Incidence of pleural effusion in patients with pulmonary embolism

Incidence and Prognostic Role of Pleural Effusion in Patients with Pulmonary Embolism: A Systematic Review and Meta-Analysis

Background: Pleural effusion is a common pulmonary embolism (PE) complication, which has been documented to increase the risk of death in PE and relate to disease progression. However, the incidence of pleural effusion varies among studies and its association with PE outcome is still unclear. This study sought to determine the pooled incidence and prognostic value of pleural effusion events in patients with PE. Methods: We systematically searched the PubMed, EMBASE, SCOPE, Web of Science, Cochrane, LILACS, CINAHL, EBSCO, AMED, and OVID databases from the inception of each database to 7 September 2022 with a restriction on human studies, to identify studies assessing the association between pleural effusion and PE including all prospective and retrospective clinical studies. An exploratory meta-analysis was performed using a random-effects model. We evaluated the heterogeneity and performed subgroup analyses. Results: The final meta-analysis included 29 studies involving 13,430 PE patients. The pooled incidence of pleural effusion in PE patients was 41.2% (95% CI: 35.7–46.6%), which tended to be unilateral (pooled incidence: 60.8%, 95% CI: 45.7–75.8%) and small (pooled incidence: 85.9%, 95% CI: 82.6–89.1%). Pooled analysis using a random-effects model (I2 = 53.2%) showed that pleural effusion was associated with an increased risk of 30-day mortality (RR 2.19, 95% CI: 1.53–3.15, p < 0.001, I2 = 67.1%) and in-hospital mortality (RR 2.39, 95% CI: 1.85–3.09, p < 0.001, I2 = 37.1%) in patients with PE. Conclusions: Our meta-analysis found that PE patients had a high incidence of pleural effusion, which was usually unilateral and small. Pleural effusion generally increases 30-day and in-hospital mortality in patients with PE, and it is recommended that physicians be aware of the risk of death from PE, especially when patients have pleural effusion. Further investigations focusing on PE with pleural effusion are warranted.

Uma Apresentação Rara de COVID-19 com Embolia Pulmonar

A doença de coronavírus 2019 (COVID-19) foi relatada em quase todos os países do mundo desde dezembro de 2019. A infecção por SARS-CoV-2 é frequentemente assintomática ou com sintomas leves, mas também pode levar à hipóxia, um estado hiperinflamatório e coagulopatia. Os parâmetros de coagulação anormais estão associados a complicações trombóticas, incluindo embolia pulmonar na COVID-19, mas pouco se sabe sobre os mecanismos. A semelhança dos sintomas iniciais de ambas as doenças também pode ser confusa, portanto, os médicos devem estar cientes do potencial para condições concomitantes. Apresentamos aqui um caso que não apresentava opacidades em vidro fosco nos pulmões, mas apresentava embolia pulmonar e derrame pleural em associação com infecção por COVID-19.

A Case of Pulmonary Embolism with Sarcomatoid Malignant Pleural Mesothelioma with Long-Term Pleural Effusion

Background

Malignant pleural mesothelioma (MPM) is a highly aggressive tumor that originates from pleural mesothelial cells. In recent years, with the development of asbestos-related industries and the increase in air pollution, its incidence has been increased. The incidence of pulmonary embolism combined with sarcomatoid MPM is very low and the prognosis is extremely poor. We here report a case of a patient with long term of pleural effusion and finally diagnosed as pulmonary embolism with sarcomatoid MPM.

Case

A 75-year-old male with a 30-year history of asbestos exposure was admitted to our hospital due to chest pain and difficulty in breathing after exercise. Radiologic examination revealed pleural effusion, computed tomography pulmonary angiography (CTPA) suggests pulmonary embolism, and we consider pleural effusion caused by pulmonary embolism. After anticoagulant therapy for pulmonary embolism and pleural puncture to reduce pleural effusion, the patient's symptoms improved. However, after that, the patient was still admitted to the hospital several times because of recurrent chest pain and dyspnea symptoms, and radiologic examination always showed unexplained pleural effusion. Finally, pathological and immunohistochemical examinations of the pleural biopsy specimens were performed, and the diagnosis was confirmed as sarcomatoid MPM.

Conclusion

In summary, sarcomatoid MPM with pulmonary embolism is relatively rare, and the prognosis is poor. Clinicians need to be alert to its occurrence. When the first diagnosis is confirmed and the effect of targeted treatment is still not good, the possibility of other diseases should be considered. In clinical practice, pleural biopsy guided by PET-CT is a good choice for patients with sarcomatoid MPM who cannot tolerate open pleural biopsies or thoracoscopy. And patients should undergo pleural morphology and immunohistochemistry as soon as possible, which are helpful for timely diagnosis.

Prevalence and clinical significance of pleural effusion in patients with acute pulmonary embolism: a retrospective study

Background

Pleural effusion is observed in a subset of patients with acute pulmonary embolism (APE) and may be linked to clinical outcome, but findings from previous studies have been inconsistent. This study aimed to investigate the prevalence and clinical significance of pleural effusion in Chinese patients with APE.

Methods

Clinical data from hospitalized patients with APE were retrospectively collected and the prevalence of pleural effusion was determined. The relationship between the presence of pleural effusion and clinical outcome of APE was analyzed by Cox proportional hazards regression and Kaplan-Meier survival analysis.

Results

The study enrolled 635 patients with APE. The prevalence of pleural effusion was 57.01% (362/635). Patients with pleural effusion had significantly higher in-hospital mortality (9.9% vs. 4.8%, P<0.05) and longer length of hospital stay (LOS) (19.99 vs. 15.31 days, P<0.05) than whose without pleural effusion. However, pleural effusion was not an independent risk factor for in-hospital mortality in patients with APE by multivariate Cox proportional hazards regression analysis [hazard ratio (HR) =1.70, 95% confidence interval (CI): 0.73-3.92, P=0.216] and Kaplan-Meier survival analysis (P=0.174).

