History

The clinical picture and presenting symptoms of pleural effusion depend on the underlying disease and the size and location of the effusion.

Symptoms linked to the underlying disease

Children with effusion as a complication of pneumonia (parapneumonic effusion or empyema) often have a history of recent upper respiratory tract infection, bronchitis, or pneumonia. These children usually present with the following symptoms:

Persistent fever
Cough
Anorexia
Malaise
Tachypnea
Dyspnea
Chest pain

Children with tuberculous pleural effusions may present with the following symptoms^[44]:

Cough
Pleuritic chest pain
Dyspnea
Night sweats
Fever
Hemoptysis
Weight loss

Malignant effusions may be more indolent and cause either no symptoms or only cough and low-grade fever.^[5]Pleural effusion due to a malignant lymphoma may present with respiratory distress, because of the size of the effusion, the mediastinal mass, or both.^[45]

In transudative effusions (congestive heart failure, nephrotic syndrome), the underlying disease usually determines the presenting symptoms. Occasionally the child may be asymptomatic until the accumulation becomes large enough to cause symptoms.^[35]

Although effusion occurs in association with systemic lupus erythematosus and other autoimmune diseases, it is rarely the initial manifestation.

Symptoms related to the size and location of the pleural effusion

An accumulation of a small amount of fluid may be asymptomatic. A large collection of fluid leads to dyspnea, respiratory distress, dull pain, and coughing. These symptoms may vary with an alteration in body position.

Subpulmonic fluid collection can be associated with vomiting, abdominal pain, and abdominal distention caused by partial paralytic ileus.

Chest pain

Chest pain is pleuritic in origin. Patients with an exudative effusion are more likely to have pain than are patients with a transudative effusion. The pain can be localized or referred to the shoulder and abdomen. It is typically described as sharp or stabbing and worsens with inspiration. The pain intensity lessens as the effusion increases in size; as the effusion increases, it separates the pleural membranes, and the pain becomes dull or disappears.

Physical Examination

The patient may look dyspneic and anxious because of pain, discomfort, or hypoxemia. A pleural rub may be the only initial manifestation during the early stage of pleurisy. The rub disappears as fluid accumulates between the pleural surfaces.

A large fluid collection causes fullness of the intercostal spaces and diminished chest excursion on the affected side. Excessive unilateral fluid accumulation shifts the mediastinum and displaces the trachea and cardiac apex to the contralateral side.

Dullness to percussion, decreased air entry, decreased tactile and vocal fremitus, and voice egophony over the effusion may be present but difficult to detect in younger children.

Differential Diagnoses

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Media Gallery

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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Author

Dagnachew (Dagne) Assefa, MD, FAAP, FCCP Pediatric Pulmonologist, Sleep Physican

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

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children's Hospital, Rush University Medical Center

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

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.