An 88-Year-Old Woman With Pneumothorax and Black Pleural Effusion.

CASE PRESENTATION: An 88-year-old woman was admitted to our hospital with the sudden onset of dyspnea after eating. The patient had undergone nephrectomy for a left renal tumor 24 years previously. The patient had been prescribed ferrous citrate for iron-deficiency anemia. She complained of appetite loss a few days before admission but had no abdominal pain. CT scan showed no abnormalities in the lungs but a mass in the liver.

Acute kidney injury in hospitalized patients with nonmalignant pleural effusions: a retrospective cohort study.

BACKGROUND: Nonmalignant pleural effusion (NMPE) is common and remains a definite health care problem. Pleural effusion was supposed to be a risk factor for acute kidney injury (AKI). Incidence of AKI in NMPE patients and whether there is correlation between the size of effusions and AKI is unknown. OBJECTIVE: To assess the incidence of AKI in NMPE inpatients and its association with effusion size. STUDY DESIGN AND METHOD: We conducted a retrospective cohort study of inpatients admitted to the Chinese PLA General Hospital with pleural effusion from 2018-2021. All patients with pleural effusions confirmed by chest radiography (CT or X-ray) were included, excluding patients with diagnosis of malignancy, chronic dialysis, end-stage renal disease (ESRD), community-acquired AKI, hospital-acquired AKI before chest radiography, and fewer than two serum creatinine tests during hospitalization. Multivariate logistic regression and LASSO logistic regression models were used to identify risk factors associated with AKI. Subgroup analyses and interaction tests for effusion volume were performed adjusted for the variables selected by LASSO. Causal mediation analysis was used to estimate the mediating effect of heart failure, pneumonia, and eGFR < 60 ml/min/1.73m2 on AKI through effusion volume. RESULTS: NMPE was present in 7.8% of internal medicine inpatients. Of the 3047 patients included, 360 (11.8%) developed AKI during hospitalization. After adjustment by covariates selected by LASSO, moderate and large effusions increased the risk of AKI compared with small effusions (moderate: OR 1.47, 95%CI 1.11-1.94 p = 0.006; large: OR 1.86, 95%CI 1.05-3.20 p = 0.028). No significant modification effect was observed among age, gender, diabetes, bilateral effusions, and eGFR. Volume of effusions mediated 6.8% (p = 0.005), 4.0% (p = 0.046) and 4.6% (p < 0.001) of the effect of heart failure, pneumonia and low eGFR on the development of AKI respectively. CONCLUSION: The incidence of AKI is high among NMPE patients. Moderate and large effusion volume is independently associated with AKI compared to small size. The effusion size acts as a mediator in heart failure, pneumonia, and eGFR.

Recurrent leishmaniasis infection isolated in the pleural fluid.

We present a rare case of recurrent leishmaniasis infection in a female in her 80s who re-presented with a pleural effusion. The patient was initially investigated as an outpatient for cytopenia and underwent a bone marrow biopsy which subsequently diagnosed visceral leishmaniasis. Following full treatment, and apparent recovery, she re-presented with pleural effusion, hypoalbuminaemia and cytopenia. Leishmania was eventually isolated in a pleural fluid sample obtained on therapeutic drainage, and she was treated for a recurrence at a tertiary infectious disease unit. This interesting and challenging case demonstrates the importance of suspecting leishmaniasis recurrence in previously treated cases and the diagnostic benefit of pleural fluid analysis in the context of suspected leishmaniasis.

IR808@MnO nano-near infrared fluorescent dye's diagnostic value for malignant pleural effusion.

BACKGROUND: Malignant pleural effusion is mostly a complication of advanced malignant tumors. However, the cancer markers such as carbohydrate antigen 125 (CA 125), carbohydrate antigen 15-3 (CA 15-3), carbohydrate antigen 19-9 (CA 19-9), and cytokeratin fragment 21-1 (CYFRA 21-1) have low sensitivity and organ specificity for detecting malignant pleural effusion. RESEARCH QUESTION: Is IR808@MnO nano-near infrared fluorescent dye worthy for the diagnosis in differentiating benign and malignant pleural effusions. STUDY DESIGN AND METHODS: This experiment was carried out to design and characterize the materials for in vitro validation of the new dye in malignant tumor cells in the A549 cell line and in patients with adenocarcinoma pleural effusion. The dye was verified to possess tumor- specific targeting capabilities. Subsequently, a prospective hospital-based observational study was conducted, enrolling 106 patients and excluding 28 patients with unknown diagnoses. All patients underwent histopathological analysis of thoracoscopic biopsies, exfoliative cytological analysis of pleural fluid, and analysis involving the new dye. Statistical analyses were performed using Microsoft Excel, GraphPad Prism, and the R language. RESULTS: The size of IR808@MnO was 136.8 ± 2.9 nm, with peak emission at 808 nm, and it has near-infrared fluorescence properties. Notably, there was a significant difference in fluorescence values between benign and malignant cell lines (p < 0.0001). The malignant cell lines tested comprised CL1-5, A549, MDA-MB-468, U-87MG, MKN-7, and Hela, while benign cell lines were BEAS-2B, HUVEC, HSF, and VE. The most effective duration of action was identified as 30 min at a concentration of 5 µl. This optimal duration of action and concentration were consistent in patients with lung adenocarcinoma accompanied by pleural effusion and 5 µl. Of the 106 patients examined, 28 remained undiagnosed, 39 were diagnosed with malignant pleural effusions, and the remaining 39 with benign pleural effusions. Employing the new IR808@MnO staining method, the sensitivity stood at 74.4%, specificity at 79.5%, a positive predictive value of 69.2%, and a negative predictive value of 82.1%. The area under the ROC curve was recorded as 0.762 (95% CI: 0.652-0.872). The confusion matrix revealed a positive predictive value of 75.7%, a negative predictive value of 75.6%, a false positive rate of 22.5%, and a false negative rate of 26.3%. INTERPRETATION: The IR808@MnO fluorescent probe represents an efficient, sensitive, and user-friendly diagnostic tool for detecting malignant pleural fluid, underscoring its significant potential for clinical adoption.

Assessment of maxillary sinus fluid volume for postmortem diagnosis of drowning.

INTRODUCTION: Drowning is a comprehensive and exclusive diagnosis at autopsy. Autopsy findings such as pleural effusion and waterlogged lungs contribute to the diagnosis. Herein, we aim to reveal the practical usefulness and postmortem changes of the maxillary sinus fluid volume to diagnose drowning. METHODS: We evaluated 52 drowning and 59 nondrowning cases. The maxillary sinus fluid volume was measured using a computed tomography (CT) scan, and pleural effusion volume and lung weight were manually measured at autopsy. The utility of these three indices for diagnosing drowning and its postmortem changes was evaluated. RESULTS: The maxillary sinus fluid volume was significantly higher in drowning cases than in other external causes and cardiovascular death cases. Receiver operating characteristic curve analysis revealed that a total maxillary sinus fluid volume >1.04 mL more usefully indicated drowning (odds ratio, 8.19) than a total pleural effusion volume >175 mL (odds ratio, 7.23) and a total lung weight >829 g (odds ratio, 2.29). The combination of maxillary sinus fluid volume and pleural effusion volume more effectively predicted drowning than one index alone. Moreover, the maxillary sinus fluid volume was less influenced by the postmortem interval than the other two indices up to a week after death. CONCLUSION: Maxillary sinus fluid volume can be more useful than pleural effusion volume and lung weight with higher sensitivity and odds ratio for diagnosing drowning. IMPLICATIONS FOR PRACTICE: Fluid accumulation in both the maxillary sinuses strongly predicts drowning in the postmortem imaging.

Atypical Layering of FDG in Pleural Effusion.

ABSTRACT: Radiopharmaceuticals can accumulate in malignant or nonmalignant pleural effusion on γ and PET imaging, and effusion shows a pattern of diffusely or focally increased activity. Herein, we report atypical layering of FDG in pleural effusion on PET/CT of 3 patients with metastatic gynecological cancer.

CT-based pleural effusion volume estimation formula demonstrates low accuracy and reproducibility for traumatic hemothorax.

