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.

Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature.

BACKGROUND: Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion. CASE PRESENTATION: A 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy. CONCLUSION: The management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

Diagnosis and Management of Hepatic Hydrothorax.

Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).

[Expert consensus on diagnosis and treatment of malignant pleural effusion caused by lung cancer].

Malignant pleural effusion (MPE) can occur in nearly all types of malignant tumors, with lung cancer being the most prevalent cause. The presence of MPE indicates an advanced stage or distant spread of the tumor, significantly reducing the patient's life expectancy. Particularly, a substantial amount of pleural effusion can impede heart and lung function, impair blood oxygen perfusion levels in the body, and greatly diminish patients' quality of life. Even when systemic treatment has alleviated the primary lung tumor in some patients, effective control over MPE remains challenging and impacts clinical outcomes. Therefore, it is crucial to implement measures for reducing or managing MPE while ensuring standardized treatment for lung cancer. In recent years, significant advancements have been made in diagnosing and treating lung cancer complicated by MPE through extensive basic and clinical research. Based on existing evidence and China's clinical practice experience, relevant experts from the China Association of Health Promotion and Education and Cancer Rehabilitation and Palliative Treatment Professional Committee of China Anti-Cancer Association (CRPC) have summarized key aspects related to diagnosis and treatment consensus opinions for lung cancer complicated by MPE. This aims to establish standardized procedures that will serve as a reference for doctors' clinical practice.

Thoracentesis to alleviate pleural effusion in acute heart failure: study protocol for the multicentre, open-label, randomised controlled TAP-IT trial.

INTRODUCTION: Pleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised trials or guidelines supports thoracentesis to alleviate pleural effusion due to acute heart failure. The Thoracentesis to Alleviate cardiac Pleural effusion Interventional Trial (TAP-IT) will investigate if a strategy of referring patients with acute heart failure and pleural effusion to up-front thoracentesis by pleural pigtail catheter insertion in addition to pharmacological therapy compared with pharmacological therapy alone can increase the number of days the participants are alive and not hospitalised during the 90 days following randomisation. METHODS AND ANALYSIS: TAP-IT is a pragmatic, multicentre, open-label, randomised controlled trial aiming to include 126 adult patients with left ventricular ejection fraction ≤45% and a non-negligible pleural effusion due to heart failure. Participants will be randomised 1:1, stratified according to site and anticoagulant treatment, and assigned to referral to up-front ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard pharmacological therapy or to standard pharmacological therapy only. Thoracentesis is performed according to local guidelines and can be performed in participants in the pharmacological treatment arm if their condition deteriorates or if no significant improvement is observed within 5 days. The primary endpoint is how many days participants are alive and not hospitalised within 90 days from randomisation and will be analysed in the intention-to-treat population. Key secondary outcomes include 90-day mortality, complications, readmissions, and quality of life. ETHICS AND DISSEMINATION: The study has been approved by the Capital Region of Denmark Scientific Ethical Committee (H-20060817) and Knowledge Center for Data Reviews (P-2021-149). All participants will sign an informed consent form. Enrolment began in August 2021. Regardless of the nature, results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER: NCT05017753.

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.

Chylothorax related to acute SARS-CoV-2 infection in a patient with Noonan syndrome with prior uncomplicated cardiac surgeries.

SARS-CoV-2 is a novel coronavirus that has rarely been associated with chylothorax. Patients with Noonan syndrome are at risk for developing chylothorax, especially after cardiothoracic interventions. We present the case of SARS-CoV-2 infection triggering the underlying tendency of a patient with Noonan syndrome to develop chylothorax who did not develop it even after prior cardiothoracic interventions. Patient presented in respiratory distress without hypoxia and was found, on imaging, to have a large right-sided pleural effusion, which was eventually classified as chylothorax. The patient was then started on a low-fat diet. Chest tube drainage substantially reduced the effusion in size, and it remained stable. Our report highlights that SARS-CoV-2 infection can cause the development of a chylothorax or a chylous effusion in patients with Noonan syndrome or among populations with a similar predisposition. A high index of suspicion in vulnerable patients or those not responding to traditional therapy should exist with providers, thus leading to the testing of the fluid to confirm the diagnosis.

¿Tuberculosis, sarcoidosis o ambas? / Tuberculosis, sarcoidosis or maybe both?

