Hemoptisis amenazante: un desafío continuo de tratamiento multidisciplinario / Life-threatening hemoptysis: a continuous multidisciplinary challenge

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[Pleural effusion and pulmonary hypertension in a patient with Parkinson disease treated with cabergoline]. / Derrame pleural e hipertensión pulmonar en un paciente con enfermedad de Parkinson en tratamiento con cabergolina.

Cabergoline is a synthetic dopamine agonist used to treat Parkinson disease. The drug occasionally induces pleuropulmonary adverse effects, which manifest as pleural thickening or effusion, interstitial pneumonitis, pulmonary infiltrates, or fibrosis. We report a rare case of pleural effusion and severe pulmonary hypertension in a 79-year-old man with Parkinson disease who had been treated with cabergoline for 1 year. The symptoms disappeared 10 months after the drug was discontinued.

Derrame pleural e hipertensión pulmonar en un paciente con enfermedad de Parkinson en tratamiento con cabergolina / Pleural effusion and pulmonary hypertension in a patient with Parkinson disease treated with cabergoline

La cabergolina es un fármaco sintético dopaminérgico, que se utiliza en el tratamiento de la enfermedad de Parkinson y que rara vez produce efectos adversos pleuropulmonares, los cuales se manifiestan como engrosamiento o derrame pleurales, neumonitis intersticial, infiltrados pulmonares o fibrosis. Presentamos un caso excepcional en un varón de 79 años con enfermedad de Parkinson, tratado con cabergolina durante un año, que presentó un derrame pleural y grave hipertensión pulmonar, que desaparecieron a los 10 meses de la retirada de este fármaco(AU)

Cabergoline is a synthetic dopamine agonist used to treat Parkinson disease. The drug occasionally induces pleuropulmonary adverse effects, which manifest as pleural thickening or effusion, interstitial pneumonitis, pulmonary infiltrates, or fibrosis. We report a rare case of pleural effusion and severe pulmonary hypertension in a 79-year-old man with Parkinson disease who had been treated with cabergoline for 1 year. The symptoms disappeared 10 months after the drug was discontinued(AU)

[Influence of the method used to obtain pleural fluid on the determination of the Acid-base balance]. / Importancia de la forma de obtención del líquido en la determinación del equilibrio ácido-base pleural.

OBJECTIVE: To analyze the methods used in our hospital for obtaining pleural fluid to determine the acid-base balance and to evaluate the clinical repercussions of each method. METHODS: Initially we studied the methods used by physicians in our hospital to collect pleural fluid for determination of the acid-base balance. In a second phase, we performed a prospective, descriptive, comparative study with the participation of 71 patients with pleural effusions in order to compare the acid-base balance according to the technique used to obtain the fluid. RESULTS: Pleural fluid was obtained using 3 methods: a) direct extraction using a heparinized syringe (group 1); b) extraction using a 20 mL syringe with subsequent aspiration from this syringe into a heparinized syringe (group 2); and c) filling a heparinized syringe from the 20 mL syringe (group 3). The only significant differences between group 1 and groups 2 and 3 were an increase in the pleural PO2 and oxygen saturation. The difference in the mean pH between groups 1 and 2 was 0.009 (95% confidence interval: -0.39 to 0.02; P=.5) and between groups 1 and 3 was 0.007 (95% confidence interval: -0.38 to 0.023; P=.6). The correlations between findings for PO2, pH, and PCO2 obtained in the different groups were statistically significant, with values superior to .95 in the last 2 variables. CONCLUSIONS: Physicians who perform thoracentesis in our hospital use different methods for obtaining fluid to determine the pleural acid-base balance. The 3 methods analyzed show no significant differences with regard to pH or PCO2. Pleural fluid may be obtained by a single puncture with a large-volume syringe, subsequently transferring the fluid to a heparinized syringe without this significantly affecting the pH or PCO2, thus reducing the number of manipulations and the risk of complications.