PURPOSE: We aimed to evaluate the accuracy and reproducibility of the CT-based volume estimation formula V = d2 * h, where d and h represent the maximum depth and height of the effusion, for acute traumatic hemothorax. MATERIALS & METHODS: Prospectively identified patients with CT showing acute traumatic hemothorax were considered. Volumes were retrospectively estimated using d2 * h, then manually measured on axial images. Subgroup analysis was performed on borderline-sized hemothorax (200-400 mL). Measurements were repeated by three non-radiologists. Bland-Altman analysis was used to assess agreement between the two methods and agreement between raters for each method. RESULTS: A total of 46 patients (median age 34; 36 men) with hemothorax volume 23-1622 mL (median 191 mL, IQR 99-324 mL) were evaluated. Limits of agreement between estimates and measured volumes were -718 - +842 mL (± 202 mL). Borderline-sized hemothorax (n = 13) limits of agreement were -300 - +121 mL (± 114 mL). Of all hemothorax, 85 % (n = 39/46) were correctly stratified as over or under 300 mL, and of borderline-sized hemothorax, 54 % (n = 7/13). Inter-rater limits of agreement were -251 - +350, -694 - +1019, and -696 - +957 for the estimation formula, respectively, and -124 - +190, -97 - +111, and -96 - +46 for the measured volume. DISCUSSION: An estimation formula varies with actual hemothorax volume by hundreds of mL. There is low accuracy in stratifying hemothorax volumes close to 300 mL. Variability between raters was substantially higher with the estimation formula than with manual measurements.

Pleural procedures: an audit of practice and complications in a regional Australian teaching hospital.

BACKGROUND: Pleural procedures are essential for the investigation and management of pleural disease and can be associated with significant morbidity and mortality. There is a lack of pleural procedure complication data in the Australian and New Zealand region. AIMS: To review pleural procedure practices at Wollongong Hospital with an emphasis on the assessment of complications, use of thoracic ultrasound (TUS), pathology results and comparison of findings with international data. METHODS: Retrospective analysis of medical records was performed on pleural procedures identified through respiratory specialist trainee logbooks at Wollongong Hospital from January 2018 to December 2021. Comparison of complication rates was made to the British Thoracic Society 2011 a national pleural audit. RESULTS: One hundred and twenty-one pleural procedures were identified. There were 71 chest drains, 49 thoracocentesis and one indwelling pleural catheter (IPC) insertion. Ninety-seven per cent of procedures were performed for pleural effusions and 3% for pneumothorax. This audit demonstrated a complication rate (excluding pain) of 16.9% for chest drains and 4.1% for thoracocentesis. This gave an overall complication event rate of 10.8% (excluding pain) for pleural procedures. There was no major bleeding, organ puncture, pleural space infection or death. Bedside TUS was used in 99% of procedures. CONCLUSION: Complication rates for pleural procedures performed by respiratory specialist trainees at Wollongong Hospital are comparable with international outcomes. This audit provides data for comparison on pleural procedure complication rates in Australia. Future studies are required to determine complication rates with IPCs.

Metastatic Pulmonary Calcification: Single-Center Review of Typical and Atypical Imaging Features.

PURPOSE: The purpose of this study is to bring attention to an atypical form of metastatic pulmonary calcification, which is conventionally described as a metabolic process with upper lobe predominance in patients with a specific clinical history, which has not been reported as a distinct entity. METHODS: Patients with metastatic pulmonary calcification (MPC) were first identified with mPower keyword search, including MPC or metastatic calcifications on computed tomography chest radiological reports. Patients were then filtered on likelihood of MPC based off imaging reports. Images were then reviewed by three senior radiologists for pertinent characteristics such as location of MPC, degree of calcifications and pleural effusions. Based on the predominant location of MPC, cases were labeled as either typical or atypical. Clinical and imaging characteristics relevant to MPC were noted and compared across typical and atypical cases. RESULTS: In our study, we describe 25 patients with MPC, 13 defined as typical MPC and 12 with atypical MPC. Through consensus of senior radiologists, MPC was deemed to be mild (52%), moderate (44%), or severe (4%). Twenty-three patients (92%) had underlying renal disease including 21 requiring dialysis at the time of diagnosis. Outside of age at diagnosis, there was no significant clinical difference between the two groups. Evaluation of imaging characteristics (average HU attenuation, 267; range, 186-295), pattern and distribution of calcification, and clinical history strongly supported a diagnosis of atypical MPC. CONCLUSION: This study presents several cases of lower lobe subpleural MPC associated with pleural effusions, which has not been reported as a distinct entity, despite comprising a significant portion of MPC cases at our institution.

Lung ultrasound for the sick child: less harm and more information than a radiograph.

