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Pediatric Pleural Effusion Workup

  • Author: Dagnachew (Dagne) Assefa, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD  more...
 
Updated: Nov 10, 2015
 

Approach Considerations

Tests may need to be ordered to rule out immune dysfunction or other underlying systemic or local pulmonary disorders that cause empyema.

Analysis of the pleural fluid is the single best method to determine the cause of a pleural effusion. Thoracentesis should be performed when sufficient fluid is present to allow a safe procedure, except when the suspected effusion is clearly secondary to a specific underlying disease (for example, congestive heart failure, nephrotic syndrome, ascites, or recent initiation of peritoneal dialysis).[30]

Simple observation of the gross appearance of the fluid may provide a clue as to the cause of the pleural effusion, as follows:

  • Grossly purulent fluid indicates an empyema
  • A putrid odor suggests an anaerobic empyema
  • Clear, pale yellow fluid suggests a transudate
  • Milky fluid is consistent with a chylothorax
  • Bloody pleural fluid is seen with trauma, malignancy, tuberculosis, uremia, and empyema due to group A Streptococcus
  • Aspergillus nigrans infection produces a black pleural fluid

In the appropriate clinical setting, measurement of pleural fluid triglyceride levels (chylous effusion), amylase (pancreatitis, esophageal rupture), and pleural fluid hematocrit (hemothorax) may be useful.

A complete blood count (CBC) with differential, blood cultures, and C-reactive protein (CRP) may help to establish the presence of infection. The white blood cell (WBC) count and CRP may be useful in monitoring treatment progress in infectious effusions. A positive blood culture finding may facilitate the selection of antibiotics in sterile empyema. (Approximately 10-22% of children with complicated parapneumonic effusions have a positive blood culture result.)[37, 46]

Measurement of titers may be helpful if specific organisms, such as Mycoplasma species, Legionella species, or adenovirus, are suspected. However, the use of these tests in early management of parapneumonic effusions is limited due to the need for convalescent titer.

If risk factors for tuberculosis are present, sputum (or gastric aspirates) for acid fast bacilli and a purified protein derivative (PPD) test should be performed.

Serum protein, LDH, amylase, glucose, and hydrogen ion concentration (pH) may be helpful in interpreting results of pleural fluid analysis. If chylous effusion is suspected, serum cholesterol and triglyceride levels should be obtained.

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Exudate Versus Transudate

Conventionally, the initial evaluation of pleural fluid is directed at determining whether the effusion is an exudate or a transudate. The classification is based on simple biochemical criteria first proposed by Light et al.[47] However, the Light criteria was developed and tested in adults, and its accuracy in children has been questioned.[6]

According to the Light criteria, the pleural fluid is defined as an exudate if it fulfils at least one of 3 criteria. If none of the criteria are met, then the fluid is considered a transudate. The criteria are as follows:

  • Pleural fluid–to–serum lactate dehydrogenase (LDH) ratio of more than 0.6
  • Pleural fluid–to–serum protein ratio of more than 0.5
  • Pleural fluid LDH level of two thirds the upper limit of the reference range

In general, exudates have protein concentration higher than 2.9 g/dL, with the pleural fluid cholesterol level more than 45 mg/dL.[48]

Biochemical analysis of the pleural fluid provides further information that may be useful in narrowing the differential diagnosis of exudative effusion, as follows:

  • Low pleural glucose level (< 60 mg/dL) or pleural fluid–to–serum glucose ratio of less than 0.5 - Seen in several conditions, such as parapneumonic effusion, tuberculosis, malignancy, esophageal rupture, and rheumatoid effusions [49]
  • LDH levels of more than 1000 IU/L - Found in empyema [50] and rheumatoid effusions [51]
  • Pleural fluid–to–serum LDH ratio of 1 and pleural fluid–to–serum protein ratio less than 0.5 -Suggest effusion due to P jiroveci pneumonia [52]
  • Pleural fluid pH below 7.3 (with normal arterial pH) - Seen in parapneumonic effusion, tuberculosis, malignancy, esophageal rupture, systemic acidosis, urinothorax, and rheumatoid effusions; [49] most exudative effusions have a pH of 7.3-7.45, whereas transudates have a pleural fluid pH ranging from 7.4-7.55 [49] (the pH of normal pleural fluid is about 7.6) [53]
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Cell Count

Pleural fluid cell count, although routinely performed, is not particularly helpful in establishing any of the diagnoses likely to occur in children. However, in certain settings, the predominant cell type may be helpful in determining etiology. Polymorphonuclear cells tend to predominate in recent effusions, and lymphocytes in long-standing ones.

