Incidence, aetiology and clinical features of eosinophilic pleural effusion: a retrospective study.

BACKGROUND: Eosinophilic pleural effusion (EPE) is a distinct entity among pleural effusions, but its diagnostic and prognostic significance is still controversial. This study aimed to evaluate the incidence and aetiological distribution of EPE in our institution and to assess the relationship between EPE and malignancy and other underlying diseases and the relevance of the percentage of eosinophils and other laboratory parameters. METHODS: A retrospective study was conducted by reviewing the medical records of 252 patients with PE from September 2017 to January 2021. RESULTS: EPE was found in 34 (13.49%) out of 252 patients. There were 20 (58.82%) males and 14 (41.18%) females in the EPE group. The mean percentage of eosinophils in EPE (21.7%, range (10.0-67.5%)) was significantly higher than the percentage of eosinophils in peripheral blood (5.65%, range (0-34.60%); p < 0.05). The most common cause of EPE was malignant disease (52.94%), followed by idiopathy (14.71%), parasites (8.82%), pneumonia (8.82%) and others (14.71%). Comparative analysis of patients with malignant versus nonmalignant EPE showed that patients with malignant EPE were significantly older, and had a lower white blood cell (WBC) count in the pleural fluid (1.8 vs 4.7 cells × 109/L, p < 0.05). However, the percentage of eosinophils in PE was not significantly different between malignant EPE and nonmalignant EPE (p = 0.66). There was no correlation between the percentage of eosinophils in PE and peripheral blood (r = 0.29; p = 0.09). CONCLUSIONS: Malignant disease ranks as the leading cause of EPE. The presence of EPE should not be considered as a predictive factor of benign conditions. Pleural parasitic infestation (PPI) should be emphasized in areas with a high incidence of parasitic disease.

Tissue-Resident Memory-Like CD8+ T Cells Exhibit Heterogeneous Characteristics in Tuberculous Pleural Effusion.

Tissue-resident memory T (TRM) cells are well known to play critical roles in peripheral tissues during virus infection and tumor immunology. Our previous studies indicated that CD69+CD4+ and CD69+CD8+ T cells in tuberculous pleural effusion (TPE) were antigen-specific memory T cells. However, the phenotypical and functional characteristics of CD8+ TRM cells in tuberculosis remain unknown. We found that CD103+CD8+ T cells were the predominant subset of CD103+ lymphocytes in TPE; both CD103 and CD69 expressed on memory CD8+ T cells from TPE were significantly increased compared with those from paired peripheral blood. Phenotypically, CD103+CD69+ and CD103+CD69-CD8+ T cells expressed higher levels of CD45RO than CD103-CD69+CD8+ T cells did; CD103+CD69-CD8+ T cells highly expressed CD27, CD127, and CD62L and some chemokine receptors. We further compared the functional differences among the four distinct CD45RO+CD8+ T subsets identified by CD103 and CD69 expression. In consist with our published results, CD69+CD8+ T cells, but not CD103+CD8+, produced high levels of IFN-γ after treatment with BCG in the presence of BFA. Nevertheless, CD103-CD69+ and CD103+CD69+ memory CD8+ T cells expressed higher levels of Granzyme B, while CD103+CD69- memory CD8+ T cells were characterized as a possibly immunosuppressive subset by highly expressing CTLA-4, CD25, and FoxP3. Furthermore, TGF-ß extremely increased CD103 expression but not CD69 in vitro. Together, CD103+CD8+ T cells form the predominant subset of CD103+ lymphocytes in TPE; CD103 and CD69 expression defines distinct CD8+ TRM-like subsets exhibiting phenotypical and functional heterogeneity. Our findings provide an important theoretical basis to optimize and evaluate new tuberculosis vaccines.

IgG4-related pleural effusion with high adenosine deaminase levels: A case report and literature review.

