Benefit of intrapleural fibrinolytic therapy in the treatment of complicated parapneumonic effusion and empyema.

Our study aimed to assess the benefit of intrapleural fibrinolysis before resorting to surgery to treat complicated parapneumonic effusion and empyema. We conducted a retrospective and descriptive study, including all patients hospitalized in the intensive care unit (ICU) of the Abderhaman Mami hospital, Tunisia for empyema treated with instillation of intrapleural fibrinolytic therapy between the 1st January 2000 and 31st December 2016. In all patients, empyema was diagnosed on clinical features, imaging findings (chest X-ray, thoracic echography and/or computed tomography (CT), and microbiological data. The fibrinolytic agent used was streptokinase. The efficiency of intrapleural fibrinolytic therapy was judged on clinical and paraclinical results. Among 103 cases of complicated parapneumonic effusion and empyema, 34 patients were included. The mean age was 34 years [15-81] with a male predominance (sex ratio at 2.77). Median APACH II score was 9. Fifty (50%) of the patients (n=17) had no past medical history; addictive behavior was described in 17 patients (50%). All patients were admitted for acute respiratory failure and one patient for septic shock. Pleural effusion was bilateral in 7 patients. Bacteria isolated were Streptococcus pneumonia (6 cases), Staphylococcus aureus (3 cases, including one which methicillin-resistant), Staphylococcus epidermidis (1 case), anaerobes (5 cases), and Klebsiella pneumoniae (1 case). First-line antimicrobial drug therapy was amoxicillin-clavulanate in 20 patients. A chest drain was placed in all cases in the first 38 hours of ICU admission. The median number of fibrinolysis sessions was 4 [2-9] and the median term of drainage was 7 days [3-16]. No side effects were observed. Video-assisted thoracoscopic surgery was proposed in 5 patients. The median length of hospitalization stay was 15 days [6-31]. One patient died due to multi-organ failure.

Clinical impact of pleural fluid carcinoembryonic antigen on therapeutic strategy and efficacy in lung adenocarcinoma patients with malignant pleural effusion.

BACKGROUND/AIMS: Epidermal growth factor receptor (EGFR) mutation is important in determining the treatment strategy for advanced lung cancer patients with malignant pleural effusion (MPE). Contrary to serum carcinoembryonic antigen (S-CEA) levels, the associations between pleural fluid CEA (PF-CEA) levels and EGFR mutation status as well as between PF-CEA levels and treatment efficacy have rarely been investigated in lung adenocarcinoma patients with MPE. METHODS: This retrospective study enrolled lung adenocarcinoma patients with MPE and available PF-CEA levels and EGFR mutation results. The patients were categorized based on PF-CEA levels: < 10 ng/mL, 10-100 ng/mL, 100-500 ng/mL, and ≥ 500 ng/mL. The association between PF-CEA levels and EGFR mutation status as well as their therapeutic impact on overall survival was compared among the four groups. RESULTS: This study included 188 patients. PF-CEA level was found to be an independent predictor of EGFR mutation but not S-CEA level. The EGFR mutation rates were higher as the PF-CEA levels increased, regardless of cytology results or sample types. Among EGFR-mutant lung adenocarcinoma patients receiving EGFR-tyrosine kinase inhibitor (TKI) treatment, those with high PF-CEA levels had significantly better survival outcomes than those with low PF-CEA levels. CONCLUSION: High PF-CEA levels were associated with high EGFR mutation rate and may lead to a favorable clinical outcome of EGFR-TKI treatment in EGFR-mutant lung adenocarcinoma patients with MPE. These findings highlight the importance of actively investigating EGFR mutation detection in patients with suspected MPE and elevated PF-CEA levels despite negative cytology results.

Isolated massive pleural effusion as a manifestation of chronic graft versus host disease successfully treated with corticosteroid.

Isolated pleural effusion is a rare manifestation of chronic graft versus host disease (cGVHD) after hematopoietic stem cell transplantation (HSCT). We herein report a 58-year-old woman presenting with massive pleural effusion approximately 1 year after allogeneic HSCT, who was successfully treated with corticosteroid. She had discontinued tacrolimus approximately 1 month before she presented with pleural effusion, which was attributed to cGVHD after a thorough exclusion process. This case illustrates a unique manifestation of atypical cGVHD and highlights the need for prompt therapy initiation.

