Pleural effusion resident survival guide: Difference between revisions

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==Approach to Pleural Fluid Analysis==
==Approach to Diagnosis and Management of Pleural Effusion==
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> '''Pleural fluid analysis''' <br>
{{familytree | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> '''Pleural fluid analysis''' <br>
Line 176: Line 176:
{{familytree | | | | C01 | | C02 | | | | | | | | | | | | | | | | | | | | | | | |C01= [[Transudate]]?|C02= [[Exudate]]? }}
{{familytree | | | | C01 | | C02 | | | | | | | | | | | | | | | | | | | | | | | |C01= [[Transudate]]?|C02= [[Exudate]]? }}
{{familytree | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | D01 | | D02 | | | | | | | | | | | | | | | | | | | | | | | |D01= Treat the cause|D02= '''Cause found'''?}}
{{familytree | | | | D01 | | D02 | | | | | | | | | | | | | | | | | | | | | | | |D01= Treat the cause|D02= '''Diagnosed'''?}}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |,|-|-|-|(| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |,|-|-|-|(| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | E01 | | E02 |-| E03 | | | | | | | | | | | | | | | | | | | |E01= '''No'''|E02= '''Yes'''|E03=Treat the cause }}
{{familytree | | | | E01 | | E02 |-|-|.| | | | | | | | | | | | | | | | | | | | |E01= '''No'''|E02= '''Yes'''|E03=Treat the cause }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | F01 |-| F02 |-| F03 | | | | | | | | | | | | | | | | | | | |F01= [[Contrast enhanced CT]]|F02='''Cause found'''?|F03= Treat the cause }}
{{familytree | | | | F01 |-| F02 |-| F03 | | | | | | | | | | | | | | | | | | | |F01= [[Contrast enhanced CT]]|F02='''Diagnosed'''?|F03= Treat the cause }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | H01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | H01=No cause found?}}
{{familytree | | | | H01 | | | | | | |!| | | | | | | | | | | | | | | | | | | | | H01=No diagnosis found?}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | I01 |-| I02 |-| I03 | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ Imaging guided pleural biopsy<br>❑ [[Thoracoscopy]]</div>|I02=Cause found|I03=Treat the cause }}
{{familytree | | | | I01 |-| I02 |-|-|'| | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ Imaging guided pleural biopsy<br>❑ [[Thoracoscopy]]</div>|I02='''Diagnosed?'''|I03=Treat the cause }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | K01=No cause found?}}
{{familytree | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | K01=No diagnosis found?}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | L01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |L01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ [[Bronchoscopy]] (if bronchial obstruction is suspected clinically)<br>❑ Mycobacterial culture<br>❑ [[Adenosine deaminase]] (to rule out tuberculosis)<br> ❑ If [[chylothorax]] is suspected clinically<br>
{{familytree | | | | L01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |L01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ [[Bronchoscopy]] (if bronchial obstruction is suspected clinically)<br>❑ Mycobacterial culture<br>❑ [[Adenosine deaminase]] (to rule out tuberculosis)<br> ❑ If [[chylothorax]] is suspected clinically<br>
Line 195: Line 195:
: ❑ Cholesterol levels<br>
: ❑ Cholesterol levels<br>
</div>}}
</div>}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |)|-|-| L02 |-|-|.| | | | | | | | | | | | | | | | | | | | | |L02='''Diagnosed?'''}}
{{familytree | | | | N01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |N01=No cause found?}}
{{familytree | | | | N01 | | | | | | |!| | | | | | | | | | | | | | | | | | | | |N01=No diagnosis found?}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | O01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |O01=Diagnose as non specific [[pleuritis]] }}
{{familytree | | | | O01 | | | | | | O02 | | | | | | | | | | | | | | | | | | | |O01=Diagnose as non specific [[pleuritis]]|O02=Treat the cause}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | P01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Reconsider following causes<br>
{{familytree | | | | P01 | | | | | | |!| | | | | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Reconsider following causes<br>
❑ [[Tuberculosis]]<br>
❑ [[Tuberculosis]]<br>
❑ [[Pulmonary embolism]]<br>
❑ [[Pulmonary embolism]]<br>
❑ [[Lymphoma]]<br>
❑ [[Lymphoma]]<br>
❑ [[Heart failure]]</div>}}
❑ [[Heart failure]]</div>}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | |)|-|-| P02 |-|-|'| | | | | | | | | | | | | | | | | | | | |P02='''Diagnosed?'''}}
{{familytree | | | | Q01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |Q01='''Waitful watch''' if no cause found}}
{{familytree | | | | Q01 | | | | | | | | | | | | | | | | | | | | | | | | | | | |Q01='''Waitful watch''' if no cause found}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}

Revision as of 01:08, 21 February 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Definition

Pleural effusion is defined as the presence of excessive fluid in the pleural cavity resulting from transudation or exudation from the pleural surfaces.

