Pediatric Pleural Effusion Clinical Presentation

Updated: Apr 30, 2018
  • Author: Dagnachew (Dagne) Assefa, MD, FAAP, FCCP; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Presentation

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.

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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.

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