RATIONALE: Levels of pleural fluid adenosine deaminase (ADA), a useful marker for the diagnosis of tuberculous pleurisy, are elevated in some reports of immunoglobulin G4 (IgG4)-related pleural effusion. We describe a patient with IgG4-related pleural effusion who exhibited a high concentration of ADA. Furthermore, we reviewed the literature to compare patients with IgG4-related pleural effusion and tuberculous pleurisy. PATIENT CONCERNS: A 75-year-old male patient had dyspnea for 1 month with a left pleural effusion that was exudative, lymphocyte dominant. The pleural fluid test results revealed a total protein (TP) concentration of 6.60 g/dl, a lactate dehydrogenase (LDH) level of 383 IU/dl, and an ADA concentration of 54.5 U/L. An interferon gamma release assay showed a negative result. DIAGNOSES: Histological analysis of the thoracoscopic pleural biopsy revealed lymphoplasmacytic infiltration, with 80 IgG4-positive plasma cells/high-power field, and an IgG4/IgG ratio of approximately 40% to 50%. Other diseases were ruled out based on symptoms, negative autoimmune antigen results, and histopathologic findings. Thus, he was diagnosed with IgG4-related pleural effusion. INTERVENTIONS: He received 15 mg of prednisolone as therapy. OUTCOMES: His pleural effusion and symptoms improved gradually within several months, and prednisolone was tapered to 6 mg daily. LESSONS: It is important to distinguish between IgG4-related pleural effusion and tuberculous pleurisy. Therefore, we compared 22 patients with IgG4-related pleural effusion from PubMed and the Japan Medical Abstracts Society to 40 patients with tuberculous pleurisy at Fukujuji Hospital from January 2017 to May 2019. According to thoracentesis findings, 14 of 18 patients with IgG4-related pleural effusion had high ADA more than 40 U/L. The pleural effusion of patients with IgG4-related pleural effusion showed higher TP levels (P < .001) and lower LDH (P < .001) and ADA levels (P = .002) than those with tuberculous pleurisy. Moreover, the pleural fluid ADA/TP ratio was a good predictor for differentiating IgG4-related pleural effusion and tuberculous pleurisy (area under the receiver operating characteristic curve of 0.909; 95% confidence level: 0.824-0.994).

Serum Creatinine as a Potential Biomarker for the Diagnosis of Tuberculous Pleural Effusion.

BACKGROUND: Previous studies have revealed the disadvantages of traditional methods for the diagnosis of tuberculous pleural effusions (TPEs) and have created interest in exploring other effective biomarkers. Many studies have focused on the correlation between pulmonary diseases and serum creatinine (Cr), a representative biomarker of renal function, but little is known about the direct relationship between Cr and TPE. Our study aimed to explore whether Cr can act as a biomarker for the diagnosis of TPE and to evaluate the correlation between Cr and TPE. MATERIALS AND METHODS: Patients with pleural effusions (PEs) were enrolled in this study. By comparing the concentrations of Cr and adenosine deaminase (ADA) in patients with TPEs and non-TPEs, we determined the sensitivity, specificity, Youden index, and area under the curve for these biomarkers. We generated receiver operating characteristic curves and quantifications to evaluate the diagnostic accuracy. RESULTS: In total, 86 patients (44 with TPE, 25 with malignant pleural effusion (MPE) and 17 with non-tuberculosis infectious PE (NTIPE)) were enrolled in the study. The concentrations of Cr in TPE were significantly higher than those in non-TPE. However, a similar trend was not observed for NTIPE and MPE. The levels of ADA in TPE were significantly higher than those in NTIPE and MPE. CONCLUSION: Cr has the potential for the diagnosis of TPE to some extent though its accuracy is not as good as that of ADA. Further studies are necessary for Cr to be applied in clinical practice for the diagnosis of TPE.

Levels of YKL-40 in pleural effusion and blood from patients with pleuritis.