  • Neutrophilic predominance - Bacterial etiology, pancreatitis (fluid, often hemorrhagic), esophageal rupture (very low pH), and the early stages of pleural tuberculosis [54]
  • Lymphocytic predominance (85-95% of total nucleated cells) - Tuberculosis, malignancy, uremia, connective tissue disease, and mycotic infections [55]
  • Monocytic effusion - Viral and mycoplasma pneumonia [30]
  • Eosinophilic effusion (>10% eosinophils) - Reactive eosinophilic pleuritis (recent pneumothorax or blood in pleural space), drugs (eg, dantrolene and nitrofurantoin), uremia, fungal and parasitic infections [56, 57]
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Microbiologic Analysis

Microbiologic analysis of the pleural fluid should be obtained from patients with undiagnosed exudative pleural effusion. Such analysis includes the following:

  • Gram, acid-fast bacilli, and fungal (KOH) staining
  • Culture for bacteria (both aerobic and anaerobic), mycobacteria, and fungi
  • Direct and enrichment culture for aerobic and anaerobic organisms - In addition send some pleural fluid in anaerobic blood culture bottle [58]

The yield of microbiologic diagnosis in children may be increased by the use of adjunct techniques to detect bacterial antigens. These include counterimmunoelectrophoresis, latex agglutination, specific (eg, pneumolysin) polymerase chain reaction (PCR) assay, and broad range (eg, 16S rDNA) PCR assay.[7, 8, 59] These tests may be particularly useful in patients who have received antibiotics prior to thoracentesis.

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Diagnosis of Tuberculous and Malignant Pleuritis

Tuberculous pleuritis

The pleural fluid adenosine deaminase and interferon-γ levels are elevated in almost all patients with tuberculous pleuritis. Measurement of adenosine deaminase or interferon-γ may be used to establish the diagnosis.[60] However, no universally accepted cutoff point is noted for either of these parameters.

In a meta-analysis, a maximum joint sensitivity and specificity of 93% for adenosine deaminase and 96% for interferon-γ was noted.[61] The specificity of this parameter may be higher when used in conjunction with a lymphocyte-to-neutrophil ratio in pleural fluid of 0.75 or greater.[62]

Molecular techniques, such as PCR assay to detect specific mycobacterial deoxyribonucleic acid (DNA) in pleural fluid, are now available for diagnosis of tuberculous pleuritis.[63] Although PCR assay tests have a great potential for providing a rapid and specific diagnosis of mycobacterial infection, they are limited by low sensitivity.[46]

Malignant pleuritis

Cytology can be performed if a malignancy is suspected. However, negative cytology does not rule out malignancy.[64] In a retrospective study, Chaignaud et al found that cytologic examination and immunotyping of cells in pleural fluid were diagnostic in 71% of children with lymphoblastic lymphoma, obviating general anesthesia and open biopsy of the mediastinal masses.[64]

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Chest Radiography

A chest radiograph, while nonspecific, is the simplest and least expensive method of identifying a pleural effusion.[30] A chest radiograph may also reveal underlying pneumonia before pleural fluid starts accumulating. (See the image below.)

Upright chest radiograph in a 3-year-old child wit Upright chest radiograph in a 3-year-old child with dyspnea and fever obtained 1 day before the development of the pleural effusion reveals pneumonia on the left side.

Frontal, lateral, and decubitus radiographs may be used to detect a pleural effusion. In general, free-flowing pleural fluid collects in the most dependent part of the pleural space on an upright chest radiograph, usually the posterior costophrenic recess and, less often, the lateral recess.[65] Blunting of the costophrenic recess is the earliest sign of pleural fluid accumulation. (See the images below.)

Upright chest radiograph in a 3-year-old child wit Upright chest radiograph in a 3-year-old child with dyspnea and fever reveals a large opacity on the left, with obliteration of the left costophrenic angle and a fluid stripe.
Upright posteroanterior chest radiograph of a chil Upright posteroanterior chest radiograph of a child with a right-sided pleural effusion.
Lateral view in a child with right-sided pleural e Lateral view in a child with right-sided pleural effusion reveals a pleural effusion and a fluid level.
Left lateral view in a patient with reaccumulated Left lateral view in a patient with reaccumulated pleural effusion on the left side of the chest reveals layering of the effusion.
Left lateral decubitus image in a 3-year-old child Left lateral decubitus image in a 3-year-old child with dyspnea and fever reveals minimal layering of the fluid, which indicates a loculated effusion.
Right lateral decubitus radiograph in a child with Right lateral decubitus radiograph in a child with a right-sided pleural effusion. Image reveals partial layering of the fluid in the right side.
Right lateral decubitus radiograph in a neonate re Right lateral decubitus radiograph in a neonate reveals layering of the chylothorax effusion after a chest tube has been removed.

