yemenjmedYemen Journal of MedicinecoVolume 3 Issue 2MultidisciplinaryEnglishMay-August 2024NNY20240911ArticleDiagnostic approach to pleural effusion based on pathogenesis and radiological findings: A narrative reviewEnglishY102113Elmukhtar M. Habas1EnglishNAla Habas2EnglishYAbdusslamSaid3EnglishYAmnnaRayani2EnglishYKalifaFarfar4EnglishYEshrakHabas5EnglishYGamalAlfitori1EnglishYAlmehdiErrayes1EnglishYAmlHabas6EnglishYAbdel NaserElzouki1EnglishY10.18231/j.yjom.2024.006Pleural effusion (PE) is a common feature of various diseases. The most common causes of PEs are infection, pulmonary embolism, and heart failure. Other diseases include rheumatological diseases, ovarian hyperstimulation syndrome, liver cirrhosis, hypoalbuminemia, and nephrotic syndrome. The principle of PE pathogenesis is either increased fluid production or decreased fluid removal from the pleural cavity, mainly by the parietal pleural layer. According to the underlying cause, the pathogenesis could be due to increased permeability, decreased oncotic pressure or increased hydrostatic pressure of parietal pleural capillaries, increased fluid oncotic pressure, tumor invasion to the pleura, increased lymphatic vessel hydrostatic pressure, lung inflammation, and increased lung interstitial fluid content. Exploring the underlying cause and pathogenic mechanism is the best approach and is immensely helpful in planning the treatment of PE. Treating the underlying cause is the primary approach in treating PEs; thoracocentesis, pleurodesis, pleurectomy, and other possible modalities are applied when indicated, mainly to relieve symptoms. Hence, this review article will discuss the conceivable pathophysiological mechanisms of PEs, common etiologies, radiological diagnostic modalities, and the available therapeutic options.EnglishPleural effusion, Thoracocentesis, Pleural effusion pathophysiology, Pleurodesis, Pleurectomyhttps://www.yemenjmed.com/admin/abstract?id=111References16191. Cao W, Wang Y, Zhou N, et al. Efficacy of ultrasound-guided thoracentesis catheter drainage for pleural effusion. Oncol Lett. 2016;12(6):4445-4448. doi: 10.3892/ol.2016.5244.2. Lababede O, Coombs BD, Webb WR, et al. Pleural Effusion Imaging. Updated Aug 2022. https://emedicine.medscape.com/article/355524-overview?form=fpf. Accessed April 2024.3. Tian P, Qiu R, Wang M, et al. Prevalence, Causes, and Health Care Burden of Pleural Effusions Among Hospitalized Adults in China. JAMA Netw Open. 2021 Aug 2;4(8):e2120306. doi: 10.1001/jamanetworkopen.2021.20306.4. Bhatnagar R, Maskell N. The modern diagnosis and management of pleural effusions. BMJ. 2015;351:h4520. doi: 10.1136/bmj.h4520.5. Habas E, Farfar K, Errayes A, et al. Updates on the pathophysiology and therapies of chylous pleural effusion:A narrative review. Yemen J Med. 2023;3:1-6. doi. 10.32677/yjm.v2i3.4330.6. Korczyński P, Gand;oacute;rska K, Konopka D, et al. Significance of congestive heart failure as a cause of pleural effusion: Pilot data from a large multidisciplinary teaching hospital. Cardiol. J. 2020;27:254. doi: 10.5603/CJ.a2018.0137.7. Zhang J, Zhou H, Aili A, et al. Prevalence and clinical significance of pleural effusion in patients with acute pulmonary embolism: a retrospective study. J Thorac Dis. 2021;13(2):541-551. doi: 10.21037/jtd-20-2552.8. Sundaralingam A, Bedawi EO, Rahman NM. Diagnostics in Pleural Disease. Diagnostics (Basel). 