms. Majority of tubercular and malignant effusion had lymphocytes as predominant pleural fluid cells and parapneumonic effusion and empyema had polymorph predominant cells.
Conclusion: Tuberculosis is still the most common cause of pleural effusion followed by malignancy. Fluid analysis can give definite clues to the diagnosis. Tuberculosis must be ruled out in all cases of pleural effusion.

Keywords: Pleural effusion, Exudative, Transudative, Thoracocentesis, cytology


How to cite this article:
Khamar N D, Gohil P R, Thacker R N, Gediya U S. A clinical study of pleural effusion and its radiological, biochemical, bacteriological and cytological correlation. J Integr Health Sci 2017;5:8-12

How to cite this URL:
Khamar N D, Gohil P R, Thacker R N, Gediya U S. A clinical study of pleural effusion and its radiological, biochemical, bacteriological and cytological correlation. J Integr Health Sci [serial online] 2017 [cited 2021 Nov 30];5:8-12. Available from: https://www.jihs.in/text.asp?2017/5/1/8/240228




  Introduction Top


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. Pleural effusion is commonly encountered by chest physicians accounting for approximately 4% of attendance to chest clinics.[1] However, it often presents a diagnostic dilemma, as no cause may be found in about 19% of cases, in spite of careful evaluation.[2] It is important to establish an accurate etiological diagnosis, so that the patient may be treated in the most appropriate and rational manner. In this study an attempt was made to arrive at the etiological diagnosis by analysis of history, clinical presentation, biochemical, radiological, cytological, and bacteriological methods.


  Methodology Top


This study was carried out in the Department of Tuberculosis and Respiratory disease & Department of General Medicine at a tertiary care hospital. In this study total 100 patients of adult age and either sex were taken, All patients who were willing to give informed consent, with age more than 18 years and Chest X-ray showing evidence of pleural effusion were included in the study. All enrolled patients underwent detailed clinical examination and routine laboratory examination like blood test for hemoglobin, total WBC count, differential WBC Count, Erythrocyte Sedimentation Rate, Random Blood Sugar, RFTs, S. Proteins, serum LDH, Urine Examination, Sputum Examination and Tuberculin Test were carried out in all patients. A plain chest X ray PA view was taken prior to thoracocentesis and another was taken after thoracocentesis to rule out complications. Additional films and ultrasound, CT scan was done whenever indicated. In case of parapneumonic effusion thoracocentesis was done for the research purpose with written consent from patient. 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 ADA levels. Additional tests indicated were performed to diagnose etiology of pleural effusion whenever required. Diagnosis was made on clinical examination, radiological examination and analysis of laboratory data.


  Results Top


Total 100 patients were included in the study.

Most of the patients were from younger age group between 18-40 years of age with more preponderance for males [Table 1].
Table 1: Age & Sex Distribution of Tuberculous Pleural effusion

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Most of the patients were tubercular (73%) followed by malignant (12%). Other causes were pneumonia, empyema and others [Table 2].
Table 2: Distribution of causes of pleural effusion

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The most common symptom was cough followed by chest pain. Pleural effusions were classified arbitrarily as, Mild: when fluid occupied <1/3 of hemithorax in CXR-PA view; Moderate: when fluid occupied >1/3 to 2/3 of hemithorax in CXR- PA view and Massive: when fluid occupied >2/3 of hemithorax in CXR-PA. [Table 3]
Table 3: Incidence of various symptoms

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Majority of tuberculous patients had mild effusion, while majority of malignant effusion were massive effusion [Table 4].
Table 4: Size of pleural effusion

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Out of 73 patients of tuberculous effusion, 59 (84.8%) patients had clear appearance. Out of 12 patients of malignant effusion, 6 (50%) patients had hemorrhagic appearance [Table 5].
Table 5: Physical appearance of pleural fluid

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94.52% of patients of tuberculous effusion, 83.34% patients of malignant effusion and 90% patients of parapneumonic effusion had pleural fluid protein > 3gm%. In congestive heart failure and hepatic hydrothorax, all (100%) patients had pleural fluid protein <3 gm% [Table 6]
Table 6: Level of protein in pleural fluid