As effusions increase in size, they produce a characteristic meniscus sign as the fluid tracks superiorly along the pleural surface.[66] Large effusions result in opacification of the hemithorax, with mediastinal shift (see the image below). Absence of shift is suggestive of underlying lobar collapse.

In adults, approximately 50 mL of fluid causes blunting of the posterior costophrenic recess on a lateral chest radiograph. By contrast, at least 200 mL is necessary to blunt the lateral recess on an upright chest radiograph.[67] A lateral decubitus film is the most sensitive view and can detect as little as 5-10 mL of free fluid.[68] A lateral decubitus film obtained with the affected side down provides valuable information about the quantity and quality of effusion.

A fluid layer of more than 1 cm on decubitus film is amenable to thoracentesis. Nonshifting fluid suggests either thick fluid or loculation. A lateral decubitus image obtained with the affected side up may facilitate the evaluation of the underlying lung for atelectasis or infiltrates.

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Ultrasonography

Pleural ultrasonography permits easy characterization of pleural effusion. In experienced hands, it is superior to standard upright chest radiography and supine chest radiography for detecting pleural effusion.[69]

Ultrasonography can easily distinguish between free and loculated pleural effusion (see the images below) and allow pleural fluid to be differentiated from pleural thickening and solid masses. Ultrasonography may also facilitate the identification of the best site for thoracentesis or insertion of a thoracotomy tube.[70, 71] The main limitation of ultrasonography is that its usefulness depends on the examiner’s skill.

Ultrasonogram of the pleural effusion in a 3-year- Ultrasonogram of the pleural effusion in a 3-year-old child with dyspnea and fever reveals many septa (arrowheads) and several large, loculated portions of fluid (arrows).
Ultrasonogram of the effusion in a 3-year-old chil Ultrasonogram of the effusion in a 3-year-old child with dyspnea and fever reveals several fluid loculations (arrows) separated by septa (arrowheads). The lung is seen under the effusion.
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CT Scanning

Pleural fluid can easily be identified on computed tomography (CT) scans. However, CT scan findings lack the accuracy required for the differentiation of exudates from transudates and chylothorax[72, 73, 74] and for accurately predicting the presence of empyema in patients with parapneumonic effusion.[75] Although CT scanning detects more parenchymal abnormalities than chest radiography does, studies found that the additional information obtained does not seem to alter management decisions or help to predict clinical outcomes. (See the image below.)[76, 77]

CT scan of the chest in a 3-year-old child with dy CT scan of the chest in a 3-year-old child with dyspnea and fever reveals a left-sided effusion and underlying parenchymal infiltrate and atelectasis.

CT scanning is increasingly used as the study of choice in empyema; it may provide additional information in complicated cases.[78] In addition, CT scan guidance may also be useful in interventions in which effusions are difficult to access.[35] However, the modality is comparatively expensive, invasive, and time consuming. The omission of routine CT scanning in empyema reduces the exposure of children to unneeded radiation and cuts costs.[76]

Pleural evaluation is greatly aided by the use of intravenous contrast, as the unenhanced pleura cannot normally be visualized.[79]

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Thoracentesis, Pleural Biopsy, and Bronchoscopy

Thoracentesis

Thoracentesis is recommended for most pleural effusions of sufficient size whenever the cause of the effusion is uncertain.

Thoracentesis should not be performed if the diagnosis is thought to be certain and the likelihood of empyema or malignancy is low. Such circumstances include small, bilateral infiltrates in congestive heart failure or nephrosis or a small parapneumonic effusion in an afebrile child recovering from pneumonia.

Thoracentesis should be performed in patients whose respiratory status is compromised by pleural effusion, in patients with empyema or malignancy, or in newborns.

Pleural biopsy

This may be needed in cases of unexplained inflammatory effusion, suspected tuberculosis, or malignancy. The two major complications of pleural biopsy are bleeding and pneumothorax.