INTRODUCTION: In recent years, there have been a significant increase in the tests and biomarkers available for pleural fluid analysis. YKL-40 is one of the inflammatory biomarkers that is used for this purpose. The aim of our study is to assess the levels and diagnostic values of YKL-40 in patients with different types of pleural effusions (PE). MATERIALS AND METHODS: This was a prospective, observational and crosssectional study. Pleural and serum YKL-40 levels were measured using enzyme-linked immunosorbent assay in 119 patients with PEs, including 23 transudates PE, 47 malignant PE, 26 parapneumonic PE (PPPE), 17 paramalignant PE (PME) and 6 tuberculous PE (TBPE). RESULT: Median pleural YKL-40 level was higher in exudates (390.3 ng/mL) than in transudates (369.5 ng/mL) (p<0.02). For a cut-off level of 378 ng/mL, it was found to predict exudates with 70% sensitivity and 64% specificity. [area under the curve (AUC)= 0.660, p= 0.01]. Median pleural YKL-40 level was highest in PMEs (407.1 ng/mL) and the lowest in transudates (369.5 ng/ mL) and high levels, with a cut-off value of 396 ng/mL, differentiated PMEs from other subgroups with 65% sensitivity and 68% specificity. (AUC= 0.680, p= 0.02). Median serum YKL-40 level was the highest in PPPEs (351.4 ng/mL) and the lowest in TBPEs (114.2 ng/mL) (p= 0.01). For a cut-off level of 284 ng/mL, it differentiated PPPEs from TBPEs with 61% sensitivity and 100% specificity (AUC= 0.830, p= 0.01). In TBPEs, pleural/serum YKL-40 ratio was strongly related with pleural ADA (r= 1, p= 0.04). CONCLUSIONS: Pleural YKL-40 may be useful for differentiating exudates and detecting PMEs. Serum YKL-40 may be good diagnostic biomarker for differentiating PPPEs and TBPEs. Additionally, measuring serum and pleural YKL-40 and pleural ADA may be reliable way to diagnose TBPEs.

Pleural and serum markers for diagnosis of malignant pleural effusion.

BACKGROUND: Differentiation between benign and malignant exudative pleural effusion remains a clinical challenge. Recently, several markers have been reported to increase the diagnostic accuracy of malignant pleural effusion, with controversial results. METHODS: Patients with exudative pleural effusion were divided into 2 groups: a malignant pleural effusion group (39 patients) diagnosed by malignant cells in pleural fluid cytology or by malignant infiltration of the pleura on pleural biopsy, and a benign pleural effusion group (51 patients) with neither malignant cells in pleural fluid cytology nor malignant infiltration of the pleura on pleural biopsy. Matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 were determined in both serum and pleural fluid samples, using commercially available enzyme-linked immunosorbent assay kits. RESULTS: The etiology of malignant pleural effusion in the malignant group was breast cancer in 43.6% and bronchogenic carcinoma in 25.6%. There was a statistically significant difference between the 2 groups regarding sex, with more males in the benign group. There was no significant difference between groups regarding age. The median levels of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 were higher in the malignant group than in the benign group, and the differences were highly significant in both pleural fluid (p < 0.001) and serum (p < 0.001). CONCLUSION: Matrix metaloproteinase-9 and tissue inhibitor of metalloproteinase-1 in serum and pleural fluid samples might be valuable markers for differentiating benign from malignant pleural effusions.

Diagnostic significance of biochemical markers and pentraxin-3 in the differential diagnosis of malign, benign pleural effusion and empyema.