In the realm of emergency medicine, the swift adoption of lung ultrasound (LU) has extended from the adult population to encompass pediatric and neonatal intensivists. LU stands out as a bedside, replicable, and cost-effective modality, distinct in its avoidance of ionizing radiations, a departure from conventional chest radiography. Recent years have witnessed a seamless adaptation of experiences gained in the adult setting to the neonatal and pediatric contexts, underscoring the versatility of bedside Point of care ultrasound (POCUS). This adaptability has proven reliable in diagnosing common pathologies and executing therapeutic interventions, including chest drainage, and central and peripheral vascular cannulation. The surge in POCUS utilization among neonatologists and pediatric intensivists is notable, spanning economically advanced Western nations with sophisticated, high-cost intensive care facilities and extending to low-income countries. Within the neonatal and pediatric population, POCUS has become integral for diagnosing and monitoring respiratory infections and chronic and acute lung pathologies. This, in turn, contributes to a reduction in radiation exposure during critical periods of growth, thereby mitigating oncological risks. Collaboration among various national and international societies has led to the formulation of guidelines addressing both the clinical application and regulatory aspects of operator training. Nevertheless, unified guidelines specific to the pediatric and neonatal population remain lacking, in contrast to the well-established protocols for adults. The initial application of POCUS in neonatal and pediatric settings centered on goal-directed echocardiography. Pivotal developments include expert statements in 2011, the UK consensus statement on echocardiography by neonatologists, and European training recommendations. The Australian Clinician Performed Ultrasound (CPU) program has played a crucial role, providing a robust academic curriculum tailored for training neonatologists in cerebral and cardiac assessment. Notably, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) recently disseminated evidence-based guidelines through an international panel, delineating the use and applications of POCUS in the pediatric setting. These guidelines are pertinent to any professional tending to critically ill children in routine or emergency scenarios. In light of the burgeoning literature, this paper will succinctly elucidate the methodology of performing an LU scan and underscore its primary indications in the neonatal and pediatric patient cohort. The focal points of this review comprise as follows: (1) methodology for conducting a lung ultrasound scan, (2) key ultrasonographic features characterizing a healthy lung, and (3) the functional approach: Lung Ultrasound Score in the child and the neonate.  Conclusion: the aim of this review is to discuss the following key points: 1. How to perform a lung ultrasound scan 2. Main ultrasonographic features of the healthy lung 3. The functional approach: Lung Ultrasound Score in the child and the neonate What is Known: • Lung Ultrasound (LUS) is applied in pediatric and neonatal age for the diagnosis of pneumothorax, consolidation, and pleural effusion. • Recently, LUS has been introduced into clinical practice as a bedside diagnostic method for monitoring surfactant use in NARDS and lung recruitment in PARDS. What is New: • Lung Ultrasound (LUS) has proven to be useful in confirming diagnoses of pneumothorax, consolidation, and pleural effusion. • Furthermore, it has demonstrated effectiveness in monitoring the response to surfactant therapy in neonates, in staging the severity of bronchiolitis, and in PARDS.

Myelomatous pleural effusion developing after autologous stem cell transplantation in a patient with multiple myeloma: A rare case.

Myelomatous pleural effusion (MPE) is a very rare condition with a poor prognosis. In our case of multiple myeloma (MM) with early recurrence presenting with a MPE, management of the treatment is discussed together with the case presentation. A 35 year old female patient with a diagnosis of lambda light chain MM presented with complaints of dyspnea and pain in the left shoulder 2 months after autologous transplantation. On physical examination, respiratory sounds were decreased in the lower lobe of the left lung and there was dullness. Pleural effusion and plasmacytoma, more prominent on the left, were detected on chest X ray and thorax computed tomography (CT). The pleural fluid collected during therapeutic thoracentesis was examined by flow cytometry, cytology, and peripheral smear examination and as a result, the patient was considered to have early recurrence after autologous transplantation, DRd chemotherapy was immediately started, and clinical and radiological improvement was observed. Pleural effusion developing in patients with MM should be evaluated in terms of MPE. In the presence of MPE, the duration of response to treatment is short, thus effective and dynamic treatment methods for bridging should be used before referral of the patients to clinical trials and hematopoietic stem cell transplantation.

A patient with widespread skin lesions presenting with massive pleural effusion.

Mycosis fungoides is the most commonly seen type of cutaneous T-cell lymphoproliferative disease. While mycosis fungoides is linked to an increased risk of developing secondary malignancies, the occurrence of B-cell-originated disease in association with it is exceedingly rare. A 66-year-old male with persistent papillomatous skin eruption was admitted due to dyspnea. Chest X-ray, positron emission tomography, and chest computed tomography revealed axillary and mediastinal lymph node enlargement and right lower pulmonary lobe infiltration along with right-sided massive pleural effusion. Histological and immunohistochemical findings of pleural biopsy and axillary lymph nodes suggested a diagnosis of pulmonary extranodal marginal zone lymphoma. Skin biopsies from the abdomen, chest, and legs revealed CD4/CD8 double-positive patch stage of mycosis fungoides. After completing six cycles of chemotherapy, complete remission of lymphoma was achieved, with the skin eruptions remaining unchanged. Herein, the authors present a unique case of concomitant diagnoses of mycosis fungoides and marginal zone B-cell lymphoma of the respiratory system to emphasize the importance of careful evaluation of each finding.