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Among tubercular effusion 89.04% had LDH > 200 IU, 82.19% had glucose > 60 mg/dl and 93.15% had ADA > 40 IU. Among cases with empyema all 100% had LDH > 200 IU, glucose <60 mg/dl and ADA > 40 IU. Among parapneumonic effusion cases all 100% had LDH > 200 IU, 44.4% had glucose < 60 mg/dl and 66.7% had ADA > 40 IU. Sputum for AFB with ZN stain was done in all cases. It was positive in 8 (10.95%) patient out of 73 patients of tuberculous pleural effusion. In other group it was negative in all cases. [Table 7].
Table 7: Level of LDH, Glucose and ADA in pleural fluid.

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Pleural fluid cytology for malignant cells was done in all pleural effusion patients. It was positive in 5 (41.67%) out of 12 patients of malignant pleural effusion. Pleural fluid for Gram’s stain and ZN stain was done in all pleural effusion patients. ZN stain was positive in 3 (4.11%) patients out of 73 tubercular effusions. Gram’s stain was negative in all cases. Pleural fluid culture and sensitivity was done in all pleural effusion patients. AFB culture was positive in 12 (16.44%) patients out of 73 tubercular effusions. Pyogenic culture was positive in 18% cases.


  Discussion Top


In this study we studied the causative and laboratory profile of patients of pleural effusion. Tubercular pleural effusion was seen in 73% which is explained by high prevalence of tuberculosis in India.[3] Malignant pleural effusion was seen in 12% while parapneumonic pleural effusion in 9%. Most patients belonged to 21-30 years age group. Male: Female was 3.76:1. Most of the patients had right sided pleural effusion (49%) while 42% had left sided pleural effusion and only 9% had bilateral. In the present study chest pain, breathlessness, cough and fever were the common symptoms. Out of 73 patients of tuberculous pleural effusion, majority 47.94% had mild fluid, 42.46% had moderate and 9.6% had large amount of fluid & 55.56% patients with malignant effusion had large fluid. The incidence of exudative effusion was 98 %. Total 91% of the patients with exudative effusion had protein content more than 3 gm% in pleural fluid while all the transudates had protein content less than 3gm% in the pleural fluid. 91.78% of the patients of tuberculous pleural effusion had lymphocytic predominance in pleural fluid [Table 8]. In malignant pleural effusion 91.67 % had lymphocytic predominance. In present study 8.22 % of the tuberculous patients had polymorphic predominance. 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.[4] 100 % patients with parapneumonic effusion had polymorphic predominance. In the present study 41.67% patients with malignant pleural effusion had pleural fluid cytology positive for malignant cells.
Table 8: Cellular analysis of pleural fluid

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  Conclusion Top


Tuberculosis is still the most common cause of pleural effusion followed by malignancy. Fluid analysis can give definite clues to the diagnosis. Tuberculosis must be ruled out in all cases of pleural effusion.



 
  References Top

1.
Light RW. Pleural diseases. 6th ed.Philadelphia: Lippincott Williams & Wilkins; 2013  Back to cited text no. 1
    
2.
Storey DD, Dines DE, Coles DT. Pleural effusion. A diagnostic dilemma. JAMA. 1976 Nov 8;236(19):2183-6. PubMed PMID: 989808  Back to cited text no. 2
    
3.
Chakraborty AK. Epidemiology of tuberculosis: current status in India. Indian J Med Res. 2004 Oct;120(4):248-76.Review.  Back to cited text no. 3
    
4.
Choi, H., Chon, H. R., Kim, S., Oh, K.-J., Jeong, S. H., Koh, W.-J.(2016). Clinical and Laboratory Differnces between Lymphocyte-and Neutrophil-Predominant Pleural Tuberculosis. PLoS ONE, 11(10),e0165428  Back to cited text no. 4
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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Abstract
Introduction
Methodology
Results
Discussion
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