Importancia de la forma de obtención del líquido en la determinación del equilibrio ácido-base pleural / Influence of the method used to obtain pleural fluid on the determination of the acid-base balance

OBJETIVO: Analizar las formas de obtención del líquido para determinar el equilibrio ácido-base pleural en nuestro medio y su influencia o relevancia clínica. MÉTODOS: En una primera fase se describieron las formas en que los médicos de nuestro hospital obtenían el líquido para determinar el equilibrio ácido-base pleural. En una segunda fase se realizó un estudio prospectivo, descriptivo y comparativo de 71 pacientes con derrame para comparar el equilibrio ácido-base pleural según las formas de obtención. RESULTADOS: El líquido pleural se obtenía de 3 formas distintas: a) extracción directa con jeringa heparinizada (grupo I); b) extracción con jeringa de 20 ml, aspirando de esta jeringa con la jeringa heparinizada (grupo II), o c) llenando la jeringa heparinizada con la jeringa de 20 ml (grupo III). Se observó un aumento significativo sólo en los valores de la presión parcial (PO2) y saturación de oxígeno entre el grupo I y los grupos II o III. La diferencia de las medias del pH entre los grupos I y II fue de 0,009 (intervalo de confianza del 95%, -0,039 a 0,02; p = 0,5), y entre los grupos I y III, de 0,007 (intervalo de confianza del 95%, -0,038 a 0,023; p = 0,6). Las correlaciones entre los distintos grupos de la PO2, pH y presión parcial de anhídrido carbónico (PCO2) fueron estadísticamente significativas y con valores superiores a 0,95 en las 2 últimas. CONCLUSIONES: Los médicos que realizan las toracocentesis en nuestro hospital procesan de formas distintas el líquido para determinar el equilibrio ácido-base pleural. Las 3 formas analizadas no mostraron diferencias significativas en cuanto al pH y la PCO2. La obtención del líquido puede realizarse con una única punción con jeringas de mayor capacidad, para posteriormente llenar la jeringa heparinizada, sin que se modifiquen de forma significativa los valores del pH y la PCO2, y con una disminución del número de manipulaciones y el riesgo de complicaciones

OBJECTIVE: To analyze the methods used in our hospital for obtaining pleural fluid to determine the acid-base balance and to evaluate the clinical repercussions of each method. METHODS: Initially we studied the methods used by physicians in our hospital to collect pleural fluid for determination of the acid-base balance. In a second phase, we performed a prospective, descriptive, comparative study with the participation of 71 patients with pleural effusions in order to compare the acid-base balance according to the technique used to obtain the fluid. RESULTS: Pleural fluid was obtained using 3 methods: a) direct extraction using a heparinized syringe (group 1); b) extraction using a 20 mL syringe with subsequent aspiration from this syringe into a heparinized syringe (group 2); and c) filling a heparinized syringe from the 20 mL syringe (group 3). The only significant differences between group 1 and groups 2 and 3 were an increase in the pleural PO2 and oxygen saturation. The difference in the mean pH between groups 1 and 2 was 0.009 (95% confidence interval: -0.39 to 0.02; P=.5) and between groups 1 and 3 was 0.007 (95% confidence interval: -0.38 to 0.023; P=.6). The correlations between findings for PO2, pH, and PCO2 obtained in the different groups were statistically significant, with values superior to .95 in the last 2 variables. CONCLUSIONS: Physicians who perform thoracentesis in our hospital use different methods for obtaining fluid to determine the pleural acid-base balance. The 3 methods analyzed show no significant differences with regard to pH or PCO2. Pleural fluid may be obtained by a single puncture with a large-volume syringe, subsequently transferring the fluid to a heparinized syringe without this significantly affecting the pH or PCO2, thus reducing the number of manipulations and the risk of complications

[Utility of amylase levels in malignant pleural effusions]. / Importancia de la determinación de la amilasa pleural en los pacientes con derrame neoplásico.