2020;10(12):1046. doi: 10.3390/diagnostics10121046.9. Mason R, Broaddus VC, Martin T, et al. editors. Murray and Nadeland;rsquo;s textbook of respiratory medicine. 5th ed. Philadelphia: Saunders Elsevier, 2010.1764-91.10. Docks B. Pathophysiology, etiology, treatment/management of pleural effusion under disease conditions. J Clin Resp Med. 2022;6(2):110-113. doi. 10.35841/aajcrm-6.2.110.11. Riley L, Karki A, Mehta HJ, et al. Obstetric and gynecologic causes of pleural effusions. Dis Mon. 2019;65(4):109-14. doi: 10.1016/j.disamonth.2018.09.003.12. Lepus CM, Vivero M. Updates in Effusion Cytology. Surg Pathol Clin. 2018;11(3):523-544. doi: 10.1016/j.path.2018.05.003.13. Sun Y, Yu H, Ma J, et al. The Role of 18F-FDG PET/CT Integrated Imaging in Distinguishing Malignant from Benign Pleural Effusion. PLoS One. 2016;11 (8):e0161764. doi: 10.1371/journal.pone.0161764.14. Karki A, Riley L, Mehta HJ, et al. Abdominal etiologies of pleural effusion. Dis Mon. 2019;65(4):95-103. doi: 10.1016/j.disamonth.2018.09.001.15. Balasingam N, Thirunavukarasu K, Selvaratnam G. Etoricoxib- induced pleural effusion: A case for rational use of analgesics. J Pharmacol Pharmacother. 2015;6(4):231-2. doi: 10.4103/0976-500X.171876.16. Nyanti LE, Abd Rahim MK HN. Diagnostic Accuracy of Lactate Dehydrogenase/Adenosine Deaminase Ratio in Differentiating Tuberculous and Parapneumonic Effusions: A Systematic Review. Tuberc Respir Dis. 2024;87(1)91-99. doi https//doi.org/104046/trd.17. Miserocchi G. Mechanisms controlling the volume of pleural fluid and extravascular lung water. Eur Respir Rev. 2009;18(114):244-52. doi: 10.1183/09059180.00002709.18. Elgwairi E, Abdalla A, Elkheshen A, et al. Pleural Effusions in Patients With Congestive Heart Failure: Frequency, Pathogenesis, Diagnosis, and Implications. Cardiol Rev. 2024;32(2):91-96. doi: 10.1097/CRD.0000000000000469.19. McCauley L, Dean N. Pneumonia and empyema: causal, casual or unknown. J Thorac Dis. 2015;7(6):992-8. doi: 10.3978/j.issn.2072-1439.2015.04.36.20. Yu H. Management of pleural effusion, empyema, and lung abscess. Semin Intervent Radiol. 2011 Mar;28(1):75-86. doi: 10.1055/s-0031-1273942.21. Arora RD, Boster J. Malignant Pleural Effusion. [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574541/. Accessed March 2024.22. Gonnelli F, Hassan W, Bonifazi M, et al. Malignant pleural effusion: current understanding and therapeutic approach. Respir Res. 2024;25(1):47. doi: 10.1186/s12931-024-02684-7.23. Chen YM, Yang WK, Whang-Peng J, et al. Elevation of interleukin-10 levels in malignant pleural effusion. Chest. 1996;110:433and;ndash;36. doi: 10.1378/chest.110.2.433.24. Asciak R, Kanellakis NI, Yao X, et al. Pleural Fluid has pro-growth Biological properties which enable Cancer Cell Proliferation. Front Oncol. 