Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

1180 Pleural Diseases: Effusion/Empyema

CT with Contrast

■Loculations, airway or parenchymal lesions, abscesses, bron-

chopleural fistula, pleural plaques

Percutaneous Pleural Biopsy

■Lymphocytic effusion (TB). Rarely for sarcoidosis or rheumatoid

(necrobiotic nodule) Malignancy (low yield)

Thoracoscopy

■Malignancy, TB

Bronchoscopy

■Hemoptysis, parenchymal or endobronchial lesion

differential diagnosis

Transudate

■CHF, hepatic hydrothorax, nephrotic syndrome, peritoneal dialy-

sis (protein <1 g/dL; glucose 300–400 mg/dL), hypoalbuminemia,

urinothorax (pleural fluid/serum creatinine >1.0), atelectasis, con-

strictive pericarditis, trapped lung, SVC obstruction

■“Classically exudative” that can be transudative: malignancy, PE, sar-

coidosis, hypothyroid

Exudate:

Infectious

■Iatrogenic: drugs; esophageal perforation, sclerotherapy; misplaced

central venous catheter or feeding tube

■Malignancy:+cytology (60–90%), pleural biopsy (17%), thoracos-

copy (>90%);

■associated chylothorax (triglycerides >110 mg/dL)

■Inflammatory: pancreatitis, asbestos, pulmonary embolism, radia-

tion, uremia, sarcoidosis, post-cardiac injury, hemothorax (pleural

fluid/bloodhematocrit >0.5)

■Negative intrapleural pressure: atelectasis, trapped lung

■Connective tissue: lupus (+LE cells, pleural fluid/serum ANA >1.0),

rheumatoid, MCTD, Churg-Strauss, Wegener’s

■Endocrine: hypothyroidism, ovarian hyperstimulation

■Lymphatic: yellow-nail syndrome, lymphangiomyomatosis

■Abdominal Translocation: pancreatitis, pseudocyst, Meigs’, chylous

ascites, urinothorax