2. Exudative pleural effusion

Due to initial hypoxic presentation and large pocket of fluid, the patient underwent therapeutic thoracentesis with immediate improvement of oxygenation status post removal of 2 liters of fluid. Following his thoracentesis patient had complaints of acute pain, which was concerning for possible trapped lung. Chest x-ray and thoracic CT scan of the chest showing re-accumulation of fluid in the right hemithorax with findings of tumor invasion in the right mainstem bronchus (Figure 2).

Figure 2. Panel A: chest x-ray post-thoracentesis showing reaccumulation of fluid. Panel B: representative panel from thoracic CT scan in soft tissue windows.

Pleural fluid analysis showed: Total nucleated cell 1,424 /mm3, RBC 9,369 / mm3, Seg 19 %, Lymphs 80% Total Protein 3.7 g/dL, Glucose 258 mg/dL, Lactate Dehydrogenase 258 IU/L, Adenosine Deaminase 12.5. Cytology was negative but insufficient sample was sent however cell count and patient history were highly concerning for a malignant pleural effusion.

It is important to recognize that loculations on imaging are suggestive of an exudative effusion. The images presented demonstrate a complex, septated loculation of the pleural fluid on Ultrasound. Ultrasound is the most sensitive imaging modality to identify a “complex septated” pleural effusion (2,3). Characteristic findings on ultrasound include: anechoic (black), complex non-septated (black with white strands), complex septated (black with white septa), or homogeneously echogenic (white) (1). Anechoic fluid is typically a transudate, complex septated fluid is usually an exudate, while complex non-septated can be either (4). This case highlights utility and importance of point of care ultrasound in better characterizing complicated pleural effusion for risk stratification and timely chest tube placement.


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  2. Heffner JE, Klein JS, Hampson C. Diagnostic utility and clinical application of imaging for pleural space infections. Chest. 2010 Feb;137(2):467-79. [CrossRef] [PubMed]
  3. Esmadi M, Lone N, Ahmad DS, Onofrio J, Brush RG. Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient. Am J Case Rep. 2013;14:63-6. [CrossRef] [PubMed]
  4. Tu CY, Hsu WH, Hsia TC, Chen HJ, Tsai KD, Hung CW, Shih CM. Pleural effusions in febrile medical ICU patients: chest ultrasound study. Chest. 2004 Oct;126(4):1274-80. [CrossRef] [PubMed]

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