BACKGROUND AND OBJECTIVE: To analyze the utility of the measurement of pleural amylase levels (AL) and pleural fluid/serum amylase ratio (AR) in malignant pleural effusions. PATIENTS AND METHOD: Prospective and comparative study of AL and its AR in relation to the patient and pleural fluid characteristics in 295 malignant effusions and 673 nonmalignant. RESULTS: There were 103 patients with AL greater than 100 U/l (11%) and 268 with AR greater than 1 (28%): 53 (18%) and 109 (37%) in malignant effusions respectively. Patients with malignant effusions had higher AL and AR, especially when tumour origin was lung cancer, had positive pleural citology or biopsy and showed an adenocarcinoma. Multivariate regression analysis revealed a significant difference in the changes in AL associated with positive pleural citology or biopsy and massive pleural effusion. The malignant effusions had higher AL in lung cancer of stage IV. CONCLUSIONS: AL and AR should not be routinely measured to exclude a malignant effusion. A high AL or AR was related to positive pleural citology or biopsy, a massive pleural effusion and lung cancer with an advanced disease.

Importancia de la determinación de la amilasa pleural en los pacientes con derrame neoplásico / Utility of amylase levels in malignant pleural effusions

Fundamento y objetivo: Analizar la utilidad diagnóstica y el significado de la determinación de la amilasa pleural (APL) y su cociente pleuroplasmático (CPP) en los derrames neoplásicos. Pacientes y método: Se ha realizado un estudio prospectivo y comparativo de la APL y su CPP según las características de los pacientes y el derrame en 295 derrames neoplásicos y 673 no neoplásicos. Resultados: Hubo un total de 103 casos con APL mayor de 100 U/l (11%) y 268 un CPP mayor de 1 (28%), de los que 53 (18%) y 109 (37%), respectivamente, correspondieron a derrames neoplásicos. La APL y el CPP aumentaron en los derrames neoplásicos, en los de origen pulmonar, en la citología o la biopsia pleural diagnóstica y en los adenocarcinoma. La regresión multivariante demostró una asociación de la APL con la citología o la biopsia positiva y un derrame masivo. Los derrames neoplásicos de origen pulmonar en estadio IV presentaron un aumento de APL o CPP. Conclusiones: La APL y su CPP no fueron útiles en el diagnóstico o cribado de un derrame pleural para descartar el origen neoplásico. El aumento de la APL o su CPP se asoció a una citología o una biopsia pleural diagnóstica; un derrame masivo y el origen pulmonar, a una enfermedad más avanzada

Background and objective: To analyze the utility of the measurement of pleural amylase levels (AL) and pleural fluid/serum amylase ratio (AR) in malignant pleural effusions. Patients and method: Prospective and comparative study of AL and its AR in relation to the patient and pleural fluid characteristics in 295 malignant effusions and 673 nonmalignant. Results: There were 103 patients with AL greater than 100 U/l (11%) and 268 with AR greater than 1 (28%): 53 (18%) and 109 (37%) in malignant effusions respectively. Patients with malignant effusions had higher AL and AR, especially when tumour origin was lung cancer, had positive pleural citology or biopsy and showed an adenocarcinoma. Multivariate regression analysis revealed a significant difference in the changes in AL associated with positive pleural citology or biopsy and massive pleural effusion. The malignant effusions had higher AL in lung cancer of stage IV. Conclusions: AL and AR should not be routinely measured to exclude a malignant effusion. A high AL or AR was related to positive pleural citology or biopsy, a massive pleural effusion and lung cancer with an advanced disease

[Influence of thoracentesis and pleural biopsy on biochemical parameters and cytology of pleural fluid]. / Influencia de la toracocentesis y la biopsia pleural en la bioquímica y la citología del líquido pleural.

