Questions – pleural effusion case
1. Differential diagnosis of high ADA - lymphoma, leukemia, RA,
SLE, Mesothelioma, empyema, brucellosis, Q fever
2. Commonest cause of transudate effusion ? Marker for the same CCF
– pro BNP
3. Safe triangle for pleural procedures -Antr- pectoralis muscle,
Posterior- latismus dorsi , Upper axilla, Lower – straight line along the
nipple horizontally
4. Proposed Mechanisms of catamenial pneumothorax
Ectopic pleural endometriosis, Increased prostaglandin release
(PGF2) a powerful broncho and vasoconstrictor during menses,
resulting in rupture of alveoli, Cervical mucus theory
5. Diagnosis of urinothorax ?
Transudative, acidic pH Pleural fluid creatinine*: Elevated levels (> 1.8
mg/dL) Pleural fluid urea nitrogen*: Elevated levels (> 30 mg/dL)
Retrograde pyelography*:
6. Causes of eosinophilic effusion? Definition ? Defined as those
containing >10% eosinophils. Hemothorax, pneumothorax, Benign
asbestos pleural effusion (BAPE), Malignancy, Drugs – warfarin,
propylthiouracil, nitrofurantoin
7. Characters of chylothorax - Chyle contains 400-6800 lymphocytes/
ml, may result in metabolic acidosis, contain more than 110 mg
TGL/dL
8. What is meant by pseudoexudates ? How to confirm ? - during
diuretic therapy, transudates may be falsely labeled as exudates. By
measuring protein gradient - >3.1 and albumin gradient > 1.2
9. What is LENT score ? to assess prognosis of malignant pleural
effusion – pleural LDH, ECOG performance status, N:L ratio, tumor
site
• causes of black pleural effusion –m Melanoma, Hemothorax –
altered blood, Pancreaticopleural fistula (pancreatic pseudocyst
rupture ), Crack cocaine use, Mediastinal cystic teratoma rupture,
Aspergillus niger empyema, Rhizopus oryzae empyema
10. A normal pleural fluid pH is between 7.60 and 7.64. all
transudates alkaline – except Urinothorax
11. What is cholethorax ? How will u diagnose ?
Bilothorax – presence of bile in pleural fluid, usually follows
cholecystectomy or trauma. When pleural fluid bilirubin to serum total
bilirubin is > 1
12. What is RAPID score ? what’s it used for ?
In parapneumonic effusion and empyema. Renal function, age,
purulence, infection source, and dietary factors( Albumin level ). To
help identify patients who are at risk for a poor outcome. RAPID
score of 5 to 7) were found to have at least a 30% chance of dying in
the subsequent 12 wks
13. Alkaline exudate Pleural effusion - in Proteus empyema (reason
: Produce ammonia by urea splitting ability)
14. The amount of sediment in the collection system less than
------------ mL daily to remove ICD in empyema (5Ml)
15. Mention Criterias for Tube Thoracostomy in Parapneumonic
Effusions
Effusion filling more than half the hemithorax, Air-fluid level, Positive
stain for microorganisms, Positive pleural fluid cultures, Pleural fluid pH
< 7.2, Pleural fluid glucose < 60 mg/dl
16. Aminoglycosides (Aminoglycosides and macrolides )have poor
penetration into the pleural space and may be inactive in the
presence of pleural fluid acidosis
17. USG signs of pl effn -
• Flapping lung or the jellyfish sign, Sinusoid sign, Curtain sign
• In the presence of moderate to large pleural effusions, the adjacent
lung may become atelectatic and appears as tissue like structure
flapping in the pleural effusion (flapping lung or the jellyfish sign).
• The movement of visceral pleural towards or away from the chest
wall with inspiration and expiration creates a sinusoidal waveform
pattern on M mode ultrasound, The sinusoid sign is a dynamic sign
and is very specific for the diagnosis of pleural effusion, and can be
helpful in distinguishing small pleural effusions from pleural thickening
• The “curtain sign” describes the variable obscuring of underlying
structures by air-containing tissue that movement of airfluid level
denoting a hydropneumothorax
18. How to differentiate Transudate vs Exudate by USG ?
2
• Transudates are almost always anechoic, Exudates on the other
hand can have any of the 3 patterns.
