Parapneumonic effusions
Abstract
In this study the incidence and course of pleural effusions (para-pneumonic effusions) in patients with acute bacterial pneumonia were prospectively evaluated. Bilateral decubitus chest x-ray films were obtained within 72 hours of admission in 203 patients with an acute febrile illness, purulent sputum and an infiltrate evident on the chest film. Ninety of the 203 patients (44 percent) had pleural effusions. Parapneumonic effusions, which requored chest tubes for resolution and/or on which the pleural fluid cultures were positive, were classified as complicated parapneumonic effusions. The 10 patients with complicated parapneumonic effusions had clinical characteristics similar to the remainder of the group and could be separated from the 80 with uncomplicated effusions only by pleural fluid analysis. A pleural fluid pH below 7.00 and/or a glucose level below 40 mg/100 ml are indications for immediate tube thoracostomy. In patients with pleural fluid pH between 7.00 and 7.20 or lactic dehydrogenase [LDH] above 1,000 IU/1,000 ml, tube thoracostomy should be considered, but each case should be individualized: serial studies of the pleural fluid are useful in some of these cases. Patients with pleural fluid pH above 7.20 and pleural fluid LDH below 1,000 mg/100 ml rarely have complicated parapneumonic effusions and do not require serial therapeutic thoracenteses.
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Cited by (450)
Pneumococcal infections
2022, Medicine (Spain)Streptococcus pneumoniae es un coco grampositivo dispuesto en parejas o cadenas cortas, cuyo reservorio natural se localiza en la nasofaringe posterior. S. pneumoniae es el agente etiológico de infecciones no invasivas como la sinusitis, la otitis media o la neumonía. La neumonía adquirida en la comunidad es la manifestación clínica más frecuente de la enfermedad neumocócica. La diseminación hematógena del neumococo da lugar a las formas invasivas de la infección como sepsis, meningitis, endocarditis, artritis séptica y peritonitis, entre otras. El diagnóstico de las infecciones no invasivas en pacientes ambulatorios está basado principalmente en los signos y síntomas del paciente, complementado con pruebas diagnósticas de imagen. En pacientes que cumplen criterios de hospitalización es necesaria la obtención de hemocultivos y de muestras de esputo, con el objetivo de realizar una identificación temprana del microorganismo y establecer una antibioterapia dirigida. La penicilina ha sido el antibiótico más utilizado para el tratamiento de la infección neumocócica; sin embargo, el incremento de la resistencia a este antibiótico se ha incrementado, aunque en nuestro entorno continúa siendo inferior al 5%. Las cefalosporinas de tercera generación son en la actualidad los antibióticos más utilizados para el tratamiento de la infección neumocócica invasiva.
Streptococcus pneumoniae are a gram-positive cocci arranged in pairs or short chains. Their natural reservoir is located in the posterior nasopharynx. S. pneumoniae are the etiological agent of non-invasive infections such as sinusitis, otitis media, or pneumonia. Community-acquired pneumonia is the most frequent clinical manifestation of pneumococcal disease. The hematogenous dissemination of pneumococci leads to invasive forms of infection such as sepsis, meningitis, endocarditis, septic arthritis, and peritonitis, among others. The diagnosis of non-invasive infections in outpatients is mainly based on the patient's signs and symptoms along with diagnostic imaging tests. In patients who meet the criteria for hospitalization, it is necessary to perform cultures of blood and sputum samples with the aim of identifying the microorganism early and establish targeted antibiotic therapy. Penicillin has been the most used antibiotic for treating pneumococcal infection. However, resistance to this antibiotic has increased, though in our setting it continues to be less than 5%. Third-generation cephalosporins are currently the most-used antibiotic for treating invasive pneumococcal infection.
The Eponymous Dr. Richard W. Light: Father of Pleural Medicine
2022, Archivos de BronconeumologiaDiagnostic utility of LDH, CA125 and CYFRA21-1 in tuberculosis pleural effusion
2022, Medicina ClinicaThe aim of this study was to assess the diagnostic value of several markers for tuberculosis pleural effusion (TPE) using the combined analysis of Lactate dehydrogenase (LDH), Carbohydrate antigen 125 (CA125), Cytokeratin-19 fragment (CYFRA21-1).