2021;11:658395. doi: 10.3389/fonc.2021.658395.25. Sahn SA. Pleural diseases related to metastatic malignancies. Eur Respir J. 1997;10:1907and;ndash;13. doi: 10.1183/09031936.97.10081907.26. Maker AV, Nguyen DM. Images in cardiothoracic surgery. Active malignant pleural effusion captured through the thoracoscope. Ann Thorac Surg. 2005;80:1941. doi: 10.1016/j.athoracsur.2003.11.065.27. Stathopoulos GT, Kalomenidis I. Malignant pleural effusion: tumor-host interactions unleashed. Am J Respir Crit Care Med. 2012;186:487and;ndash;92. doi: 10.1164/rccm.201203-0465PP.28. Moudgil H, Sridhar G, Leitch AG. Reactivation disease: the commonest forms of tuberculous pleural effusion in Edinburgh. 1980and;ndash;1991. Respir Med. 1994;88301and;ndash;4. doi 101016/0954-6111(94)90060-4.29. Shaw JA, Irusen EM, Diacon AH, Koegelenberg CF. Pleural tuberculosis: A concise clinical review. Clin Respir J. 2018;12(5)1779-1786. doi 101111/crj12900.30. Ong A, Creasman J, Hopewell PC, et al. A molecular epidemiological assessment of extrapulmonary tuberculosis in San Francisco. Clin Infect Dis. 2004;38(1)25-31. doi 101086/380448.31. Cohen LA, Light RW. Tuberculous Pleural Effusion. Turk Thorac J. 2015;16(1):1-9. doi: 10.5152/ttd.2014.32. Berger HW, Mejia E. Tuberculous pleurisy. Chest. 1973;63(1):88-92. doi: 10.1378/chest.63.1.88.33. McNally E, Ross C, Gleeson LE. The tuberculous pleural effusion. Breathe (Sheff). 2023;19(4):230143. doi: 10.1183/20734735.0143-2023.34. Stead WW, Eichenholz A SH. Operative and pathologic findings in twenty-four patients with syndrome of idiopathic pleurisy with effusion, presumably tuberculosis. Am Rev Tuberc 1955;71473and;ndash;502.35. radiopaedia update, 2024. https://radiopaedia.org/articles/tuberculous-empyema#:~:text=Tuberculous%20empyema%20is%20a%20chronic,number%20of%20tubercle%20bacilli%201. Acessed Jun 2024.36. Light RW. Pleural effusion due to pulmonary emboli. Curr Opin Pulm Med. 2001;7(4):198-201. doi: 10.1097/00063198-200107000-00006.37. Findik S. Pleural effusion in pulmonary embolism. Curr Opin Pulm Med. 2012 Jul;18(4):347-54. doi: 10.1097/MCP.0b013e32835395d5.38. Rudrappa M, Paul M. Chylothorax. [Updated 2023 Feb 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459206/.39. Heidecker J, Kaplan A, Sahn SA. Pleural fluid and peripheral eosinophilia from hemothorax: hypothesis of the pathogenesis of EPE in hemothorax and pneumothorax. Am J Med Sci. 2006;332(3):148-52. doi: 10.1097/00000441-200609000-00011.40. Pereira AE, Terra RM, Teixeira LR. et al. Recurrent post-traumatic non-eosinophilic pleural effusion: report of three cases. Clinics (Sao Paulo). 2008;63(3):414-5. doi: 10.1590/s1807-59322008000300023.41. Jabbar A, Qureshi R, Nasir K, Dhrolia M, Ahmad A. Transudative and Exudative Pleural Effusion in Chronic Kidney Disease Patients: A Prospective Single-Center Study. Cureus. 2021;13(10):e18649. doi: 10.7759/cureus.18649.42. Huggins JT, Sahn SA. Drug-induced pleural disease. Clin Chest Med. 2004;25(1):141-53. doi: 10.1016/S0272-5231(03)00125-4.43. Antony VB. Drug-induced pleural disease. Clin Chest Med. 1998;19(2):331-40. doi: 10.1016/s0272-5231(05)70080-0.44. Tryfon S, Papadopoulou E, Saroglou M, et L. Clinical and pathophysiological characteristics of valproate-induced pleural effusion. Clin Toxicol (Phila). 2021;59(10):869-876. doi: 10.1080/15563650.2021.1945081.45. Kassem MM, Wallen JM. Esophageal Perforation and Tears. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532298/. Accessed February 2024.46. Y K, F AB, A T, D H. Boerhaave syndrome in an elderly man successfully treated with 3-month indwelling esophageal stent. Radiol Case Rep. 2018;13(5):1084-1086. doi: 10.1016/j.radcr.2018.04.026.47. Yap D, Ng M, Mbakada N. A rare complication of ileostomy obstruction: Boerhaave syndrome. Ann R Coll Surg Engl. 2018;100(8):e1-e4. doi: 10.1308/rcsann.2018.0129.48. Lieu MT, Layoun ME, Dai D, et al. Tension hydropneumothorax as the initial presentation of Boerhaave syndrome. Respir Med Case Rep. 2018 Jul 31;25:100-103. doi: 10.1016/j.rmcr.2018.07.007.49. Alonso JC. Pleural effusion in liver disease. Semin Respir Crit Care Med. 2010;31(6):698-705. doi: 10.1055/s-0030-1269829.50. Singh A, Bajwa A, Shujaat A. Evidence-based review of the management of hepatic hydrothorax. Respiration. 2013;86:155and;ndash;173. doi: 10.1159/000346996.51. Pippard B, Bhatnagar M, McNeill L, et al. Hepatic Hydrothorax: A Narrative Review. Pulm Ther. 2022;8(3):241-254. doi: 10.1007/s41030-022-00195-8.52. Badillo R, Rockey DC. Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients and review of the literature. Medicine (Baltimore) 2014;93:135and;ndash;142. doi: 10.1097/MD.0000000000000025.53. Hung TH, Tseng CW, Tsai CC, et al. The long-term outcomes of cirrhotic patients with pleural effusion. Saudi J Gastroenterol. 2018;24(1):46and;ndash;51. doi: 10.4103/sjg.SJG_336_17.54. Roussos A, Philippou N, Mantzaris GJ, et al. Hepatic hydrothorax: pathophysiology diagnosis and management. J Gastroenterol Hepatol. 2007;22(9):1388and;ndash;1393. doi: 10.1111/j.1440-1746.2007.05069.x.55. Lv Y, Han G, Fan D. Hepatic hydrothorax. Ann Hepatol. 2018;17(1):33and;ndash;46. doi: 10.5604/01.3001.0010.7533.56. Esposito AJ, Chu SG, et al. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med. 2019;40(3):545-560. doi: 10.1016/j.ccm.2019.05.003.57. Gulhane S, Gangane N. Detection of lupus erythematosus cells in pleural effusion: An unusual presentation of systemic lupus erythematosus. J Cytol. 2012;29(1):77-9. doi: 10.4103/0970-9371.93232.58. Anevlavis S, Tzouvelekis A, Bouros D. Mechanisms of pleural involvement in orphan diseases. Respiration. 2012;83(1):5-12. doi: 10.1159/000335128.59. Alexandrakis MG, Kyriakou D, Alexandraki R, et al. Pleural interleukin-1 beta in differentiating transudates and exudates: comparative analysis with other biochemical parameters. Respiration. 2002;69(3):201-6. doi: 10.1159/000063620.60. Andrews BS, Penny R. The role of immune complexes in the pathogenesis of disease. Aust N Z J Med. 1976;6(6):591-602. doi: 10.1111/j.1445-5994.1976.tb04003.x.61. Bouros D, Pneumatikos I, Tzouvelekis A. Pleural involvement in systemic autoimmune disorders. Respiration. 2008;75(4):361-71. doi: 10.1159/000119051.62. Delvigne A. Symposium: Update on prediction and management of OHSS. Epidemiology of OHSS. Reprod Biomed. 