Case history

Presenting complaints :

56 year old male known case of diabetes mellitus and hypertension presented with complaints of fever associated with chills and rigor and cough with yellow colour, sputum, and breathlessness of grade 4.

Examination:

Patient was febrile , tachycardic (pulse rate was 119/min) and saturation
was 98% in room air.
Respiratory system examination revealed pleural rub.
Other system examinations were normal.

Diagnosis and Treatment:

Blood investigations revealed elevated WBC and CRP levels. CT chest done show consolidation in the right middle lobe lateral segment, pleural effusion of pleural covering the right middle lobe with internal scattered air pockets – localised hydropneumothorax possibility of bronchopleural fistula shall be considered. Patient was initiated on Iv antibiotics. Pulmonologist opinion was obtained and he advised for diagnostic pleural tapping. The pleural analysis revealed elevated WBC levels with lymphocyte predominance along with elevated LDH and ADA levels. Patient was treated with IV antibiotics and was followed up with serial chest X-rays he improved symptomatically and hence was discharged.

Discussion:

When a patient is found to have a pleural effusion, the first step done is to determine whether the effusion is a transudate or an exudate for which a diagnostic thoracocentesis is performed.

Lights criteria

-Pleural fluid / serum protein > 0.5

-Pleural fluid/serum ldh > 0.6

-Pleural fluid ldh > 2/3rd upper normal serum limit

If anyone of the following criteria is met, a exudative pleural effusion is considered otherwise a diagnosis of transudative pleural effusion is made.

The transudative pleural effusion is most likely due to systemic factors having an effect on the formation and absorption of pleural fluid. The leading causes are left ventricular failure and cirrhosis.

The exudative plural effusion is mostly due to local factors like pneumonia, malignancy, and pulmonary embolism.

Parapneumonic effusion are pleural effusions which are associated with bacterial pneumonia, lung abscess and bronchiectasis. And the term empyema will be used when it is a grossly purulent effusion.

The parapneumonic effusion treatment plan includes therapeutic thoracocentesis and other procedures. If the free fluid separates the lungs from the chest wall by about 1 cm, a therapeutic thoracocentesis is considered. The presence of other factors like loculated pleural fluid , pleural fluid pH <7.2 , pleural fluid glucose< 60 mg/dl, positive gram or culture of the pleural fluid , gross pus in pleural space then procedure more invasive than the thoracocentesis are considered. Chest tube insertion, and instillation of a combination of fibrinolytic agent with deoxyribonuclease or thoracoscopy with the breakdown of adhesions have been successful. Decortication is considered as a last measure when other interventions are ineffective.

Dr R.M. Madhumitha
DNB General Medicine 1^st Year Resident
Kauvery Hospital, Chennai

Mentors:

Dr Jayaraman K
Senior consultant, Internal medicine
Kauvery Hospital, Chennai

Dr Anantha Subramanian
Pulmonologist
Kauvery Hospital, Chennai