Light's Criteria

Pleural fluid is classified as an exudate if one or more of the following criteria are met.

Pleural fluid protein divided by serum protein > 0.5
Pleural fluid LDH divided by serum LDH > 0.6
Pleural fluid LDH > 2/3 of upper limit of normal serum LDH

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Transudate

Exudate

Initial Diagnosis

 
 
 
 
 
 
Characterize the symptoms

Shortness of breath
Chest pain

Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination

❑ Asymmetrical chest expansion
❑ Dullness to percussion
❑ Decreased tactile fremitus
❑ Mediastinal shift]

❑ Shift away from the effusion side in massive effusion
❑ Shift towards the effusion side in lobar bronchial obstruction
❑ Decreased breath sounds
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs suggestive of specific etiology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Congestive heart failure

❑ Distended neck veins
❑ S3 heart sound

Peripheral edema
 
 
Hepatic cause

Signs of liver failure

Ascites
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest radiograph
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest radiograph equivocal?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Approach to Thoracocentesis

 
 
 
 
 
 
Assess the clinical significance of pleural effusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shortness of breath at rest
 
❑ Rule out pulmonary embolism
❑ Therapeutic thoracocentesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
> 10 mm thickness of effusion on USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No known cause
 
Proceed with thoracocentesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CHF suspected?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Bilateral effusion
❑ Afebrile
❑ No chest pain
 
❑ Unilateral effusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Trial of diuretics
 
❑ Proceed with Thoracocentesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pleural Fluid Analysis

Appearance

 
 
 
 
 
 
Appearance of pleural fluid

Fluid appearanceSuspected cause
Putrid odourAnaerobic empyema
Food particlesEsophageal rupture
Bile stainedBilliary fistula
MilkyChylothorax or pseudochylothorax
Anchovy sauce like appearanceAmoebic abscess
Grossly bloodyMalignancy
Pulmonary embolism with infarction
Trauma
Asbestosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood stained pleural effusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform haematocrit on pleural effusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
>50% of peripheral haematocrit
 
< 50% peripheral haematocrit
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Haemothorax
 
Consider alternative diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Differential Cell Count

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differential cell counts
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neutrophil predominant
 
Lymphocyte predominant (>50% lymphocytes)
 
Eosinophil predominant (≥ 10% eosinophils)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignancy
Tuberculosis
Cardiac failure
Lymphoma
❑ Rheumatoid pleurisy
Sarcoidosis
CABG effusion
 
❑ Air or blood in the effusion fluid
Parapneumonic effusion
❑ Benign asbestosis
Churg-strauss syndrome
Lymphoma
Pulmonary infarction
❑ Parasitic infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pleural Fluid pH

 
 
 
 
 
 
Pleural fluid pH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 7.30
 
< 7.20
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider following causes
Malignancy
Rheumatoid arthritis
Esophageal rupture
Tuberculosis
 
❑ Perform tube drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Cytology

Interpretation of Cytology Results

Result Interpretation
Inadequate sample No mesothelial cells detected
No malignant cells seen Sample is adequate; no atypical cells seen;malignancy is not excluded
Atypical cells Inflammatory or malignant cells; further investigation required
Suspicious malignancy Cells with few malignant features present; no definitive malignant cells present
Malignant Definite malignant cells detected; further immunocytochemistry required

Approach to Diagnosis and Management of Pleural Effusion

 
 
 
 
 
Pleural fluid analysis

❑ Protien
LDH
Gram stain
Cytology
❑ Culture

❑ Pleural fluid pH (if infection is suspected)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Light's criteria

❑ Measure both serum and pleural fluid protein and LDH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Transudate?
 
Exudate?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat the cause
 
Diagnosed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Contrast enhanced CT
 
Diagnosed?
 
Treat the cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Imaging guided pleural biopsy
Thoracoscopy
 
Diagnosed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bronchoscopy (if bronchial obstruction is suspected clinically)
❑ Mycobacterial culture
Adenosine deaminase (to rule out tuberculosis)
❑ If chylothorax is suspected clinically
❑ Measure pleural fluid cholesterol crystals
Chylomicrons
Triglycerides
❑ Cholesterol levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnose as non specific pleuritis
 
 
 
 
 
Treat the cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reconsider following causes

Tuberculosis
Pulmonary embolism
Lymphoma

Heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Waitful watch if no cause found
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

Dont's

References