From January to December in 2018, a total of 37 patients with pleural effusion (22 cases of transudative pleural effusion, 15 cases of tuberculosis pleural effusion and 22 cases of Transudative pleural effusion who were hospitalized in our hospital were reviewed. Receiver operating characteristic (ROC) curves and logistic regression equations was used to evaluate the diagnostic efficiency of each marker.
The levels of LDH and CYFRA21-1 of tuberculosis pleural effusions were obviously higher than those of transudative pleural effusion with statistically significant difference (<0.05). The areas under the ROC curve of LDH, CA125 and CYFRA21-1 were 0.92, 0.344 and 0.656, respectively. The diagnostic sensitivity of LDH, CA125 and CYFRA21-1 were 100%, 13.3%, 73.3%, respectively. The combined detection of LDH, CA125 and CYFRA21-1 were higher than those of any other combinations of the indexes.
The study showed a high diagnostic sensitivity and specificity of combined speculation of LDH, ADA and CYFRA21-1 in Tuberculosis pleural effusion.
El objetivo de este estudio fue evaluar el valor diagnóstico de diversos marcadores de derrame pleural tuberculoso (DPTB) utilizando el análisis combinado de lactato deshidrogenasa (LDH), antígeno carbohidrato 125 (CA-125) y fragmento de citoqueratina-19 (CYFRA 21-1).
De enero a diciembre de 2018, revisamos un total de 37 pacientes hospitalizados en nuestro hospital con derrame pleural (22 casos de derrame pleural trasudativo y 15 casos de derrame pleural tuberculoso). Se utilizaron las curvas ROC y ecuaciones de regresión logística para evaluar la eficacia diagnóstica de cada marcador.
Los niveles de LDH y CYFRA 21-1 de los pacientes con derrame pleural tuberculoso fueron obviamente superiores a los pacientes con derrame pleural trasudativo, con diferencia estadísticamente significativa (p < 0,05). Las áreas bajo la curva ROC de LDH, CA-125 y CYFRA 21-1 fueron 0,92, 0,344 y 0,656, respectivamente. La sensibilidad diagnóstica de LDH, CA-125 y CYFRA 21-1 fueron del 100, 13,3 y 73,3%, respectivamente. La detección combinada de LDH, CA-125 y CYFRA 21-1 fue superior a cualesquiera otras combinaciones de los índices.
El estudio reflejó una alta sensibilidad diagnóstica y especificidad del análisis combinado de LDH, ADA y CYFRA 21-1 en el derrame pleural tuberculoso.
Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery
2022, Respiratory MedicinePleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined “complicated” since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.
Evaluation and management of pleural sepsis
2021, Respiratory MedicinePleural sepsis stems from an infection within the pleural space typically from an underlying bacterial pneumonia leading to development of a parapneumonic effusion. This effusion is traditionally divided into uncomplicated, complicated, and empyema. Poor clinical outcomes and increased mortality can be associated with the development of parapneumonic effusions, reinforcing the importance of early recognition and diagnosis. Management necessitates a multimodal therapeutic strategy consisting of antimicrobials, catheter/tube thoracostomy, and at times, video-assisted thoracoscopic surgery.
Pleural Infection
2021, Encyclopedia of Respiratory Medicine, Second EditionPleural effusion complicates over 20% of pneumonias, with incidence growing in both adult and pediatric populations. Mortality rates are high in adults with pleural infection, especially in the elderly and in hospital-acquired cases. Bacteriology can be complex with substantial differences between community-acquired and hospital-acquired infections. Bedside ultrasound now allows prompt and accurate assessment of pleural effusion in pneumonia patients. Fluid drainage and antimicrobial treatment remain the cornerstone of management. Advent of minimally invasive surgery and intrapleural fibrinolytic/deoxyribonuclease therapy have dramatically improved management. New prognostic scores (e.g. RAPID) have been verified.
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