• (1) anechoic: echo-free (black) space between the visceral and
parietal pleura - transudate
• (2) complex non septated echogenic material is present in a non
homogenous pattern without septations
• (3) complex septated: floating fibrin strands or septae in a lattice like
pattern are present/ This can be seen in parapneumonic effusions,
empyemas, and malignant effusions
• (4) homogenously echogenic: very cellular echogenic material is
strewn homogenously in the effusion, as in an empyema or
hemorrhagic effusions
19. sub pulmonic effusion - A distance of more than 2 cm between
the left lung inferior border and the stomach bubble is suggestive
20. What are the indications of doing FOB prior to thoracoscopy ?
(mediatinal shift to same side and history of hemoptysis, presence of
parenchymal involvement in CT)
21. Pleural fluid WBC count of > …… and cholesterol > ……
suggest an exudative pleural effusion
(>1000 and > 60 mg/dL)
22. Which is the predominant cell in normal pl;eural fluid ?
Macrophages - 75% , Lymphocytes - 25%, Mesothelial cells, neutrophils,
and eosinophils- < 2 % each
23. characters of Mesothelioma fluid - high viscocity, due to elevated
pleural hyaluronic acid
24. How to differentiate a hemothorax from hemorrhagic pleural effusion ?
(hematocrit > 50%)
25. What’s Contarini’s condition ?
26. What is TIPS? Where is it used ? – Trans Jugular intrahepatic portal
shunt, in hepatic hydrothorax 27. What’ s Meig’s syndrome ? (benign
ovarian mass with ascites and pleural effusion )
28. Give mechanisms by which malignant disease leads to pleural effusion
– other than direct invasion - Mediastinal lymphnode involvement with
decreased pleura llymphatic drainage, Thoracic duct interruption
(chylothorax), Bronchial obstruction (decreased pleural pressures),
Hypoproteinemia, Posto bstructive pneumonitis, Pulmonary embolism,
Postradiation therapy, drug induced
29. which is the close histopathological mimic of mesothelioma? Name
tests to differentiate both ? Adenocarcinoma. best markers for
mesothelioma calretinin, keratin , podoplanin , whereas
the best markers for metastatic adenocarcinomas are CEA, MOC-3 1 , B72
. 3 , Ber-EP4, BG-8, and TTF
30. blood markers for mesothelioma
soluble mesothelin-related peptides, (SMRP), osteopontin, and
megakaryocyte-potentiating
factor (MPF)
31., stages of empyema? What’s empyema necessitans ?
32. Pleural fluid formed daily is removed by which pleura? Why ?
Parietal pleura, because visceral pleura contains no stoma
33. Pleurodesis by which agent is not affected even if the patient is on
steroids? TGF beta
34. Talc of particle size less than 15 microns are not used for pleurodesis.
True or false ? Why?
True – because such particles are absorbed through stoma and can cause
ARDS
35. Causes of hemorrhagic pleural effusion?
Malignancy. Pulm embolism . Bleeding disorders, trauma . Vasculitis . On
anticoagulants
36. Causes of bilateral pleural effusion?
All transudates, metastatic, CTD
37. Mild: The pleural fluid does not extend beyond the fourth rib
Moderate: The pleural fluid extends to the second through fourth rib
Massive: The pleural fluid extends beyond the second rib
37. Grocco's Sign. a triangular area of dullness at the lower part of the
opposite side posteriorly
Garland's triangle is a triangular area of hyperresonance located posteriorly
close to the spine above a large pleural effusion due to “relaxed” lung
above the medial part of the effusion (parts of the lung above the lateral
part of the effusion are compressed by the effusion causing compression
atelectasis