Pleurodesis using OK-432 for persistent pleural effusion after cardiac surgery in the neonatal period or early infancy.

OBJECTIVE: To evaluate the efficacy of pleurodesis using OK-432 after cardiac surgery in the neonatal period or early infancy. METHODS: We retrospectively reviewed the data of 11 consecutive patients who underwent cardiac surgery in the neonatal period or early infancy and pleurodesis using OK-432 for persistent postoperative pleural effusion in two institutions. RESULTS: The median age at surgery was 8 days (interquartile range [IR], 2-18) with a body weight of 2.84 kg (IR, 2.30-3.07). The maximum amount of pleural drainage before pleurodesis was 94.7 (IR, 60.2-107.7) ml/kg/day. Pleurodesis was initiated at postoperative day 20 (IR, 17-22) and performed in bilateral pleural spaces in seven patients and unilateral in four. The median numbers of injection were 4 (IR, 3-6) times per patient and 3 (IR, 2-3) times per pleural space. In 10 patients, pleural effusion was decreased effectively, and drainage tubes were removed without reaccumulation within 15 (IR, 12-28) days after initial pleurodesis. However, in one patient, with severe lymphedema, pleural effusion was uncontrollable, resulting in death due to sepsis. Adverse events were observed in nine patients; temporal deterioration of lung compliance and arterial blood gas occurred in two, insufficient drainage requiring new chest tube(s) in five, temporal atrial tachyarrhythmia in one, and lymphedema in four. CONCLUSIONS: Pleurodesis using OK-432 is effective and reliable for persistent postoperative pleural effusion in neonates and early infants. Most of the complications, which derived from inflammatory reactions, were temporary and controllable. However, severe lymphedema is difficult to control.

Chylothorax after chimeric antigen receptor T cell therapy for relapsed and refractory diffuse large B-cell lymphoma: A case report.

RATIONALE: Anti-CD19-targeted chimeric antigen receptor (CAR) T cell therapy is effective in treating relapsed/refractory diffuse large B-cell lymphoma (DLBCL). This therapy is associated with several side effects that can be life-threatening such as cytokine release syndrome (CRS). However, chylothorax associated with CRS after CAR-T therapy has not been reported. PATIENT CONCERNS: A 23-year-old male diagnosed with DLBCL relapsing after autologous peripheral blood stem cell transplantation was treated with anti-CD19-targeted CAR-T cell therapy. After CAR-T cell transfusion, he developed grade 3 CRS includes fever, dyspnea, tachycardia and hypotension. The symptoms of CRS persisted and chest plain film revealed bilateral pleural effusion. DIAGNOSIS: Chylothorax was confirmed by the pleural effusion analysis that triglyceride level was 1061 mg/dL. Bacterial and fungal culture of pleural fluid reported no pathogen was detected. Cytological examination of pleural effusion revealed no malignant cells. INTERVENTIONS: The chylothorax resolved after treatment with intravenous administration of tocilizumab. OUTCOMES: On 30-day follow-up, the patient was in stable clinical condition with complete remission of DLBCL on whole-body positron emission tomography scan. LESSONS: We reported a rare case of CAR-T associated chylothorax in a patient with relapsed and refractory DLBCL. Grade 3 CRS with high interleukin-6 level was presented in our patient. The symptoms of CRS were improved with tocilizumab treatment and the chylothorax resolved later on. It is suggested that high interleukin-6 releases might induce chyle leakage resulting from activations of endothelium and coagulation. Our finding highlights the occurrence of chylothorax during the course of CAR-T cell therapy and the importance of proper monitoring and prompt management of this life-threatening side effect.

Effect of early administration of tolvaptan on pleural effusion post-hepatectomy.

