0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57
Pleural Diseases: Effusion/Empyema 1181Exudate: Lab-Based Differential
■Protein
➣>4.0 g/dL: TB
➣7.0–8.0 g/dL: Waldenstrom’s, myeloma
■LDH >1000 IU/L: complicated parapneumonic/empyema, rheuma-
toid, malignancy, paragonimiasis
■Pleural fluid/serum LDH >1.0 and pleural fluid/serum protein < 0.5:
PCP
■Glucose <60 mg/dL, or pleural fluid/serum glucose < 0.5: rheuma-
toid, complicated parapneumonic/empyema, malignancy, TB,
esophageal rupture
■pH <7.30: rheumatoid, complicated parapneumonic/empyema,
malignancy, TB, lupus, esophageal rupture (as low as 6.00)
■Pleural fluid/serum amylase >1.0: pancreatitis, esophageal rupture,
malignancy, pneumonia, ectopic pregnancy, hydronephrosis, cir-
rhosis
■Total nucleated cells:
➣<5000/mcl: TB, malignancy
➣>10,000/mcl: parapneumonic effusion, pancreatitis, lupus
➣>50,000/mcl: complicated parapneumonic effusion/empyema
■Differential cell count:
➣50–70% lymphocytes: malignancy
➣85 to 95% lymphocytes: TB, lymphoma, sarcoidosis, rheumatoid,
yellow-nail syndrome, chylothorax
➣>10% eosinophils: pneumothorax, hemothorax, pulmonary
infarction, asbestos, parasitic, fungal, drugs, malignancy
➣>5% mesothelial cells: TB unlikely
management
Parapneumonic Effusions/Empyema
■Antibiotics, consider drainage, oxygen, analgesia
Staging
■I. Uncomplicated parapneumonic: exudative, neutrophilic
■II. Complicated parapneumonic: neutrophilic, pH <7.30, glucose <60
mg/dL, LDH >1000 IU/L. Often sterile
■III. Empyema:+gram stain or pus (+culture not required)
■Anaerobes, strep pneumonia, staph aureus (post-surgery/trauma),
GNRs (nosocomial, diabetes, EtOH)specific therapy
I. Uncomplicated parapneumonic: antibiotics; serial CXR/exams