Presentamos un caso clínico de una paciente de 34 años con diagnóstico simultáneo de sarcoidosis y tuberculosis, sin ser inmunodeprimida ni tener factores de riesgo para ello. Esto supone un hallazgo muy poco común, y cuando aparece suele deberse a la inmunosupresión ocasionada por el tratamiento con esteroides de la sarcoidosis. En el caso que vamos a describir a continuación este hecho no sucede, motivo por el que se le otorga relevancia. Para llegar a los dos diagnósticos se realizaron las pruebas complementarias necesarias (analíticas sanguíneas, biopsias transbronquiales, pruebas de imagen, toracocentesis y biopsias pleurales), lo que permitió instaurar el tratamiento adecuado y, en consecuencia, la mejoría de la paciente. Con la presentación de este caso se pretende recalcar la importancia de hacer un buen enfoque diagnóstico en el servicio de urgencias, haciendo un hincapié en todos los signos y síntomas tanto directos como indirectos. (AU)

We report a case study of a 34-year-old patient with a simultaneous diagnosis of sarcoidosis and tuberculosis. The patient was not immunosuppressed and did not have risk factors for this. This is a very rare finding, and when it appears it is usually due to immunosuppression caused by corticosteroid treatment of sarcoidosis. In the case reported below, this does not occur, which is why it is relevant. To make both diagnoses, the necessary complementary tests were performed (blood tests, transbronchial biopsies, imaging tests, thoracentesis and pleural biopsies), which enabled appropriate treatment to be established and, consequently, the patient's improvement. Reporting this case enables us to emphasize the importance of making a good diagnosis in A&E, emphasizing all direct and indirect signs and symptoms. (AU)

Recurrent bilateral idiopathic chylothorax: a therapeutic challenge.

Chylothorax is a rare condition caused by pleural effusion resulting from thoracic duct injury. Recurrent chylothorax is often resistant to conservative treatment and presents a clinical conundrum in its management. Here, we report a compelling case of recurrent chylothorax that persisted despite the administration of total parenteral nutrition, octreotide and thoracic duct embolisation. The patient eventually required thoracic duct ligation and talc pleurodesis, which resulted in the resolution of the effusion. Our case is an illustrative example of the effective multidisciplinary management of recurrent bilateral idiopathic chylothorax.

A Retrospective Cohort Study Evaluating the Safety and Efficacy of Sequential versus Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection.

Methods: We conducted a retrospective review of patients with pleural infection requiring intrapleural therapy at two tertiary referral centres. Results: We included 84 (62.2%) and 51 (37.8%) patients who received sequential and concurrent intrapleural therapy, respectively. Patient demographics and clinical characteristics, including age, RAPID score, and percentage of pleural opacity on radiographs before intrapleural therapy, were similar in both groups. Treatment failure rates (defined by either in-hospital mortality, surgical intervention, or 30-day readmission for pleural infection) were 9.5% and 5.9% with sequential and concurrent intrapleural therapy, respectively (p = 0.534). This translates to a treatment success rate of 90.5% and 94.1% for sequential and concurrent intrapleural therapy, respectively. There was no significant difference in the decrease in percentage of pleural effusion size on chest radiographs (15.1% [IQR 6-35.7] versus 26.6% [IQR 9.9-38.7], p = 0.143) between sequential and concurrent therapy, respectively. There were also no significant differences in the rate of pleural bleeding (4.8% versus 9.8%, p = 0.298) and chest pain (13.1% versus 9.8%, p = 0.566) between sequential and concurrent therapy, respectively. Conclusion: Our study adds to the growing literature on the safety and efficacy of concurrent intrapleural therapy in pleural infection.

Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY): protocol of a prospective, multicentre, observational study.