2009; 19(1):8and;ndash;13. doi: 10.1016/s1472-6483(10)60040-5.62. Royal College of Obstetricians and;amp; Gynaecologists . The management of ovarian hyperstimulation syndrome. Available at: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/the-management-of-ovarian-hyperstimulation-syndrome-green-top-gu.63. Ma X, Yin J, Yang R, et al. Clinical Features of Severe Ovarian Hyperstimulation Syndrome with Hydrothorax. J Clin Med. 2023;12(19):6210. doi: 10.3390/jcm12196210.65. Man A, Schwarz Y, Greif J. Pleural effusion as a presenting symptom of ovarian hyperstimulation syndrome. Eur Respir J. 1997;10:2425and;ndash;2426. doi: 10.1183/09031936.97.10102425.66. Yildizhan R, Adali E, Kolusari A, et al. Ovarian Hyperstimulation Syndrome with pleural effusion: a case report. Cases J. 2008 Nov 18;1(1):323. doi: 10.1186/1757-1626-1-323.67. Loret de Mola JR, Arredondo-Soberon F, et al. Markedly elevated cytokines in pleural effusion during the ovarian hyperstimulation syndrome: transudate or ascites? Fertil Steril. 1997;67:780and;ndash;782. doi: 10.1016/S0015-0282(97)81383-0.68. Katano A, Minamitani M, Yamashita H, et al. Delayed Onset of Pleural Effusion After Thoracic Radiation Therapy for Hodgkin Lymphoma: A Case Report With Over 30-Year Follow-Up. Cureus. 2022;14(7):e27138. doi: 10.7759/cureus.27138.69. Hodgson DC. Late effects in the era of modern therapy for Hodgkin lymphoma. Hematology Am Soc Hematol Educ Program. 2011;2011:323-9. doi: 10.1182/asheducation-2011.1.323.70. Karkhanis VS, Joshi JM. Pleural effusion: diagnosis, treatment, and management. Open Access Emerg Med. 2012;4:31-52. doi: 10.2147/OAEM.S29942.71. Aqeel M, Medhora M, Gore E, et al. Evaluation of Radiation-induced Pleural Effusions after Radiotherapy to Support Development of Animal Models of Radiation Pneumonitis. Health Phys. 2021;121(4):434-443. doi: 10.1097/HP.0000000000001462.72. Zhao J, Day RM, Jin JY, et al. Thoracic radiation-induced pleural effusion and risk factors in patients with lung cancer. Oncotarget. 2017;8(57):97623-97632. doi: 10.18632/oncotarget.18824.73. Emamian SA, Kaasband;oslash;l MA, Olsen JE, et al. Accuracy of the diagnosis of pleural effusion on supine chest X-ray. Eur. Radiol. 2014;7:57and;ndash;60. doi: 10.1007/s003300050109.74. Moy MP, Levsky JM, Berko NS, et al. A new, simple method for estimating pleural effusion size on CT scans. Chest. 2013;143(4):1054-1059. doi: 10.1378/chest.12-1292.75. Koh DM, Burke S, Davies N, et al. Transthoracic US of the chest: clinical uses and applications. Radiographics. 2002;22(1):e1. doi: 10.1148/radiographics.22.1.g02jae1e1.76. Wang T, Du G, Fang L, et al. Value of ultrasonography in determining the nature of pleural effusion: Analysis of 582 cases. Medicine (Baltimore). 2022 Aug 19;101(33):e30119. doi: 10.1097/MD.0000000000030119.77. Lynch KC, Oliveira CR, Matheson JS, et al. Detection of pneumothorax and pleural effusion with horizontal beam radiography. Vet Radiol Ultrasound. 2012;53(1):38-43. doi: 10.1111/j.1740-8261.2011.01854.x.78. Kitazono MT, Lau CT, Parada AN, et al. Differentiation of pleural effusions from parenchymal opacities: accuracy of bedside chest radiography. AJR Am J Roentgenol. 2010;194(2)407-12. doi 102214/AJR092950.79. Cardinale L, Volpicelli G, Lamorte Aand;nbsp; et al. . Revisiting signs, strengths and weaknesses of Standard Chest Radiography in patients of Acute Dyspnea in the Emergency Department. J Thorac Dis 2012;4(4)398-407 doi 103978/j.issn2072-143920120505.80. Long R, Lau A, Barrie Jand;nbsp; et al. . Limitations of Chest Radiography in Diagnosing Subclinical Pulmonary Tuberculosis in Canada. Mayo Clin Proc Innov Qual Outcomes. 