Disseminated Cryptococcus neoformans presenting with an isolated pleural effusion in a patient receiving temozolomide and long-term steroids.

Cryptococcus neoformans is a ubiquitous environmental organism found worldwide. Infection with this organism occurs predominantly in immunocompromised hosts, including persons living with HIV or those with impaired cellular immunity. Cryptococcal pleural effusions have been described in cases with extensive pulmonary involvement. Here we present the case of a woman receiving temozolomide and steroids for glioblastoma multiforme, who developed cough and dyspnoea and was found to have an uncomplicated pleural effusion. Pleural fluid culture grew Cryptococcus neoformans with negative culture on bronchoalveolar lavage. High serum cryptococcal antigen titre of 1:64 prompted lumbar puncture which demonstrated positive cerebrospinal fluid for Cryptococcus neoformans She was treated with liposomal amphotericin B and flucytosine, followed by consolidation and maintenance therapy with fluconazole. Pleural involvement in the absence of pulmonary involvement has rarely been reported. We review pulmonary and radiographic manifestations of cryptococcal infection, when to assess for disseminated infection, and management principles.

Pleural Effusion: Diagnostic Approach in Adults.

Pleural effusion affects 1.5 million patients in the United States each year. New effusions require expedited investigation because treatments range from common medical therapies to invasive surgical procedures. The leading causes of pleural effusion in adults are heart failure, infection, malignancy, and pulmonary embolism. The patient's history and physical examination should guide evaluation. Small bilateral effusions in patients with decompensated heart failure, cirrhosis, or kidney failure are likely transudative and do not require diagnostic thoracentesis. In contrast, pleural effusion in the setting of pneumonia (parapneumonic effusion) may require additional testing. Multiple guidelines recommend early use of point-of-care ultrasound in addition to chest radiography to evaluate the pleural space. Chest radiography is helpful in determining laterality and detecting moderate to large pleural effusions, whereas ultrasonography can detect small effusions and features that could indicate complicated effusion (i.e., infection of the pleural space) and malignancy. Point-of-care ultrasound should also guide thoracentesis because it reduces complications. Computed tomography of the chest can exclude other causes of dyspnea and suggest complicated parapneumonic or malignant effusion. When diagnostic thoracentesis is indicated, Light's criteria can help differentiate exudates from transudates. Pleural aspirate should routinely be evaluated using Gram stain, cell count with differential, culture, cytology, protein, l-lactate dehydrogenase, and pH levels. Additional assessments should be individualized, such as tuberculosis testing in high-prevalence regions. Parapneumonic effusions are the most common cause of exudates. A pH level less than 7.2 is indicative of complicated parapneumonic effusion and warrants prompt consultation for catheter or chest tube drainage, possible tissue plasminogen activator/deoxyribonuclease therapy, or thoracoscopy. Malignant effusions are another common cause of exudative effusions, with recurrent effusions having a poor prognosis.

Gelatinous Pleural Effusion: A Diagnostic Challenge for Pleural Mesothelioma in an 80-Year-Old Man.

BACKGROUND Gelatinous pleural effusion, due to raised hyaluronic acid, can be associated with pleural infection and malignancies, such as tuberculosis, metastatic pleural disease, and mesothelioma. This report is of an 80-year-old man presenting with a gelatinous pleural effusion and diagnosis of pleural mesothelioma. CASE REPORT An 80-year-old man with diabetes mellitus, ischemic heart disease, metastatic prostate cancer, 30-pack-year smoking history, and 5-year history of asbestos exposure (during his 30s), presented with a 4-week history of breathlessness and was found to have right-sided pleural effusion. Thoracic computed tomography (CT) showed mild right-sided pleural thickening. Pleural tap revealed exudative fluid, with a pH of 7.4, and unremarkable cytology and microbiology analyses. The patient was treated for pneumonia and para-pneumonic effusion and discharged home. He came back 5 weeks later with worsening of symptoms and re-accumulation of pleural fluid. Repeated thorax CT showed extensive right-sided pleural lobular thickening. Pleural tap again yielded an exudative fluid, with a pH of 7.37. Cytology and microbiology did not reveal any positive signs for malignancy or infection. This time the pleural fluid appeared gelatinous in consistency. Pleural biopsy showed atypical epithelioid mesothelial cells arranged in trabeculae, with a tubulo-papillary configuration. Also, immunohistochemistry panel showed tumor cells expressed calretinin, EMA, WT1, and D2-40, with negative TTF1, CEA, and BerEp4. Final diagnosis was epithelioid mesothelioma. CONCLUSIONS This report has shown that a gelatinous pleural effusion can be associated with malignant and inflammatory pleural diseases. In this case, imaging and pleural biopsy with histopathology confirmed a diagnosis of pleural mesothelioma.