INTRODUCTION: Recurrence rate following radical therapy for lung cancer remains high, potentially reflecting occult metastatic disease, and better staging tools are required. Minimal pleural effusion (mini-PE) is associated with particularly high recurrence risk and is defined as an ipsilateral pleural collection (<1/3 hemithorax on chest radiograph), which is either too small to safely aspirate fluid for cytology using a needle, or from which fluid cytology is negative. Thoracoscopy (local anaesthetic thoracoscopy (LAT) or video-assisted thoracoscopic surgery (VATS)) is the gold-standard diagnostic test for pleural malignancy in patients with larger symptomatic effusions. Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY) will prospectively evaluate thoracoscopic staging in lung cancer associated-mini-PE for the first time. METHODS AND ANALYSIS: STRATIFY is a prospective multicentre observational study. Recruitment opened in January 2020. The primary objective is to determine the prevalence of detectable occult pleural metastases (OPM). Secondary objectives include assessment of technical feasibility and safety, and the impact of thoracoscopy results on treatment plans, overall survival and recurrence free survival. Inclusion criteria are (1) suspected/confirmed stages I-III lung cancer, (2) mini-PE, (3) Performance Status 0-2 (4), radical treatment feasible if OPM excluded, (5) ≥16 years old and (6) informed consent. Exclusion criteria are any metastatic disease or contraindication to the chosen thoracoscopy method (LAT/VATS). All patients have LAT or VATS within 7 (±5) days of registration, with results returned to lung cancer teams for treatment planning. Following an interim analysis, the sample size was reduced from 96 to 50, based on a lower-than-expected OPM rate. An MRI substudy was removed in November 2022 due to pandemic-related site setup/recruitment delays. These also necessitated a no-cost recruitment extension until October 2023. ETHICS AND DISSEMINATION: Protocol approved by the West of Scotland Research Ethics Committee (Ref: 19/WS/0093). Results will be published in peer-reviewed journals and presented at international meetings. TRIAL REGISTRATION NUMBER: ISRCTN13584097.

Post-Cardiac Injury Syndrome Following Permanent Pacemaker Implantation Presenting Exclusively As Massive Pleural Effusion: A Rare Occurrence.

Post-Cardiac Injury Syndrome (PCIS) akin to Dressler's syndrome is late-onset pericarditis that is triggered by the body's immune system and presents commonly as pleuro- pericardial symptoms and raised inflammatory markers. Its occurrence following the insertion of a pacemaker has been reported infrequently and varies in different studies with an estimated prevalence of 1-2%. Our case reports a unique incidence of isolated pleural effusion following the implantation of a pacemaker in a 62-year-old female with complete heart block with no evidence of pericardial effusion on imaging. She developed dyspnoea, pleuritic chest pain, and lethargy. She successfully responded to treatment with NSAIDs and colchicine with no recurrence. This report demonstrates the uncommon course of the disease and highlights the need to consider PCIS as a possible diagnosis in patients presenting with predominant pulmonary findings and suspect it early so that timely treatment can be started, thereby preventing complications.

Intrapleural Thrombolytics as First Line Therapy for Complicated Parapneumonic Effusions and Empyema in Patients with Prohibitive Surgical Risk: A Cases Series.

OBJECTIVE: In complicated parapneumonic effusion or Empyema, approximately 25% of patients require surgical intervention which can be associated with a mortality risk of almost 20%. However, the use combination of rt-tPA and DNase in elderly patients with prohibitive surgical risk has improved outcomes. The main goal of our study is to highlight the utility of intrapleural thrombolysis in patients with prohibitive risk for surgery. METHODS: A retrospective record review study of patients (n=23) with complicated parapneumonic pleural effusion or empyema treated with tPA and DNase from January 1st of 2015 to March 18th, 2019 at VACHCS. Data collected to describe the outcome of intrapleural thrombolytics included demographic, pleural fluid analysis, surgical risk assessment, diagnosis and initiation treatment day, doses, chest imaging, drainage rate, chest tube size and average days in place, inflammatory markers, microbiology, antibiotics, and complications. RESULTS: Only 21.7% of patients were considered surgical candidates. Seventy-four percent had a 30-day post-surgical mortality risk of > 2.5% using the National Surgery Office (NSO) risk calculator. Post-operative inpatient stay was 99.7% and estimated post operative ICU stay average was >80%. Primary outcome (pleural drainage improvement) obtained in 73.9%. Most common serious complications included sepsis (52.2%) and nonserious was residual hydropneumothorax (47.8%). CONCLUSION: This study demonstrates that administration of intrapleural thrombolytics through a percutaneous pleural catheter achieved successful drainage safely and without the need for surgical interventions in a selected group of advanced age, elderly patients with pleural infections who were deemed to be high surgical risk.