Bronchoscopy

Routine flexible bronchoscopy is not indicated in children with pleural effusion. Aspiration of a foreign body in younger children is a possibility and is an indication for bronchoscopy.

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Contributor Information and Disclosures
Author

Dagnachew (Dagne) Assefa, MD, FAAP, FCCP Pediatric Pulmonologist, Pediatric Lung Care, Bon Secours

Dagnachew (Dagne) Assefa, MD, FAAP, FCCP is a member of the following medical societies: American Academy of Pediatrics, American Academy of Sleep Medicine, American College of Chest Physicians, American Thoracic Society, European Respiratory Society

Disclosure: Nothing to disclose.

Coauthor(s)

Arthur B Atlas, MD Assistant Clinical Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey

Arthur B Atlas, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Sleep Medicine, American College of Chest Physicians, American Lung Association, American Thoracic Society, Medical Society of New Jersey

Disclosure: Received grant/research funds from astra zeneca for none.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Girish D Sharma, MD Associate Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush University Medical Center

Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Wang NS. Anatomy of the pleura. Clin Chest Med. 1998 Jun. 19(2):229-40. [Medline].

  2. Agostoni E, Zocchi L. Mechanical coupling and liquid exchanges in the pleural space. Clin Chest Med. 1998 Jun. 19(2):241-60. [Medline].

  3. Alkrinawi S, Chernick V. Pleural infection in children. Semin Respir Infect. 1996 Sep. 11(3):148-54. [Medline].

  4. Hardie W, Bokulic R, Garcia VF, et al. Pneumococcal pleural empyemas in children. Clin Infect Dis. 1996 Jun. 22(6):1057-63. [Medline].

  5. Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med. 1998 Jun. 19(2):363-71. [Medline].

  6. Alkrinawi S, Chernick V. Pleural fluid in hospitalized pediatric patients. Clin Pediatr (Phila). 1996 Jan. 35(1):5-9. [Medline].

  7. Le Monnier A, Carbonnelle E, Zahar JR, et al. Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids. Clin Infect Dis. 2006 Apr 15. 42(8):1135-40. [Medline].

  8. Saglani S, Harris KA, Wallis C, Hartley JC. Empyema: the use of broad range 16S rDNA PCR for pathogen detection. Arch Dis Child. 2005 Jan. 90(1):70-3. [Medline].

  9. Buckingham SC, King MD, Miller ML. Incidence and etiologies of complicated parapneumonic effusions in children, 1996 to 2001. Pediatr Infect Dis J. 2003 Jun. 22(6):499-504. [Medline].

  10. Hardie WD, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin- nonsusceptible Streptococcus pneumoniae. Pediatrics. 1998 Mar. 101(3 Pt 1):388-92. [Medline].

  11. Quintero DR, Fan LL. Approach to pleural effusions and empyemas. Paediatr Respir Rev. 2004. 5 Suppl A:S151-2. [Medline].

  12. Hausdorff WP, Feikin DR, Klugman KP. Epidemiological differences among pneumococcal serotypes. Lancet Infect Dis. 2005 Feb. 5(2):83-93. [Medline].

  13. Byington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J. 2006 Mar. 25(3):250-4. [Medline].

  14. Eltringham G, Kearns A, Freeman R, et al. Culture-negative childhood empyema is usually due to penicillin-sensitive Streptococcus pneumoniae capsular serotype 1. J Clin Microbiol. 2003 Jan. 41(1):521-2. [Medline].

  15. Obando I, Munoz-Almagro C, Arroyo LA, et al. Pediatric parapneumonic empyema, Spain. Emerg Infect Dis. 2008 Sep. 14(9):1390-7. [Medline]. [Full Text].

  16. Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med. 2003 May 1. 348(18):1737-46. [Medline].

  17. Kaplan SL, Mason EO Jr, Wald ER, et al. Decrease of invasive pneumococcal infections in children among 8 children's hospitals in the United States after the introduction of the 7-valent pneumococcal conjugate vaccine. Pediatrics. 2004 Mar. 113(3 Pt 1):443-9. [Medline].

  18. Poehling KA, Talbot TR, Griffin MR, et al. Invasive pneumococcal disease among infants before and after introduction of pneumococcal conjugate vaccine. JAMA. 2006 Apr 12. 295(14):1668-74. [Medline].

  19. Li ST, Tancredi DJ. Empyema Hospitalizations Increased in US Children Despite Pneumococcal Conjugate Vaccine. Pediatrics. 2009 Nov 30. [Medline].