OBJECTIVE: To investigate the diagnostic significance of biochemical markers and pentraxin-3 in the differential diagnosis of pleural effusions. METHODS: The prospective clinical study was conducted at the Suleyman Demirel University, Isparta, Turkey, from January 2013 to June 2014, and comprised patients with pleural effusion. Pleural effusions were tested for glucose, protein, lactate dehydrogenase, and pentraxin 3 while simultaneous C-reactive protein and white blood cell levels were studied in the serums. Data was analysed using SPSS 22. RESULTS: Of the 96 patients, 48(50%) had malignant disease, 33(34%) had benign pleural effusion, and 15(16%) had empyema. In terms of glucose, protein, lactate dehydrogenase in the pleural effusions and C-reactive protein values in serums, significant differences were observed among the three groups (p<0.05). The pentraxin-3 levels in the empyema group was significantly higher than in the benign cases (p<0.033). No significant difference was observed in terms of the other variables between the groups (p>0.05). CONCLUSIONS: Serum C-reactive protein and pentraxin-3 levels were not found to be individually conclusive in the differential diagnosis of pleural effusion. Also, lactate dehydrogenase levels were higher and glucose levels were lower in empyema.

High-throughput autoantibody analysis in malignant pleural effusion and tuberculosis pleural effusion.

BACKGROUND: Malignant pleural effusion (MPE) and tuberculosis pleural effusion (TPE) are 2 kinds of common pleural diseases. Finding efficient and accurate biomarkers to distinguish the 2 is of benefit to basic and clinical research. In the present study, we carried out the first high-throughput autoantibody chip to screen the beneficial biomarker with samples of MPE and TPE and the corresponding serum. METHODS: We collected pleural effusion and serum of patients with MPE (n = 10) and TPE (n = 10) who had been in Beijing Chao-Yang hospital from June 2013 to August 2014. Using RayBio Human Protein Array-G2 to measure the concentration of 487 defined autoantibodies. RESULTS: Fold changes of Bcl-2-like protein 11 (BIM) autoantibody in MPE-serum/TPE-serum and MPE/TPE groups were 10 (P = .019) and 6 (P = .001); for decorin autoantibody, MPE-serum/TPE-serum ratio was 0.6 (P = .029), and MPE/TPE ratio was 0.3 (P < .001). CONCLUSION: BIM autoantibody is a promising MPE biomarker by high-throughput autoantibody analysis in MPE and TPE.

Laboratory Discrimination Between Neutrophilic Malignant and Parapneumonic Pleural Effusions.

BACKGROUND: Malignant pleural effusion (MPE) occasionally demonstrates neutrophilic predominance, commonly found in parapneumonic pleural effusion (PPE). In comparison with lymphocytic MPE, neutrophilic MPE may have different characteristics associated with a more intense inflammatory response and poor prognosis. These characteristics of neutrophilic MPE may lead to inappropriate management and delayed diagnosis. Moreover, the limited diagnostic yield of microbiologic and cytologic tests makes early differential diagnosis between neutrophilic MPE and PPE more challenging. This study investigated objective laboratory findings to help distinguish neutrophilic MPE from PPE. MATERIALS AND METHODS: A retrospective study was conducted on patients with neutrophilic MPE and PPE. Routine blood and pleural fluid data of the 2 groups were compared, and the diagnostic performances of predictors for neutrophilic MPE were assessed using receiver-operating characteristic curves. RESULTS: Forty-one and 140 patients with neutrophilic MPE and PPE, respectively, were included. In final analysis, serum C-reactive protein, pleural fluid neutrophil-to-lymphocyte ratio, and pleural fluid carcinoembryonic antigen were significantly different between the 2 groups. With cut-off values of C-reactive protein <6.0 mg/dL, neutrophil-to-lymphocyte ratio <3.0 and carcinoembryonic antigen >8.0 ng/mL, the presence of any 2 or more parameters provided an area under the curve of 0.928 (95% CI, 0.851-0.999), yielding a sensitivity of 88%, specificity of 98%, positive predictive value of 92% and negative predictive value of 96% for identifying MPE. CONCLUSIONS: MPE should be considered even in patients with neutrophilic exudative effusion, especially if at least 1 predictor for neutrophilic MPE is present. Our results may help guide differentiation of neutrophilic MPE from PPE.