Cough-induced chylothorax in a two-year-old boy - case report and review of the literature.

BACKGROUND: Chylothorax is a very rare form of pleural effusion in children, especially after the neonatal period, and predominantly occurs secondary to cardiothoracic surgery. It can lead to significant respiratory distress, immunodeficiency, and malnutrition. Effective treatment strategies are therefore required to reduce morbidity. CASE PRESENTATION: A previously healthy two-year old boy was admitted with history of heavy coughing followed by progressive dyspnea. The chest X-ray showed an extensive opacification of the right lung. Ultrasound studies revealed a large pleural effusion of the right hemithorax. Pleural fluid analysis delivered the unusual diagnosis of chylothorax, most likely induced by preceded excessive coughing. After an unsuccessful treatment attempt with a fat-free diet and continuous pleural drainage for two weeks, therapy with octreotide was initiated. This led to complete and permanent resolution of his pleural effusion within 15 days, without any side effects. CONCLUSIONS: Severe cough may be a rare cause of chylothorax in young children. Octreotide seems to be an effective and safe treatment of spontaneous or traumatic chylothorax in children. There is, however, a lack of comprehensive studies for chylothorax in children and many issues concerning diagnostic strategies and treatment algorithms remain.

A PET-CT score for discriminating malignant from benign pleural effusions.

BACKGROUND AND OBJECTIVES: The results of previous PET-CT studies are contradictory for discriminating malignant from benign pleural effusions. We purpose to develop a PET-CT score for differentiating between benign and malignant effusions. PATIENTS AND METHODS: We conducted a prospective study of consecutive patients with pleural effusions undergoing PET-CT from October 2013 to October 2019 (referral cohort). PET-CT scan features evaluated using the SUV were: linear thickening; nodular thickening; nodules; masses; circumferential thickening; mediastinal and fissural pleural involvement; intrathoracic lymph nodes; pleural loculation; inflammatory consolidation; pleural calcification; cardiomegaly; pericardial effusion; bilateral effusion; lung mass; liver metastasis and other extra-pleural malignancy. The results were validated in an independent prospective cohort from November 2019 to June 2021. RESULTS: One hundred and ninety-nine patients were enrolled in the referral cohort (91 with malignant effusions and 108 benign). The most useful parameters for the development of a PET-CT score were: nodular pleural thickening, pleural nodules with SUV>7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV>4.5 (5 points) and cardiomegaly (-1 point). With a cut-off value of >9 points in the referral cohort, the score established the diagnosis of malignant pleural effusion with sensitivity 87.9%, specificity 90.7%, positive predictive value 88.9%, negative predictive value 89.9%, positive likelihood ratio 7.81 and negative likelihood ratio 0.106. These results were validated in an independent prospective cohort of 75 patients. CONCLUSIONS: PET-CT score was shown to provide relevant information for the identification of malignant pleural effusion.

A case of synchronous IgG4-associated pleuritis and type 1 autoimmune pancreatitis.

A 50-year-old man presented to the emergency department with left chest pain, epigastralgia, and low-grade fever for several days. A CT scan showed left pleural effusion, ground-glass opacities in the lower lobes of both lungs, and a capsule-like rim in the pancreas. ERCP showed narrowing of the main pancreatic duct. EUS-FNA was performed, but pathological findings showed no IgG4-positive cells. A thoracoscopic biopsy was performed, and pathological findings showed many IgG4-positive cells. A diagnosis of autoimmune pancreatitis and IgG4-associated pleurisy was made according to international diagnostic criteria. After that, oral steroid therapy was started, and left pleural effusion and pancreatic enlargement improved.