PURPOSE: This study evaluated the efficacy of tolvaptan administration at the early stage after hepatectomy to control pleural effusion and improve the postoperative course. METHODS: Patients were administered tolvaptan (7.5 mg) and spironolactone (25 mg) from postoperative day 1 to postoperative day 5 (tolvaptan group, n = 68) for 13 months. Early administration of tolvaptan was not provided in the control group (n = 68); however, diuretics were appropriately administered according to the patient's condition. The amount of pleural effusion on computed tomography on postoperative day 5 was compared between the two groups. RESULTS: The amount of pleural effusion and increase in body weight on postoperative day 5 showed significant differences in both groups (p < 0.001 and p = 0.019, respectively). However, the rate of pleural aspiration and the duration of postoperative hospitalization were comparable between the groups. The amount of intraoperative blood loss and lack of early administration of tolvaptan were identified as independent risk factors contributing to pleural effusion on multivariate analysis. CONCLUSION: Early administration of tolvaptan to patients after hepatectomy was found to be capable of controlling postoperative pleural effusion and increase in body weight, but it did not reduce the rate of pleural aspiration or the hospitalization period.

Recurrent pleural effusion as a rare manifestation after prolonged PD1 inhibitor (camrelizumab)-based immunotherapy: A case report.

Immune-related adverse events (irAEs) pose a significant challenge for the widespread adoption of immuno-oncology therapies, but their symptoms can vary widely. In particular, the relationship between irAEs and pleural effusion (PE) in patients with advanced non-small cell lung cancer (NSCLC) remains unclear. In this report, we present the case of an advanced NSCLC patient who developed persistent PE despite receiving camrelizumab (an anti-programmed death receptor 1 [PD-1] antibody) and chemotherapy as first-line treatment. While the patient's tumor biomarkers decreased after multiple cycles of treatment, the PE persisted despite negative findings on cytology and pleural biopsy. Additionally, the use of anti-angiogenic drugs failed to alleviate the PE. Screening for rheumatic connective tissue markers and tuberculosis yielded negative results, but intrathoracic dexamethasone injections in two doses resulted in a significant reduction of the PE. This case suggests that PE may represent a rare type of irAE that should be monitored for during prolonged immuno-oncology therapy.

Combined intrapleural alteplase and DNase therapy in complicated pleural infection arising from postsurgery oesophageal leak.

Managing a complicated pleural infection related to postsurgery can pose a clinical challenge, especially when initial interventions such as intercostal chest drain and antibiotics prove ineffective. We describe a man in his mid-60s who developed a recurrence of exudative pleural effusion caused by an oesophageal leak following laparoscopic total gastrectomy with Roux-y oesophagojejunostomy for gastric adenocarcinoma. Surgical repairs and oesophageal stenting were performed to address the oesophageal leak. Despite attempts at intercostal chest tube drainage, ultrasonography-guided targeted drainage of the locule and antibiotics, he did not show any improvement. He was unfit for surgical decortication. Due to the risk of bleeding, we chose a modified dose of intrapleural alteplase 5 mg and DNase 5 mg at 12-hour intervals for a total of three doses. This led to the complete resolution of the effusion. This case highlights that intrapleural tPA/DNase can be an adjunctive therapy in postsurgery-related complicated pleural effusion.

Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study.

BACKGROUND: Pleural infection, an infection of the pleural space, is frequently treated with antibiotics and thoracic tube drainage. In case of insufficient drainage, an intrapleural fibrinolytic agent is considered before surgical intervention. However, the effectiveness of fibrinolytic monotherapy is still controversial. Therefore, we aimed to examine the association between urokinase monotherapy and treatment failure in patients with pleural infection. METHODS: In this retrospective observational study, patients with pleural infection underwent chest tube insertion were divided into two groups including patients treated with or without intrapleural instillation of urokinase. The propensity score overlap weighting was used to balance the baseline characteristics between the groups. Treatment failure was defined by the composite primary outcome of in-hospital death and referral for surgery. RESULTS: Among the 94 patients, 67 and 27 patients were in the urokinase and non-urokinase groups, respectively. Urokinase monotherapy improved the composite outcome between the groups (19.4% vs. 48.1%, p = 0.01). After adjusting using propensity score overlap weighting, urokinase monotherapy improved the composite outcome compared to the non-urokinase group (19.0% vs. 59.5%, p = 0.003). CONCLUSIONS: Urokinase monotherapy can be an important nonsurgical treatment option for patients with pleural infection. TRIAL REGISTRATION: The participants were retrospectively registered.

Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema.

BACKGROUND: Pleural infection is life-threatening and increasingly prevalent. In addition to usual care, twice-daily, separate administration of tissue plasminogen activator and deoxyribonuclease (tPA-DNase) reduces radiological pleural opacity with lower surgical referral rates. AIMS: This retrospective cohort study examines the use of once-daily, concurrent administration of tPA-DNase for complex parapneumonic pleural effusion and empyema. METHODS: Patients with pleural infection who received intrapleural tPA-DNase between October 2014 and July 2020 at Logan Hospital, where it is given concurrently and once-daily as salvage therapy, were retrospectively identified. Radiographic opacification, inflammatory markers, clinical response and complications were examined. RESULTS: Thirty-one patients were identified. Mean age was 48.8 years (standard deviation [SD], 17.2). Median tPA-DNase administration was 3 (interquartile range [IQR], 2-3). Chest x-ray pleural opacity decreased significantly (P = 0.047) from a median of 39.6% (IQR, 28.8-65.7%) to 9.7% (IQR, 2.5-23.2%), a median relative reduction of 75.5% (IQR, 47.7-93.9%). White cell count and C-reactive protein improved significantly (P = 0.002 and P = 0.032, respectively) from a median of 16.3 × 109 /L (IQR, 11.8-20.6 × 109 /L) to 9.9 × 109 /L (IQR, 8.0-12.3 × 109 /L) and 311.0 mg/L (IQR, 218.8-374.0 mg/L) to 69.0 mg/L (IQR, 36.0-118.0 mg/L), respectively. No patients experienced significant bleeding or died. Five patients (16.1%) were referred for surgery. CONCLUSION: This is pilot evidence that a practical regimen of concurrent, once-daily intrapleural tPA-DNase improved pleural opacification and inflammatory markers without bleeding or mortality. The surgical referral rate was higher than in studies assessing twice-daily administration, though the validity of this outcome as a measure of treatment success is limited, and further studies are needed to assess the optimal dose and frequency of intrapleural therapy and indications for surgical referral.

Management and Risk Factors for Pleural Effusion in Japanese Patients with Chronic Myeloid Leukemia Treated with First-line Dasatinib in Real-world Clinical Practice.

Objective Pleural effusion (PE) is a common adverse event that occurs during dasatinib therapy for chronic myeloid leukemia (CML). However, the pathomechanism of PE and appropriate management of Asian patients with CML have not been elucidated. This study investigated the incidence rate, risk, and appropriate management of PE in Asian patients with CML treated with dasatinib. Methods We retrospectively collected data on patients in the chronic phase of CML who received first-line dasatinib therapy and were registered in the CML-Cooperative Study Group database. Patients We identified 44 cases of PE in a series of 89 patients and analyzed previously reported risk factors and effective management of PE. Results A univariate analysis revealed that age, diabetes mellitus, chronic renal failure, hypertension, the history of cardiovascular events, and dasatinib dose were significantly associated with PE. A multivariate analysis revealed that age ≥65 years old was the only independent risk factor for PE. Dasatinib dose reduction and switching to a tyrosine kinase inhibitor showed a statistically significant difference in effectively reducing PE volume compared to single diuretic use. Conclusion Although further studies are warranted, our observations showed that advanced age is a significant risk factor for PE, and tyrosine kinase inhibitor dose reduction or replacement of dasatinib may be an effective management strategy for PE in Asian CML patients who received first-line treatment with dasatinib in real-world clinical practice.

Drug transdermal delivery by electrophonophoresis can increase the concentration of rifampicin in the pleural effusion of patients with tuberculous pleurisy but has no effect on the concentration of rifampicin in plasma.