  20. [Guideline] Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax. 2005 Feb. 60 Suppl 1:i1-21. [Medline]. [Full Text].

  21. Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics. 2004 Jun. 113(6):1735-40. [Medline].

  22. Gonzalez BE, Hulten KG, Dishop MK, Lamberth LB, Hammerman WA, Mason EO Jr, et al. Pulmonary manifestations in children with invasive community-acquired Staphylococcus aureus infection. Clin Infect Dis. 2005 Sep 1. 41(5):583-90. [Medline].

  23. Freij BJ, Kusmiesz H, Nelson JD, McCracken GH Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect Dis. 1984 Nov-Dec. 3(6):578-91. [Medline].

  24. Bryant RE, Salmon CJ. Pleural empyema. Clin Infect Dis. 1996 May. 22(5):747-62; quiz 763-4. [Medline].

  25. Cowan MR, Primm PA, Scott SM, Abramo TJ, Wiebe RA. Serious group A beta-hemolytic streptococcal infections complicating varicella. Ann Emerg Med. 1994 Apr. 23(4):818-22. [Medline].

  26. Brook I. Microbiology of empyema in children and adolescents. Pediatrics. 1990 May. 85(5):722-6. [Medline].

  27. Merino JM, Carpintero I, Alvarez T, et al. Tuberculous pleural effusion in children. Chest. 1999 Jan. 115(1):26-30. [Medline].

  28. Kim HJ, Lee HJ, Kwon SY, et al. The prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis. Chest. 2006 May. 129(5):1253-8. [Medline].

  29. Cruz AT, Starke JR. Clinical manifestations of tuberculosis in children. Paediatr Respir Rev. 2007 Jun. 8(2):107-17. [Medline].

  30. Panitch HB, Papastamelos C, Schidlow DV. Abnormalities of the pleural space. Taussig LM, Landau LI, eds. Pediatric Respiratory Medicine. 1999. 1178-96.

  31. Sassoon CS, Light RW. Chylothorax and pseudochylothorax. Clin Chest Med. 1985 Mar. 6(1):163-71. [Medline].

  32. Soto-Martinez M, Massie J. Chylothorax: diagnosis and management in children. Paediatr Respir Rev. 2009 Dec. 10(4):199-207. [Medline].

  33. Munoz-Almagro C, Jordan I, Gene A, et al. Emergence of invasive pneumococcal disease caused by nonvaccine serotypes in the era of 7-valent conjugate vaccine. Clin Infect Dis. 2008 Jan 15. 46(2):174-82. [Medline].

  34. Chonmaitree T, Powell KR. Parapneumonic pleural effusion and empyema in children. Review of a 19-year experience, 1962-1980. Clin Pediatr (Phila). 1983 Jun. 22(6):414-9. [Medline].

  35. Mocelin HT, Fischer GB. Epidemiology, presentation and treatment of pleural effusion. Paediatr Respir Rev. 2002 Dec. 3(4):292-7. [Medline].

  36. Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics. 2010 Jan. 125(1):26-33. [Medline].

  37. Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. 2002 Feb 15. 34(4):434-40. [Medline].

  38. Calbo E, Diaz A, Canadell E, et al. Invasive pneumococcal disease among children in a health district of Barcelona: early impact of pneumococcal conjugate vaccine. Clin Microbiol Infect. 2006 Sep. 12(9):867-72. [Medline].

  39. Desrumaux A, Francois P, Pascal C, et al. [Epidemiology and clinical characteristics of childhood parapneumonic empyemas]. Arch Pediatr. 2007 Nov. 14(11):1298-303. [Medline].

  40. Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics. 2005 Jun. 115(6):1652-9. [Medline].

  41. Meyerovitch J, Shohet I, Rubinstein E. Analysis of thirty-seven cases of pleural empyema. Eur J Clin Microbiol. 1985 Jun. 4(3):337-9. [Medline].

  42. Barbas CS, Cukier A, de Varvalho CR, Barbas Filho JV, Light RW. The relationship between pleural fluid findings and the development of pleural thickening in patients with pleural tuberculosis. Chest. 1991 Nov. 100(5):1264-7. [Medline].

  43. Ampofo K, Byrington C. Management of Parapneumonic Empyema. Pediatr infec Dis J. 2007. 26:445-446.

  44. Lazarus AA, McKay S, Gilbert R. Pleural tuberculosis. Dis Mon. 2007 Jan. 53(1):16-21. [Medline].

  45. Pietsch JB, Whitlock JA, Ford C, Kinney MC. Management of pleural effusions in children with malignant lymphoma. J Pediatr Surg. 1999 Apr. 34(4):635-8. [Medline].

