Diagnostic Considerations

Transudative pleural effusion

Considerations in the differential diagnosis of transudative pleural effusion include the following:

Congestive heart failure (most common)
Cirrhosis with hepatic hydrothorax
Nephrotic syndrome
Peritoneal dialysis/continuous ambulatory peritoneal dialysis
Hypoproteinemia
Glomerulonephritis
Superior vena cava obstruction
Fontan procedure
Urinothorax
CSF leak to the pleural space

Exudative pleural effusion

Conditions to consider in the differential diagnosis of exudative pleural effusion include the following:

Malignancy
Pneumonia
Tuberculosis
Pulmonary embolism
Fungal infection
Pancreatic pseudocyst
Intra-abdominal abscess
Post CABG surgery
Postcardiac injury syndrome
Pericardial disease
Meigs syndrome
Ovarian hyperstimulation syndrome
Rheumatoid pleuritis
Lupus erythematosus
Drug-induced pleural disease
Asbestos pleural effusion
Yellow nail syndrome
Uremia
Trapped lung
Chylothorax
Pseudochylothorax
Acute respiratory distress syndrome
Chronic pleural thickening
Malignant mesothelioma
Hypothyroidism

Additional causes of pleural effusion or mimics of pleural effusion are as follows:

Congestive heart failure and pulmonary edema
Diaphragmatic injuries
Esophageal rupture and tears
Hypothyroidism and myxedema coma
Lung neoplasms
Pancreatitis
Q fever
Rheumatoid arthritis

Workup

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Media Gallery

Large right-sided pleural effusion. This effusion was malignant.
Left-sided pleural effusion.
Left lateral decubitus film displaying freely layering left-sided pleural effusion.
Lung entrapment with right hydropneumothorax and pleural drain in place.
Massive right pleural effusion resulting in mediastinal shift to the left.
Right-sided pleural effusion after partial drainage showing improved left mediastinal shift.
Bilateral pleural effusions with loss of bilateral costophrenic sulci (meniscus sign). Anteroposterior, upright chest radiograph. Image courtesy of Allen R. Thomas, MD.
Isolated, left-sided pleural effusion with visualized loss of left, lateral costophrenic sulcus. Posteroanterior upright chest radiograph. Image courtesy of Allen R. Thomas, MD.

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Author

Kamran Boka, MD, MS Attending Physician in Pulmonary and Critical Care Medicine, StatCare

Kamran Boka, MD, MS is a member of the following medical societies: American College of Critical Care Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Guy W Soo Hoo, MD, MPH Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Chief, Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System

Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Rubins, MD Professor of Medicine, University of Minnesota Medical School; Director, Palliative Medicine, Hennepin County Medical Center

Jeffrey Rubins, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Chest Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment