TOC | Pulm

PLEURAL EFFUSION            see  Differential Diagnosis

A. Transudates: P-protein<3.0, P/S protein<0.5, P-LDH<200, P/S LDH<0.6

1. CHF
2. Nephrotic syndrome
3. Cirrhosis with ascites
4. Meigs' syndrome of ovarian tumor (benign or malignant) with ascites
5. Peritoneal dialysis

B. Exudates: P-protein>3.0, P/S protein>0.5, P-LDH>200, P/S LDH>0.6

1. Para pneumonic effusion (viral, bacterial, fungal)
2. Pulm. infarction
3. Neoplasm
4. Collagen diseases: Lupus erythromatoses, RA
5. Subphrenic inflammatory conditions
6. Pancreatitis
7. Hypoplasia or obstruction of lymphatics

C. Hemorrhagic

1. Trauma: chest trauma, subclavian vein catheter leakage
2. Pulm. infarction
3. Neoplasms
4. Tuberculosis

D. Lipid

1. Chylous: rupture or obstruction of thoracic or lymphatic ducts
2. Cholesterol: any long standing cellular effusion

E. Empyema: WBC pus, organisms, pH<7.3

Ref:

Evaluatinig Pleural Effusions - Jeffrey B. Rubins, Gene L. Colice
PostGrad Med  May 1, 1999;105:39

2009

Pleural effusion - differential diagnosis        REF:  DynaMed 2009

Updated 2009 Jun 26 05:12 PM: created 2009 Jun 25

Infectious Causes

Bacterial infections:

• bacterial pneumonia
  • parapneumonic effusion and empyema in adults
  • parapneumonic effusion and empyema in children
• tuberculous empyema (Monaldi Arch Chest Dis 2006 Mar;65(1):26)
• spontaneous bacterial empyema in cirrhosis as complication from hepatic hydrothorax (Turk J Gastroenterol 2004 Mar;15(1):63)

Viral infections:

• viral pneumonia
  • parapneumonic effusion and empyema in adults
  • parapneumonic effusion and empyema in children
• HIV infection

Neoplasms

Neoplasms:

• Kaposi's sarcoma
• pyothorax-associated lymphoma (Adv Anat Pathol 2005 Nov;12(6):324)
• chylothorax-associated lymphoma (Eur J Cardiothorac Surg 2007 Aug;32(2):362 full-text)
• mesothelioma
  • localized fibrous mesothelioma
  • diffuse malignant mesothelioma
• benign asbestos pleural effusion(1)
• ovarian cancer
• Meigs' syndrome (ovarian fibroma associated with hydroperitoneum and hydrothorax)(1)

Iatrogenic Causes

Iatrogenic causes:

• artificial pneumothorax therapy(1)
• abdominal surgical procedures(1)
• post-surgical subphrenic abscess(1)
• post-surgical pulmonary embolism(1)
• coronary artery bypass graft surgery (Clin Chest Med 2006 Jun;27(2):267)
• duropleural fistula(1)
• esophageal dilatation(1)
• esophageal endoscopy(1)
• medication-induced pleural disease(1)
• chronic hemodialysis(1)

Medical Causes

Pulmonary conditions:

• trapped lung syndrome - restrictive visceral pleural peel (Am J Med Sci 2008 Jan;335(1):21)
• pulmonary embolism
• asbestos exposure(1)

Cardiac conditions:

• heart failure
• constrictive pericarditis
• Dressler's syndrome (postmyocardial infarction syndrome)(1)

Hepatic conditions:

• alcohol use disorder
• cirrhosis
• hepatic hydrothorax(1)

Pancreatic conditions:

• chronic pancreatitis
• acute pancreatitis

Autoimmune conditions:

• rheumatoid arthritis
• rheumatoid pleuritis(1)
• pleuritis associated with systemic lupus erythematosus

Other conditions:

• trauma
• uremic pleuritis(1)
• ovarian hyperstimulation syndrome(1)
• remote inflammatory pleural process(1)
• hemothorax
• pseudochylothorax(1)
• duropleural fistula(1)
• ascites
• childbirth - post-partum pleural effusion(1)
• yellow nail syndrome (yellow nails, lymphedema, and pleural effusion)(1)

Chylothorax

Neoplasms:

• malignant obstruction of thoracic duct is most common cause of nontraumatic chylothorax
• lymphoma accounts for 70% of cases of neoplastic causes of chylothorax

Trauma and iatrogenic causes:

• blunt trauma
• penetrating trauma
• surgery
  • excision of cervical lymph nodes
  • radical neck dissection
  • ligation of patent ductus arteriosus
  • aortic surgery
  • esophagectomy
  • surgery for mediastinal tumors
  • pneumonectomy
  • sympathectomy
  • radical abdominal lymph node dissection
• diagnostic procedures
  • lumbar arteriography
  • subclavian vein catheterization

Congenital causes:

• atresia of thoracic duct
• birth trauma
• pleural thoracic duct fistula

Miscellaneous causes:

• lymphangioleiomyomatosis
• Gorham's disease (massive osteolysis)

Reference:

• Eur J Cardiothorac Surg 2007 Aug;32(2):362 full-text

2009