Pleural effusion differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]; Nate Michalak, B.A.

Overview

Evaluation of a patient with a pleural effusion requires a thorough clinical history and physical examination in conjunction with pertinent laboratory tests and imaging studies. According to the British Thoracic Society Pleural Disease Guideline 2010, thoracentesis should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. Pleural fluid should always be sent for protein, lactate dehydrogenase, Gram stain, cytology and microbiological culture.[1] Additional studies which may be indicated in selected cases include pH, glucose, acid-fast bacilli and tuberculosis culture, triglyceride, cholesterol, amylase, and hematocrit. Light's criteria is applied to distinguish the fluid between transudative or exudative.[2] A broad array of underlying conditions result in exudative effusions, while a limited number of disorders are assoicated with transudative effusions, which include congestive heart failure, cirrhosis, nephrotic syndrome, peritoneal dialysis, hypoalbuminemia, urinothorax, atelectasis, constrictive pericarditis, trapped lung, superior vena cava obstruction, and duropleural fistula.

Differentiating Pleural Effusion from other Diseases

Exudative Pleural Effusions

Etiology Underlying conditions
Infectious Bacterial pneumonia, tuberculous effusion, fungal disease, atypical pneumonia, nocardia, actinomyces, subphrenic abscess, hepatic abscess, splenic abscess, hepatitis, parasites
Iatrogenic Drug-induced, esophageal perforation, esophageal sclerotherapy, central venous catheter misplacement or migration, enteral feeding tube in pleural space
Vasculitis Wegener granulomatosis, Churg–Strauss syndrome, familial Mediterranean fever
Malignancy Carcinoma, lymphoma, mesothelioma, leukemia, chylothorax
Inflammatory Pancreatitis, benign asbestos pleural effusion (BAPE), pulmonary infarction, radiation therapy, sarcoidosis, post-cardiac injury syndrome (PCIS), hemothorax, acute respiratory distress syndrome (ARDS), cholesterol effusion
Increased negative intrapleural pressure Atelectasis, trapped lung
Connective tissue disease Lupus pleuritis, rheumatoid pleuritis, mixed connective tissue disease, Sjögren syndrome
Endocrine dysfunction Hypothyroidism, ovarian hyperstimulation syndrome
Lymphatic abnormalities Chylothorax, yellow nail syndrome, lymphangiomyomatosis, lymphangiectasis
Movement of fluid from abdomen to pleural space Acute pancreatitis, pancreatic pseudocyst, Meigs syndrome, chylous ascites

Other Differentials

Pleural effusions should be differentiated from other diseases presenting with chronic cough, shortness of breath and tachypnea. The differentials include the following:[3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit
Chronic obstructive pulmonary disease (COPD)
  • On CT scan:
  • On MRI:
    • Increased diameter of pulmonary arteries
    • Peripheral pulmonary vasculature attentuation
    • Loss of retrosternal airspace due to right ventricular enlargement
    • Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
 ✔ ✔ - - - ✔ ✔ - - -
Pneumonia ✔ ✔ ✔ ✔ - ✔ ✔ - - -
Congestive heart failure
  • Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 ≥3.5 mV
    • Total QRS amplitude in each of the limb leads ≤0.8 mV
    • R/S ratio <1 in lead V4
 ✔ ✔ ✔ - - ✔ - - - -
Pulmonary embolism
  • On CT angiography:
    • Intra-luminal filling defect
  • On MRI:
    • Narrowing of involved vessel
    • No contrast seen distal to obstruction
    • Polo-mint sign (partial filling defect surrounded by contrast)
 ✔ ✔ ✔ (Low grade) ✔ ✔ (In case of massive PE) ✔ - - - -
Percarditis
  • ST elevation
  • PR depression
  • Large collection of fluid inside the pericardial sac (pericardial effusion)
  • Calcification of pericardial sac
 ✔ ✔ ✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - ✔ - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Vasculitis

Homogeneous, circumferential vessel wall swelling

✔ ✔ ✔ ✔ ✔ ✔ - ✔ ✔ ✔

References

  1. ↑ Hooper C, Lee YC, Maskell N (2010). "Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii4–17. doi:10.1136/thx.2010.136978. PMID 20696692. Unknown parameter |month= ignored (help)
  2. ↑ Light RW, Macgregor MI, Luchsinger PC, Ball WC (1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Ann. Intern. Med. 77 (4): 507–13. PMID 4642731. Unknown parameter |month= ignored (help)
  3. ↑ Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.
  4. ↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
  5. ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
  6. ↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
  7. ↑ Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.
  8. ↑ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.
  9. ↑ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.
  10. ↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
  11. ↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
  12. ↑ Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.
  13. ↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
  14. ↑ Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.
  15. ↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
  16. ↑ Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.
  17. ↑ Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.
  18. ↑ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
  19. ↑ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.
  20. ↑ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.
  21. ↑ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.
  22. ↑ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.

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