BACKGROUND: Electrophonophoresis (EP) has been widely used in various clinical fields. The purpose of this study was to evaluate the dermal permeability of rifampicin (RIF) in patients with tuberculous pleurisy assisted by EP and to verify the clinical application of this percutaneous drug delivery system in the treatment of tuberculous pleurisy, verify the system's influencing factors, and determine whether plasma drug concentration was increased. METHOD: Patients were given oral isoniazid 0.3-0.4 g, rifampicin 0.45-0.60 g, pyrazinamide 1.0-1.5 g and ethambutol 0.75 g according to their body weight once a day. After 5 days of anti-tuberculosis treatment, 3 ml of rifampicin was delivered transdermally with EP. Pleural effusion and peripheral blood samples in patients were collected at and after dosing. The drug concentration in the samples was determined by high-performance liquid chromatography. RESULT: The median plasma concentration (interquartile ranges) of RIF in 32 patients was 8.80 (6.65, 13.14) µg/ml before RIF transdermal injection plus EP and decreased to 8.09 (5.58, 11.82) µg/ml after 30 min of RIF transdermal injection plus EP. The RIF concentration in pleural effusion was higher than that before RIF-transdermal plus EP. In patients who received RIF via EP transdermal administration, the concentration of the drug at the local site was statistically higher than the concentration at the local site prior to penetration. However, no such enhancement was observed in plasma after transdermal administration of RIF. CONCLUSION: EP can effectively increase the concentration of rifampicin in the pleural effusion of tuberculous pleurisy and has no effect on the circulating plasma concentration. The increased concentration of the drug in the lesion helps to destroy the bacteria.

Clinical relevance of bronchiectasis in patients with community-acquired pneumonia.

BACKGROUND: Data regarding the clinical characteristics and treatment outcomes of patients with community-acquired pneumonia (CAP) and bronchiectasis (BE) are rare. This study aims to elucidate the clinical relevance of BE in patients with CAP. METHODS: Patients hospitalized with CAP in a single center were retrospectively analyzed and divided into significant BE (BE with ≥ 3 lobes or cystic BE on computed tomography) and control groups. Clinical and microbiological characteristics were compared between the two groups. RESULTS: In the final analysis, 2112 patients were included, and 104 (4.9%) had significant BE. The significant BE group exhibited a higher prevalence of sputum production, dyspnea, and complicated parapneumonic effusion or empyema than the control group. Pseudomonas aeruginosa was more frequently isolated in the significant BE group than in the control group, whereas Mycoplasma pneumoniae was less commonly identified. Length of hospital stay (LOS) was significantly longer in the significant BE group than the control group (12 [8-17] days vs. 9 [6-13] days, p < 0.001). In contrast, 30-day and in-hospital mortality rates did not significantly differ between the two groups. Furthermore, significant BE was an independent predictor of prolonged hospitalization in two models based on CURB-65 and pneumonia severity index. CONCLUSIONS: Significant BE occurred in approximately 5% of patients with CAP and was more likely to be associated with sputum, dyspnea, complicated parapneumonic effusion or empyema, and isolation of P. aeruginosa. Significant BE was an independent predictor of LOS in patients with CAP.

Development of a human herpesvirus 8-negative effusion-based lymphoma during treatment with dasatinib for chronic myeloid leukemia.

We present the case of an 85-year-old male patient diagnosed with human herpesvirus 8 (HHV8)-negative effusion-based lymphoma (EBL) that developed from long-lasting pleural effusion (PE) induced by dasatinib treatment for chronic myeloid leukemia (CML). After the onset of this disorder, dasatinib treatment was discontinued and drainage was performed to regress the effusion. The major molecular response (MMR) was thus lost. The patient did not tolerate nilotinib treatment, but bosutinib was successful in restoring MMR. During these clinical courses, the patient suffered from a recurrence of EBL, which was treated with rituximab-based chemotherapy. The PE sample just before the 3rd cycle of chemotherapy revealed the proliferation of CD57-positive T cells, along with the disappearance of lymphoma cells. Anti-tumor immunity may have been activated following the immunochemotherapy in the undisturbed immunological environment when both EBL and CML almost regressed. After four cycles of R-CVP therapy, the patient has been in remission for 16 months and no longer requires drainage.