Serial Observation of Blood Alcohol Concentration post Ethanol Pleurodesis (SOBER) Study: A Prospective Observational Study.

OBJECTIVES: To measure the blood alcohol concentration levels in patients after chemical pleurodesis with ethanol sclerosant via video-assisted thoracoscopic surgery. DESIGN: Prospective observational study. SETTING: Single tertiary university hospital. PARTICIPANTS: Eight patients undergoing chemical pleurodesis with ethanol sclerosant for management of recurrent pneumothoraces or pleural effusions. INTERVENTIONS: After ethics board approval, written informed consent was obtained from 8 patients undergoing chemical pleurodesis with ethanol sclerosant for management of recurrent pneumothoraces or pleural effusions. Five patients received a dose of 100 mL of 70% ethanol/1% iodine, and 3 patients received 30 mL. Blood alcohol concentration measurement was obtained at 30, 60, 90, and 120 minutes after the ethanol was instilled in the interpleural space. The postoperative quality of recovery scale was conducted preoperatively and then at 30 and 60 minutes postoperatively and on postoperative days 1 and 3. MEASUREMENTS AND MAIN RESULTS: The highest observed blood alcohol concentration was recorded at 30 minutes post-instillation of ethanol in all patients. The blood alcohol concentration peak for 75% of patients (6/8) was >0.05 g/dL at 30 minutes post-instillation of ethanol, and for 4 patients (50%), this remained >0.05 g/dL at 60 minutes. The median area under curve of ethanol absorbed was 5.66 g/dL/min (3.24-7.29). CONCLUSIONS: Significant systemic absorption of ethanol can occur after instillation of ethanol sclerosant, which potentially may affect the quality of recovery in patients. Postoperative management of these patients may need to be specifically tailored to take into account these observations.

Comparison of cobas EGFR Mutation Test v2 and PANAMutyper-R-EGFR for Detection and Semi-Quantification of Epidermal Growth Factor Receptor Mutations in Plasma and Pleural Effusion Supernatant.

BACKGROUND: Plasma epidermal growth factor receptor (EGFR) mutation tests are less invasive than tissue EGFR mutation tests. We determined which of two kits is more efficient: cobas EGFR Mutation test v2 (cobasv2; Roche Molecular Systems, Pleasanton, CA, USA) or PANAMutyper-R-EGFR (Mutyper; Panagene, Daejeon, Korea). We also evaluated whether pleural effusion supernatant (PE-SUP) samples are assayable, similar to plasma samples, using these two kits. METHODS: We analyzed 156 plasma and PE-SUP samples (31 paired samples) from 116 individuals. We compared the kits in terms of accuracy, assessed genotype concordance (weighted κ with 95% confidence intervals), and calculated Spearman's rho between semi-quantitatively measured EGFR-mutant levels (SQIs) measured by each kit. We also compared sensitivity using 47 EGFR-mutant harboring samples divided into more-dilute and less-dilute samples (dilution ratio: ≥ or <1:1,000). RESULTS: cobasv2 tended to have higher accuracy than Mutyper (73% vs 69%, P=0.53), and PE-SUP samples had significantly higher accuracy than plasma samples (97% vs 55-71%) for both kits. Genotype concordance was 98% (κ=0.92, 0.88-0.96). SQIs showed strong positive correlations (P<0.0001). In less-dilute samples, accuracy and sensitivity did not differ significantly between kits. In more-dilute samples, cobasv2 tended to have higher sensitivity than Mutyper (43% vs 20%, P=0.07). CONCLUSIONS: The kits have similar performance in terms of EGFR mutation detection and semi-quantification in plasma and PE-SUP samples. cobasv2 tends to outperform Mutyper in detecting less-abundant EGFR-mutants. PE-SUP samples are assayable using either kit.

[Detection of carcinoembryonic antigen levels in pleural effusion and serum and their ratio for differential diagnosis of pleural effusion resulting from tuberculosis and lung cancer].