OBJECTIVE: To assess the influence of thoracentesis and pleural biopsy on biochemical parameters and cytology of pleural fluid from patients with lymphocytic exudate. PATIENTS AND METHODS: A prospective, descriptive study was performed in 72 patients with pleural effusion who had lymphocytic exudate and in whom biopsy was indicated. Biochemical variables and cytology of pleural fluid were analyzed at baseline, 48 hours later (immediately prior to biopsy), and 48 hours after biopsy. RESULTS: The patients had a mean (SD) age of 63 (17) years, 57% were smokers, and 61% were men. Effusion was right-sided in 36% of patients, unilateral in 80%, and massive in 21%. The etiology was benign in 43 cases and neoplastic in 29 (40%). Pleural lactate dehydrogenase (LDH) was found to be increased following biopsy. This effect was significant in the overall population of 72 patients (649 [481] U/L just prior to biopsy and 736 [536] U/L 48 hours after biopsy; mean increase, 86 U/L; 95% confidence interval, 45-128 U/L; P< .001), in patients with pleural tumors (799 [529] U/L prior to biopsy and 957 [571] U/L 48 hours later, P< .001), and in those with LDH concentration greater than 266 U/L. CONCLUSIONS: The results of our study show that a single thoracentesis procedure does not alter biochemical parameters or pleural cytology after 48 hours in lymphocytic exudates. Pleural needle biopsy leads to a significant increase in the concentration of LDH in patients with pleural tumors or higher baseline concentrations of LDH. Thoracentesis, pleural biopsy, or a combination of the two do not lead to significant changes in the number of eosinophils in pleural fluid.

[Bilateral hemothorax secondary to combined antiplatelet therapy with clopidogrel and acetylsalicylic acid]. / Hemotórax bilateral secundario al tratamiento antiagregante con clopidogrel y ácido acetilsalicílico.

Clopidogrel is a platelet aggregation inhibitor that increases the risk of bleeding complications when combined with acetylsalicylic acid. We report a rare case of a 79-year-old male treated with clopidogrel and acetylsalicylic acid after coronary angioplasty and stenting to treat unstable angina. Two months after initiation of therapy, the patient presented with symptomatic bilateral pleural effusion. Examination of both effusions confirmed the diagnosis of spontaneous bilateral hemothorax due to combined anti-platelet therapy. Serious functional sequelae were still present 18 months after diagnosis despite bilateral pleural drainage and respiratory physiotherapy.

Hemotórax bilateral secundario al tratamiento antiagregante con clopidogrel y ácido acetilsalicílico / Bilateral hemothorax secondary to combined antiplatelet therapy with clopidogrel and acetylsalicylic acid

El clopidogrel es un inhibidor de la agregación plaquetaria que aumenta el riesgo de complicaciones hemorrágicas cuando se combina con el ácido acetilsalicílico. Presentamos un caso excepcional en un varón de 79 años tratado con clopidogrel y ácido acetilsalicílico después de una angioplastia coronaria y la colocación de un stent por una angina inestable. A los 2 meses de tratamiento presentó un derrame pleural bilateral sintomático. El estudio de ambos derrames confirmó el diagnóstico de un hemotórax espontáneo bilateral atribuido a los antiagregantes. El drenaje pleural bilateral y la fisioterapia respiratoria no impidieron la persistencia de importantes secuelas funcionales a los 18 meses del diagnóstico

Clopidogrel is a platelet aggregation inhibitor that increases the risk of bleeding complications when combined with acetylsalicylic acid. We report a rare case of a 79-year-old male treated with clopidogrel and acetylsalicylic acid after coronary angioplasty and stenting to treat unstable angina. Two months after initiation of therapy, the patient presented with symptomatic bilateral pleural effusion. Examination of both effusions confirmed the diagnosis of spontaneous bilateral hemothorax due to combined anti-platelet therapy. Serious functional sequelae were still present 18 months after diagnosis despite bilateral pleural drainage and respiratory physiotherapy