Intrapleural Urokinase Injection after Medical Thoracoscopy for Empyema and Complicated Para-Pneumonic Effusion: A Case Series.

Empyema and complicated para-pneumonic effusion (CPPE) often require surgical intervention because of insufficient antibiotic effect and chest tube drainage. From January 2017 to September 2021, we encountered seven patients who underwent intrapleural urokinase injection after medical thoracoscopy for the treatment of empyema or CPPE. None of the seven patients required further surgical interventions or showed any complications associated with the therapeutic procedures. The combined use of intrapleural urokinase injections and medical thoracoscopy may be an effective and safe therapeutic option for the management of empyema and CPPE.

Correlación fisiopatológica, diagnóstica y terapéutica en el derrame pleural paraneumónico / Pathophysiological, diagnostic and therapeutic correlation in parapneumonic pleural effusion

Introducción: La inflamación de la pleura desencadenada por bacterias y mediada por citocinas, aumenta la permeabilidad vascular y produce vasodilatación, lo cual genera desequilibrio entre la producción de líquido pleural y su capacidad de reabsorción por eficientes mecanismos fisiológicos. La condición anterior conduce al desarrollo de derrame pleural paraneumónico. Objetivo: Exponer la importancia de la correlación fisiopatológica y diagnóstica con los pilares fundamentales de actuación terapéutica en el derrame pleural paraneumónico. Métodos: Revisión en PubMed y Google Scholar de artículos publicados hasta abril de 2021 que abordaran el derrame pleural paraneumónico, su fisiopatología, elementos diagnósticos, tanto clínicos como resultados del estudio del líquido pleural, pruebas de imágenes, y estrategias terapéuticas. Análisis y síntesis de la información: El progreso de una infección pulmonar y la producción de una invasión de gérmenes al espacio pleural favorece la activación de mecanismos que conllevan al acúmulo de fluido, depósito de fibrina y formación de septos. Este proceso patológico se traduce en manifestaciones clínicas, cambios en los valores citoquímicos y resultados microbiológicos en el líquido pleural, que acompañados de signos radiológicos y ecográficos en el tórax, guían la aplicación oportuna de los pilares de tratamiento del derrame pleural paraneumónico. Conclusiones: Ante un derrame pleural paraneumónico, con tabiques o partículas en suspensión en la ecografía de tórax, hallazgo de fibrina, líquido turbio o pus en el proceder de colocación del drenaje de tórax, resulta necesario iniciar fibrinólisis intrapleural. Cuando el tratamiento con fibrinolíticos intrapleurales falla, la cirugía video-toracoscópica es el procedimiento quirúrgico de elección(AU)

Introduction: The inflammation of the pleura triggered by bacteria and mediated by cytokines, increases vascular permeability and produces vasodilation, which generates imbalance between the production of pleural fluid and its resorption capacity by efficient physiological mechanisms. The above condition leads to the development of parapneumonic pleural effusion. Objective: To expose the importance of the pathophysiological and diagnostic correlation with the fundamental pillars of therapeutic action in parapneumonic pleural effusion. Methods: Review in PubMed and Google Scholar of articles published until April 2021 that addressed parapneumonic pleural effusion, its pathophysiology, diagnostic elements, both clinical and results of the pleural fluid study, imaging tests, and therapeutic strategies. Analysis and synthesis of information: The progress of a lung infection and the production of an invasion of germs into the pleural space favors the activation of mechanisms that lead to the accumulation of fluid, fibrin deposition and formation of septa. This pathological process results in clinical manifestations, changes in cytochemical values and microbiological results in the pleural fluid, which accompanied by radiological and ultrasound signs in the chest, guide the timely application of the pillars of treatment of parapneumonic pleural effusion. Conclusions: In the event of a parapneumonic pleural effusion, with septums or particles in suspension on chest ultrasound, finding fibrin, turbid fluid or pus in the procedure of placement of the chest drain, it is necessary to initiate intrapleural fibrinolytic. When treatment with intrapleural fibrinolytics fails, video-thoracoscopic surgery is the surgical procedure of choice(AU)

Bula gigante secundaria a neumonía adquirida en la comunidad en niños / Giant Bulla Secondary to Community-Acquired Pneumonia in Children