OBJECTIVE: To study the clinical value of detecting carcinoembryonic antigen levels in pleural effusion (PCEA) and serum (SCEA) and their ratio (P/S) in the differential diagnosis of pleural effusions resulting from tuberculosis and lung cancer. METHODS: This retrospectively study was conducted among 82 patients with pleural effusion caused by pulmonary tuberculous (TB; control group) and 120 patients with pleural effusion resulting from lung cancer in our hospital between April, 2016 and March, 2018. PCEA, SCEA and P/S were compared between the two groups and among the subgroups of lung cancer patients with squamous cell carcinoma (SqCa), adenocarcinoma (ACA), small cell carcinoma (SCLC). The receiveroperating characteristic curve (ROC) analysis was used to confirm the optimal critical value to evaluate the diagnostic efficiency of different combinations of PCEA, SCEA and P/S. RESULTS: PCEA, SCEA and P/S were significantly higher in the overall cancer patients and in all the 3 subgroups of cancer patients than in the patients with TB (P < 0.05). The areas under the ROC curve of PCEA, SCEA and P/S were 0.925, 0.866 and 0.796, respectively; PCEA had the highest diagnostic value, whose diagnostic sensitivity, specificity, accurate rate, and diagnostic threshold were 83.33%, 96.34, 88.61%, and 3.26 ng/ml, respectively; SCEA had the lowest diagnostic performance; the diagnostic performance of P/S was between that of SCEA and PCEA, but its combination with SCEA greatly improved the diagnostic performance and reduced the rates of misdiagnosis and missed diagnosis. Parallel tests showed that the 3 indexes combined had significantly higher diagnostic sensitivity than each or any two of the single indexes (P < 0.05), but the diagnostic specificity did not differ significantly. The area under the ROC curve of combined detections of the 3 indexes was 0.941 for diagnosis of lung cancer-related pleural effusion, higher than those of any other combinations of the indexes. CONCLUSIONS: The combined detection of PCEA, SCEA and P/S has a high sensitivity for diagnosis of lung cancer-related pleural effusion and provides important information for rapid and accurate diagnosis of suspected cases.

TAFRO Syndrome with an Anterior Mediastinal Mass and Lethal Autoantibody-Mediated Thrombocytopenia: An Autopsy Case Report.

TAFRO syndrome, a rare systemic inflammatory disease, can lead to multiorgan failure without appropriate treatment. Although thrombocytopenia is frequently seen in patients with TAFRO syndrome, little is known about its pathogenesis. Moreover, while recent studies have reported the presence of an anterior mediastinal mass in some patients, the pathological status of this remains unclear. Here, we report a case of fatal bleeding in a patient with TAFRO syndrome accompanied by an anterior mediastinal mass. A 55-year-old female was transferred to our hospital with a 2-week history of fever, epistaxis, and dyspnea. Laboratory tests revealed severe thrombocytopenia, computed tomography (CT) showed pleural effusions, and bone marrow biopsy revealed reticulin myelofibrosis. We suspected TAFRO syndrome, but the CT scan showed an anterior mediastinal mass that required a biopsy to exclude malignancy. She soon developed severe hemorrhagic diathesis and died of intracranial hemorrhage despite intensive treatment. She had multiple autoantibodies against platelets, which caused platelet destruction. An autopsy of the mediastinal mass revealed fibrous thymus tissues with infiltration by plasma cells. Our case suggests that thrombocytopenia could be attributed to antibody-mediated destruction and could be lethal. Hence, immediate treatment is imperative in cases of severe thrombocytopenia, even when accompanied by an anterior mediastinal mass.

Anaplastic Large Cell Lymphoma Manifesting as Pleural Effusion in a Patient with Long-Standing Eosinophilia.