  46. Forbes BA. Critical assessment of gene amplification approaches on the diagnosis of tuberculosis. Immunol Invest. 1997 Jan-Feb. 26(1-2):105-16. [Medline].

  47. Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972 Oct. 77(4):507-13. [Medline].

  48. Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. 1997 Apr. 111(4):970-80. [Medline].

  49. Sahn, SA. Pathogenesis and clinical features of diseases associated with a low pleural fluid glucose. Chretien, J, Bignon, J, Hirsch, A. The Pleura in Health and Disease. New York: Marcel Dekker; 1985. 267-285.

  50. Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med. 1980 Oct. 69(4):507-12. [Medline].

  51. Pettersson T, Klockars M, Hellstrom PE. Chemical and immunological features of pleural effusions: comparison between rheumatoid arthritis and other diseases. Thorax. 1982 May. 37(5):354-61. [Medline]. [Full Text].

  52. Horowitz ML, Schiff M, Samuels J, Russo R, Schnader J. Pneumocystis carinii pleural effusion. Pathogenesis and pleural fluid analysis. Am Rev Respir Dis. 1993 Jul. 148(1):232-4. [Medline].

  53. Sahn SA, Willcox ML, Good JT Jr, Potts DE, Filley GF. Characteristics of normal rabbit pleural fluid: physiologic and biochemical implications. Lung. 1979. 156(1):63-9. [Medline].

  54. Villena Garrido V, Ferrer Sancho J, Hernandez Blasco L, et al. [Diagnosis and treatment of pleural effusion]. Arch Bronconeumol. 2006 Jul. 42(7):349-72. [Medline].

  55. Yam LT. Diagnostic significance of lymphocytes in pleural effusions. Ann Intern Med. 1967 May. 66(5):972-82. [Medline].

  56. Adelman M, Albelda SM, Gottlieb J, Haponik EF. Diagnostic utility of pleural fluid eosinophilia. Am J Med. 1984 Nov. 77(5):915-20. [Medline].

  57. Kalomenidis I, Light RW. Eosinophilic pleural effusions. Curr Opin Pulm Med. 2003 Jul. 9(4):254-60. [Medline].

  58. [Guideline] Maskell NA, Butland RJ. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax. 2003 May. 58 Suppl 2:ii8-17. [Medline].

  59. Camargos P, Fonseca AC, Amantéa S, Oliveira E, Benfica MD, Chamone C. The role of latex agglutination test for the etiological diagnosis of pleural effusion in children and adolescents. Clin Respir J. 2015 Jul 6. [Medline].

  60. Lee YC, Rogers JT, Rodriguez RM, Miller KD, Light RW. Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions. Chest. 2001 Aug. 120(2):356-61. [Medline].

  61. Greco S, Girardi E, Masciangelo R, Capoccetta GB, Saltini C. Adenosine deaminase and interferon gamma measurements for the diagnosis of tuberculous pleurisy: a meta-analysis. Int J Tuberc Lung Dis. 2003 Aug. 7(8):777-86. [Medline].

  62. Burgess LJ, Maritz FJ, Le Roux I, Taljaard JJ. Combined use of pleural adenosine deaminase with lymphocyte/neutrophil ratio. Increased specificity for the diagnosis of tuberculous pleuritis. Chest. 1996 Feb. 109(2):414-9. [Medline].

  63. Light RW. Clinical practice. Pleural effusion. N Engl J Med. 2002 Jun 20. 346(25):1971-7. [Medline].

  64. Chaignaud BE, Bonsack TA, Kozakewich HP, Shamberger RC. Pleural effusions in lymphoblastic lymphoma: a diagnostic alternative. J Pediatr Surg. 1998 Sep. 33(9):1355-7. [Medline].

  65. Qureshi NR, Gleeson FV. Imaging of pleural disease. Clin Chest Med. 2006 Jun. 27(2):193-213. [Medline].

  66. Wilson, AG. Pleura and pleural disorders. Armstrong P, Wilson AG, Dee P, et al,. Imaging of diseases of the chest. London: Mosby; 1995. 641-716.

  67. Blackmore CC, Black WC, Dallas RV, Crow HC. Pleural fluid volume estimation: a chest radiograph prediction rule. Acad Radiol. 1996 Feb. 3(2):103-9. [Medline].