Introducción: Los neumatoceles y las bulas pulmonares son lesiones que se observan en los niños casi siempre asociadas a neumonías infecciosas, aunque sus causas pueden ser diversas. La importancia clínica de estos procesos radica en el peligro de crecimiento progresivo, que puede comprometer las funciones respiratoria y cardiovascular. Objetivo: Describir las experiencias derivadas del proceso de diagnóstico por imágenes y del tratamiento invasivo de casos atendidos. Presentación de los casos: Desde finales de 2021 y durante un período de un año, se atendieron, en la unidad de cuidados intensivos pediátricos del Hospital Pediátrico Universitario de Cienfuegos, cinco niños con neumonías extensas, que desarrollaron bulas de gran tamaño varios días después del tratamiento antimicrobiano adecuado. Estas necesitaron drenaje y aspiración percutáneos debido a su magnitud y a la presencia de síntomas cardiovasculares. Conclusiones: Las bulas que aparecieron como complicación de la neumonía en el niño pueden presentarse con una frecuencia no despreciable, y hay que mantenerse atentos a su evolución, porque, a diferencia de los neumatoceles, pueden crecer progresivamente y comprometer las funciones respiratoria y cardiovascular. El drenaje percutáneo y aspiración continua por cinco días resultó un método seguro y eficaz para tratar estos procesos(AU)

Introduction: Pneumoatoceles and pulmonary bullae are lesions that are observed in children almost always associated with infectious pneumonia, although their causes may be diverse. The clinical importance of these processes lies in the danger of progressive growth, which can compromise respiratory and cardiovascular functions. Objective: To describe the experiences derived from the imaging process and the invasive treatment of treated cases. Presentation of the cases: Since the end of 2021 and for a period of one year, five children with extensive pneumonia were treated in the pediatric intensive care unit of the University Pediatric Hospital of Cienfuegos, who developed large bullae several days after appropriate antimicrobial treatment. The bullae required percutaneous drainage and aspiration due to their magnitude and the presence of cardiovascular symptoms. Conclusions: The bulla that appeared as a complication of pneumonia in the child can occur with a not negligible frequency, and it is necessary to be attentive to their evolution, because, unlike pneumoatoceles, can grow progressively and compromise respiratory and cardiovascular functions. Percutaneous drainage and continuous aspiration for five days was a safe and effective method to treat these processes(AU)

Deciphering the puzzle: a case report of Tjalma syndrome (pseudo-pseudo Meigs' syndrome) with profoundly elevated CA-125 and pleural effusion.

Elevated CA-125 levels, polyserous effusions (such as pleural effusion, ascites, etc.) in young women with systemic lupus erythematosus (SLE) may signal pseudo-pseudo Meigs' syndrome (PPMS), after excluding other causes. We describe a 32-year-old SLE patient with recurrent bilateral pleural effusions and unexplained hypercalcemia for 10 months. Extensive evaluations revealed no infections or tumors. Cytokine analysis showed elevated interleukin (IL) levels, especially IL-6 in pleural effusion. Treatment with immunosuppressive therapy resulted in reduced cancer antigen (CA) 125 levels and decreased effusion volume, demonstrating a positive response to intervention in this case of PPMS.

Intracavitary fibrinolysis directly under vision during medical thoracoscopy: a case report.

Medical thoracoscopy is a minimally invasive single-port endoscopic technique that allows for direct visualization of the pleural surface as well as diagnostic and therapeutic procedures. When fibrous adhesions are extensive, its utility is limited. In patients with malignant pleural effusion and loculated effusion, fibrinolytics have been used through chest drainage to break down septations to relieve breathlessness and to improve pleurodesis success We described the use of intrapleural fibrinolytics during a medical thoracoscopy to break the septations and perform pleural biopsies in a patient with multiloculated pleural effusion. To the best of our knowledge, no studies on this subject have been published in the literature, only case reports. We believe that direct instillation of fibrinolytics during medical thoracoscopy is safe and has the potential to increase both the therapeutic and diagnostic capacity of medical thoracoscopy and fibrinolysis.