Anaplastic large cell lymphoma (ALCL) is a lymphoma of T-cell origin, characterized by the presence of large lymphoid cells with abundant cytoplasm and pleomorphic, often horseshoe-shaped nuclei (hallmark cells), as well as strong and uniform expression of cluster of differentiation (CD)30. Two distinct clinicopathologic categories of ALCL include primary cutaneous ALCL and systemic ALCL. Systemic ALCL is further classified into anaplastic lymphoma kinase (ALK)-positive, ALK-negative, and breast implant-associated ALCL. Most ALCLs occurring in adults are ALK negative and present in lymph nodes rather than extranodal sites.Primary diagnosis of ALCL in the pleural fluid is extremely rare, with no convincing recent reports available that are based in current understanding of this entity. Herein, we describe a well-characterized case of ALK-negative ALCL with no rearrangement but amplification of DUSP22/IRF4, diagnosed by cytologic examination of the pleural effusion in a 68-year-old white man with a 3-year history of unexplained eosinophilia and pulmonary infiltrates. Also, we present a review of the literature and discuss the current understanding of ALCL based on the 2016 revision of the World Health Organization (WHO) classification of lymphoid neoplasms.

Carbohydrate antigen 125 in heart failure. New era in the monitoring and control of treatment. / Antígeno carbohidrato 125 en insuficiencia cardiaca. Nueva era en la monitorización y control del tratamiento.

In recent years, we have seen a great interest in the search for new biomarkers in heart failure (HF), fundamentally in the field of diagnosis, prognosis, monitoring and as a therapeutic guide. However, most of them do not meet the required criteria for daily clinical practice. The carbohydrate antigen 125 (CA 125) is the mucin 16 glycoprotein (MUC16) antibody, and its use has been restricted to the therapeutic monitoring of ovarian cancer; however, its elevation is confirmed in other non-tumour processes such as HF. In this last scenario, CA 125 is synthesised by serous epithelial cells in response to congestion and/or inflammatory stimuli. In recent years, increasing evidence has emerged suggesting that plasma levels of this glycoprotein could be useful as a biomarker in HF. CA 125 levels correlate with clinical, haemodynamic and echocardiographic parameters related to the severity of the disease, as well as being independently associated with mortality or readmission due to HF. From the clinical perspective, CA 125 provides information on the degree of extravascular congestion present in HF. Recent evidence consistently shows that its kinetics after admission due to decompensation offer an excellent predictive capacity for adverse events and to guide treatment, mainly diuretic. These qualities make it an ideal candidate for use in evolutionary monitoring and to guide depletive treatment in HF.

Tumour associated lymphocytes in the pleural effusions of patients with mesothelioma express high levels of inhibitory receptors.

OBJECTIVE: Pleural effusion (PE) is a common feature of malignant pleural mesothelioma. These effusions typically contain lymphocytes and malignant cells. We postulated that the PE would be a source of lymphocytes for analysis of tumor immune milieu. The aim of this study was to compare the phenotype and T cell receptor usage of pleural effusion T cells with paired concurrently drawn peripheral blood lymphocytes. We used multi-parameter flow cytometry and high-throughput T cell receptor sequencing to analyse peripheral blood and pleural effusion mononuclear cells. RESULTS: Both CD8+ and CD4+ T cells from effusion showed increased expression of T cell inhibitory receptors PD-1, LAG-3 and Tim-3 compared to blood. Comprehensive T cell receptor sequencing on one of the patients showed a discordant distribution of clonotypes in the antigen-experienced (PD-1+) compartment between effusion and blood, suggesting an enrichment of antigen specific clonotypes in the effusion, with potential as an immunological response biomarker.

Pleural Fluid Serum Bilirubin Ratio for Differentiating Exudative and Transudative Effusions.