2023 ;7(3)165-170. doi 101016/j.mayocpiqo202303003.81. Nakajima R, Abe K, Sakai S. Diagnostic Ability of FDG-PET/CT in the Detection of Malignant Pleural Effusion. Medicine (Baltimore). 2015;94 (29):e1010. doi: 10.1097/MD.0000000000001010.82. Pourjabbar S, Singh S, Sharma A, et al. What is the minimal radiation dose that can be used for detecting pleural effusion?. AJR Am J Roentgenol. 2014;203 (1):118-22. doi: 10.2214/AJR.13.11842.83. Eisenberg RL. Pneumonia. What Radiology Residents Need to Know: Chest Radiology. 2019:55and;ndash;81. doi: 10.1007/978-3-030-16826-1_6.84. Song JW, Im JG, Goo JM, et al. Pseudochylous pleural effusion with fat-fluid levels: report of six cases. Radiology. 2000;216(2):478-80. doi: 10.1148/radiology.216.2.r00jl09478.85. and;Ccedil;ullu N, Kalemci S, Karakaş and;Ouml;, et al. Efficacy of CT in diagnosis of transudates and exudates in patients with pleural effusion. Diagn Interv Radiol. 2014;20(2):116-20. doi: 10.5152/dir.2013.13066.86. Halvorsen RA, Fedyshin PJ, Korobkin M, et al. Ascites or pleural effusion? CT differentiation: four useful criteria. Radiographics. 1986;6(1):135-49. doi: 10.1148/radiographics.6.1.3685482.87. Gorkem SB, Coskun A, Yikilmaz A, et al. Evaluation of pediatric thoracic disorders: comparison of unenhanced fast-imaging-sequence 1.5-T MRI and contrast-enhanced MDCT. AJR Am J Roentgenol. 2013;200(6):1352-7. doi: 10.2214/AJR.12.9502.88. Hierholzer J, Luo L, Bittner RC, et al. MRI and CT in the differential diagnosis of pleural disease. Chest. 2000;118(3):604-9. doi: 10.1378/chest.118.3.604.89. Lichtenstein DA. Ultrasound examination of the lungs in the intensive care unit. Pediatr Crit Care Med. 2009; ;10(6):693-8. doi: 10.1097/PCC.0b013e3181b7f637.90. Cavanna L, Mordenti P, Bertand;egrave; R, et al. Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer. World J Surg Oncol.;12:139. doi: 10.1186/1477.91. Yang PC, Luh KT, Chang DB, et al. Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol. 1992;159(1):29-33. doi: 10.2214/ajr.159.1.1609716.92. Usta E, Mustafi M, Ziemer G. Ultrasound estimation of volume of postoperative pleural effusion in cardiac surgery patients. Interact Cardiovasc Thorac Surg. 2010 Feb;10(2):204-7. doi: 10.1510/icvts.2009.222273.93. Shiroshita A, Nozaki S, Tanaka Y, Luo Y, Kataoka Y. Thoracic ultrasound for malignant pleural effusion: a systematic review and meta-analysis. ERJ Open Res. 2020;6(4):1-7. doi: 10.1183/23120541.00464-2020.94. Sperandeo M, Quarato CMI, Squatrito R, et al. Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis. Diagnostics (Basel). 2022;12(3):725. doi: 10.3390/diagnostics12030725.95. Nakajima R, Abe K, Sakai S. Diagnostic Ability of FDG-PET/CT in the Detection of Malignant Pleural Effusion. Medicine (Baltimore). 2015;94 (29):e101017.96. Erasmus JJ, McAdams HP, Rossi SE, et al. FDG PET of pleural effusions in patients with non-small cell lung cancer. AJR Am J Roentgenol. 2000;175(1):245-9. doi: 10.2214/ajr.175.1.1750245.97. Faiz SA, Pathania P, Song J, et al. Indwelling Pleural Catheters for Patients with Hematologic Malignancies. A 14-Year, Single-Center Experience. Ann Am Thorac Soc. 2017;14(6):976-85. doi: 10.1513/AnnalsATS.201610-785OC.