  68. Moskowitz H, Platt RT, Schachar R, Mellins H. Roentgen visualization of minute pleural effusion. An experimental study to determine the minimum amount of pleural fluid visible on a radiograph. Radiology. 1973 Oct. 109(1):33-5. [Medline].

  69. Kelbel C, Borner N, Schadmand S, et al. [Diagnosis of pleural effusions and atelectases: sonography and radiology compared]. Rofo. 1991 Feb. 154(2):159-63. [Medline].

  70. Hirsch JH, Rogers JV, Mack LA. Real-time sonography of pleural opacities. AJR Am J Roentgenol. 1981 Feb. 136(2):297-301. [Medline].

  71. Lipscomb DJ, Flower CD, Hadfield JW. Ultrasound of the pleura: an assessment of its clinical value. Clin Radiol. 1981 May. 32(3):289-90. [Medline].

  72. Wolek R, Mason BJ, Reeser P, Zins JH. Pleural fluid: accuracy of computed tomography in differentiating exudates from transudates. Conn Med. 1998 May. 62(5):259-65. [Medline].

  73. Aquino SL, Webb WR, Gushiken BJ. Pleural exudates and transudates: diagnosis with contrast-enhanced CT. Radiology. 1994 Sep. 192(3):803-8. [Medline].

  74. Arenas-Jimenez J, Alonso-Charterina S, Sanchez-Paya J, et al. Evaluation of CT findings for diagnosis of pleural effusions. Eur Radiol. 2000. 10(4):681-90. [Medline].

  75. Donnelly LF, Klosterman LA. CT appearance of parapneumonic effusions in children: findings are not specific for empyema. AJR Am J Roentgenol. 1997 Jul. 169(1):179-82. [Medline].

  76. Jaffe A, Calder AD, Owens CM, Stanojevic S, Sonnappa S. Role of routine computed tomography in paediatric pleural empyema. Thorax. 2008 Oct. 63(10):897-902. [Medline].

  77. Calder A, Owens CM. Imaging of parapneumonic pleural effusions and empyema in children. Pediatr Radiol. 2009 Jun. 39(6):527-37. [Medline].

  78. Donnelly LF, Klosterman LA. The yield of CT of children who have complicated pneumonia and noncontributory chest radiography. AJR Am J Roentgenol. 1998 Jun. 170(6):1627-31. [Medline].

  79. Calder A, Owens CM. Imaging of parapneumonic pleural effusions and empyema in children. Pediatr Radiol. 2009 Jun. 39(6):527-37. [Medline].

  80. Jaffe A, Balfour-Lynn IM. Management of empyema in children. Pediatr Pulmonol. 2005 Aug. 40(2):148-56. [Medline].

  81. Light RW, Rodriguez RM. Management of parapneumonic effusions. Clin Chest Med. 1998 Jun. 19(2):373-82. [Medline].

  82. Teixeira LR, Sasse SA, Villarino MA, Nguyen T, Mulligan ME, Light RW. Antibiotic levels in empyemic pleural fluid. Chest. 2000 Jun. 117(6):1734-9. [Medline].

  83. Thys JP, Vanderhoeft P, Herchuelz A, Bergmann P, Yourassowsky E. Penetration of aminoglycosides in uninfected pleural exudates and in pleural empyemas. Chest. 1988 Mar. 93(3):530-2. [Medline].

  84. Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax. 2002 Apr. 57(4):343-7. [Medline].

  85. Gilbert CR, Lee HJ, Skalski JH, Maldonado F, Wahidi M, Choi PJ, et al. The Use of Indwelling Tunneled Pleural Catheters for Recurrent Pleural Effusions in Patients With Hematologic Malignancies: A Multicenter Study. Chest. 2015 Sep 1. 148 (3):752-8. [Medline].

  86. Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3. 352(9):865-74. [Medline].

  87. Barbato A, Panizzolo C, Monciotti C, et al. Use of urokinase in childhood pleural empyema. Pediatr Pulmonol. 2003 Jan. 35(1):50-5. [Medline].

  88. Kilic N, Celebi S, Gurpinar A, et al. Management of thoracic empyema in children. Pediatr Surg Int. 2002 Jan. 18(1):21-3. [Medline].

  89. Kornecki A, Sivan Y. Treatment of loculated pleural effusion with intrapleural urokinase in children. J Pediatr Surg. 1997 Oct. 32(10):1473-5. [Medline].

  90. Krishnan S, Amin N, Dozor AJ, Stringel G. Urokinase in the management of complicated parapneumonic effusions in children. Chest. 1997 Dec. 112(6):1579-83. [Medline].

  91. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med. 2006 Jul 15. 174(2):221-7. [Medline].

  92. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg. 2009 Jan. 44(1):106-11; discussion 111. [Medline].

  93. Laisaar T, Pullerits T. Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions. Chest. 2003 Feb. 123(2):432-5. [Medline].

  94. Subramaniam R, Joseph VT, Tan GM, Goh A, Chay OM. Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children. J Pediatr Surg. 2001 Feb. 36(2):316-9. [Medline].

  95. Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics. 2006 Sep. 118(3):e547-53. [Medline].

  96. Padman R, King KA, Iqbal S, Wolfson PJ. Parapneumonic effusion and empyema in children: retrospective review of the duPont experience. Clin Pediatr (Phila). 2007 Jul. 46(6):518-22. [Medline].

  97. Aziz A, Healey JM, Qureshi F, et al. Comparative analysis of chest tube thoracostomy and video-assisted thoracoscopic surgery in empyema and parapneumonic effusion associated with pneumonia in children. Surg Infect (Larchmt). 2008 Jun. 9(3):317-23. [Medline].

  98. Kim BY, Oh BS, Jang WC, et al. Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema. Am J Surg. 2004 Sep. 188(3):321-4. [Medline].

  99. Petrakis IE, Kogerakis NE, Drositis IE, et al. Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure?. Am J Surg. 2004 Apr. 187(4):471-4. [Medline].

  100. Gates RL, Caniano DA, Hayes JR, Arca MJ. Does VATS provide optimal treatment of empyema in children? A systematic review. J Pediatr Surg. 2004 Mar. 39(3):381-6. [Medline].

  101. Chan PW, Crawford O, Wallis C, Dinwiddie R. Treatment of pleural empyema. J Paediatr Child Health. 2000 Aug. 36(4):375-7. [Medline].

  102. McLaughlin FJ, Goldmann DA, Rosenbaum DM, et al. Empyema in children: clinical course and long-term follow-up. Pediatrics. 1984 May. 73(5):587-93. [Medline].

  103. Walker CA, Shirk MB, Tschampel MM, Visconti JA. Intrapleural alteplase in a patient with complicated pleural effusion. Ann Pharmacother. 2003 Mar. 37(3):376-9. [Medline].

  104. Wells RG, Havens PL. Intrapleural fibrinolysis for parapneumonic effusion and empyema in children. Radiology. 2003 Aug. 228(2):370-8. [Medline].

 
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Upright chest radiograph in a 3-year-old child with dyspnea and fever obtained 1 day before the development of the pleural effusion reveals pneumonia on the left side.
Upright chest radiograph in a 3-year-old child with dyspnea and fever reveals a large opacity on the left, with obliteration of the left costophrenic angle and a fluid stripe.
Left lateral decubitus image in a 3-year-old child with dyspnea and fever reveals minimal layering of the fluid, which indicates a loculated effusion.
Upright posteroanterior chest radiograph of a child with a right-sided pleural effusion.
Lateral view in a child with right-sided pleural effusion reveals a pleural effusion and a fluid level.
Right lateral decubitus radiograph in a child with a right-sided pleural effusion. Image reveals partial layering of the fluid in the right side.
Posteroanterior view in a patient with reaccumulated pleural effusion in the left side of the chest.
Left lateral view in a patient with reaccumulated pleural effusion on the left side of the chest reveals layering of the effusion.
Anteroposterior view of the chest reveals a large chylothorax on the right side of the chest in a neonate.
Anteroposterior view in a neonate reveals reaccumulation of the chylothorax in the right hemithorax after a chest tube has been removed.
Right lateral decubitus radiograph in a neonate reveals layering of the chylothorax effusion after a chest tube has been removed.
Ultrasonogram of the pleural effusion in a 3-year-old child with dyspnea and fever reveals many septa (arrowheads) and several large, loculated portions of fluid (arrows).
Ultrasonogram of the effusion in a 3-year-old child with dyspnea and fever reveals several fluid loculations (arrows) separated by septa (arrowheads). The lung is seen under the effusion.
CT scan of the chest in a 3-year-old child with dyspnea and fever reveals a left-sided effusion and underlying parenchymal infiltrate and atelectasis.
 
 
 
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