INTRODUCTION: In pleural effusion, differentiating exudative and transudative fluid is an important clinical evaluation. The objective of the study was to determine the efficacy of pleural fluid serum bilirubin ratio in differentiating exudative and transudative effusions. In resource-limited settings with no facilities to measure lactate dehydrogenase levels, using pleural fluid bilirubin ratio may help in better clinical decision. METHODS: It was a cross sectional study, conducted in the emergency department of Tribhuvan University Teaching Hospital. All the patients attending for emergency care with pleural effusion from 6th Jan 2015 to 5th Jan 2016 were included. The cases were divided as exudates and transudates on basis of final diagnosis. Serum and pleural fluid specimen were collected and sent for investigations. The data for various laboratory parameters especially those of lights criteria and bilirubin ratio were then analyzed and fluid nature was compared with results from parameters and final diagnoses. RESULTS: Among 103 cases, 74 (71.84%) had exudate and 29 (28.16%) had transudate. The commonest cause of effusion was pneumonia 37 (35.92%), second being tubercular 24 (23.30%) followed by malignant effusion 13 (12.60%), congestive heart failure 12 (11.65%), chronic kidney disease 11 (10.67%) and liver cirrhosis 6 (5.82%). The mean bilirubin ratio for exudates exceeded that for transudates. Considering the cutoff point of 0.6, the sensitivity, specificity, positive predictive value and negative predictive value were respectively 88.00%, 93.00%, 97.00% & 75.00%. CONCLUSIONS: Pleural fluid serum bilirubin ratio can be utilized as a diagnostic tool for differentiating exudative and transudative effusions.

Cancer antigen-125 levels correlate with pleural effusions and COPD-related complications in people living at high altitude.

Chronic obstructive pulmonary disease (COPD) is the most frequently encountered progressive lung disease in clinical practice. This study sought to determine the predictive ability of the tumor biomarker cancer antigen-125 (CA-125) in the identification of COPD in a cohort of 284 patients with COPD living at high altitude (with an average elevation of over 2500 m).Patients were classified by pleural effusion volumes into 4 categories and serum CA-125 concentrations were measured in each category. The analyses revealed that CA-125 concentrations were positively and significantly correlated with pleural effusion volume. CA-125 concentrations were also positively correlated with pulmonary heart disease and acute exacerbations of COPD, and negatively correlated with pulmonary hypertension.The study evidence suggests that serum CA-125 concentrations are positively correlated with the risk of pleural effusions among patients with COPD living in high-altitude areas, and that CA-125 concentrations are also correlated with pulmonary heart disease, acute exacerbations, and pulmonary hypertension.

Diagnostic accuracy of interleukin-22 and adenosine deaminase for tuberculous pleural effusions.

OBJECTIVE: Reliable markers for accurately diagnosing tuberculous pleural effusions (TPE) are needed. This study sought to investigate the diagnostic potential of pleural interleukin-22 (IL-22) and compare it with the performance of adenosine deaminase (ADA). METHOD: This prospective study involved 49 patients with TPE and 60 patients with pleural effusion of other causes. Pleural levels of IL-22 and ADA were determined, respectively, using ELISA or an enzymatic method. A receiver operating characteristic curve was constructed and the area under the curve (AUC) was calculated to summarize the diagnostic accuracy of single markers or marker combinations. RESULTS: Levels of IL-22 in pleural effusion were significantly higher in TPE patients than in other patients (322.36 ± 406.65 vs. 83.13 ± 22.15 pg/ml, P < 0.05). With a cut-off value of 97.82 pg/ml, the diagnostic sensitivity of IL-22 for TPE was 71.42%, specificity was 81.67%, and the area under the curve (AUC) was 0.83. ADA levels were also increased in TPE, and its AUC for diagnosing TPE was 0.90. The combination of IL-22 and ADA enhanced diagnostic accuracy, offering sensitivity of 83.67%, specificity of 91.67%, and an AUC of 0.93. CONCLUSION: IL-22 may be useful for diagnosing TPE, and combining it with ADA may further enhance diagnostic accuracy. Our results justify more rigorous studies with larger samples to confirm the diagnostic potential of IL-22 for TPE.