Conclusions

Pleural effusion is a frequent occurrence in patients with APE and therefore merits greater attention from clinicians; however, it is not an independent risk factor for in-hospital mortality.

Pleural Effusions in Pulmonary Emboli: A Single Centre Experience

OBJECTIVES

Pleural effusions commonly occur in conjunction with acute pulmonary emboli (PE). There are no guidelines on the investigation and management of these effusions. We aimed to review local management to inform future practice Material and Methods: This was a retrospective, observational single centre study, looking at all computed tomography pulmonary angiograms done in a large hospital in the North East of England in 2019. Electronic notes, imaging and discharge letters of patients with PE were reviewed. Statistical analysis was performed to describe patient-specific variables, clinical characteristics, pathological findings and subsequent management decisions.  Results: 1630 computed tomography pulmonary angiographies (CTPAs) were requested to investigate for PE. Three hundred sixteen (19.4%) were positive for PE. Of those, 89 (28.1%) were identified as having associated pleural effusions. Five (5.8%) patients had a contemporaneous pleural aspiration. All pleural effusions were exudative. Four were consistent with known malignant diagnoses. The other patient had concurrent pneumonia and pancreatitis. Nineteen (21%) had no risk factors for effusion development. The presence of pulmonary infarction/consolidation was associated with the development of a pleural effusion.

CONCLUSIONS

This project is a single centre review with the largest number of patients looking at pleural effusions associated with pulmonary emboli. Although pleural effusions commonly occur with PE and lung infarction, pleural aspiration is rarely performed. Management is not altered by the presence of an effusion.

Pleural effusion in acute pulmonary embolism in Bahrain: Radiological and pleural fluid characteristics

Background and Objectives

Pleural effusion is seen in around half of the cases of pulmonary embolism (PE). There are no data on the incidence of pleural effusion in cases of PE in the Kingdom of Bahrain. This study was done to determine the frequency and radiological features of pleural effusion in cases of acute PE and also to characterize the pleural fluid biochemistry and cell type in patients subjected to diagnostic thoracentesis.

Methods

This was a retrospective, observational single-center study. All the data of patients subjected to computed tomography pulmonary angiography (CTPA) in suspected cases of acute PE over a 4-year period were analyzed.

Results

A total of 1756 patients were subjected to CTPA from January 2013 to December 2016. A diagnosis of acute PE was made in 200 patients (11.4%). Pleural effusion was identified in 70 cases (35%). Majority of the effusions were small to moderate in size, bilateral, and associated with peripheral emboli. Consolidation, atelectasis, and ground glass attenuation were common associated findings on CTPA in these patients. Consolidation was more common in patients of PE associated with pleural effusion as compared to those with PE alone (62.85% and 33.8%, respectively, odds rato: 3.279 and 95% confidence interval: 1.798-6.091, P < 0.001). Diagnostic thoracentesis was done in 6 (8.6%) of the cases. All the patients had an exudative effusion with normal glucose values and neutrophil predominance.

Conclusion

PE was associated with pleural effusion in around one-third of the patients in Bahrain. The effusions were mainly small and bilateral. The emboli in cases associated with pleural effusion were mostly peripheral. Consolidation was the parenchymal abnormality detected on CTPA which was significantly associated with the presence of pleural effusion. Most of the pleural effusions were not suitable for thoracentesis. In patients subjected to fluid analysis, the effusions were exudative, neutrophilic predominant, and associated with normal glucose levels.

Dynamics of CT visible pleural effusion in patients with pulmonary infarction

Background Pleural effusion remains largely unexplored in patients with pulmonary embolism and concurrent pulmonary infarction. The aim of the study was to investigate the relationship between the size of pulmonary infarction and pleural effusion as well as the time course of pleural effusion in patients with pulmonary infarction. Patients and methods Data from 103 patients with pulmonary infarction was retrospectively analysed along with patient comorbidities, size of pulmonary infarction, presence and size of pleural effusion with the time between the onset of clinical symptoms of pulmonary infarction and CT study. Results Assessment of possible correlations between the size of pulmonary infarction and age revealed a significant negative correlation. There was a highly significant difference (p = 0.005) in the mean size of pulmonary infarction in patients with effusion (34.5 cm3) compared to those without it (14.3 cm3), but the size of the effusion had no correlation with the size of pulmonary infarction. The size of the effusion peaked between 4th-5th day after the onset of clinical symptoms of pulmonary infarction. In the first 5 days after the onset of clinical symptoms of pulmonary infarction a significant correlation was found between the size of the effusion and time with approximation of 1.3 mm/12 h. Conclusions The data shows that patients with a pleural effusion are more likely to have a larger pulmonary infarction than those without it. If present, the effusion can be expected to increase in a relatively slow linear fashion in the first 5 days after the onset of clinical symptoms of pulmonary infarction.

Limitations of an automated embolism segmentation method in clinical practice

PURPOSE

Automated pulmonary embolism (PE) segmentation is frequently used as a preprocessing step in the quantitative analysis of pulmonary embolism. Objective of this study is to analyze the potential limitation in automated PE segmentation using clinical cases.

METHODS

A database of 304 computer tomography pulmonary angiography (CTPA) examinations was collected and confirmed to be PE. After processing using an automated scheme, two radiologists classified these cases into four groups of A, B, C and D, which represent 4 different segmentation results namely, (1) entire pulmonary artery identified without motivation artifacts, (2) entire pulmonary artery identified with motivation artifacts, (3) part of the pulmonary artery identified, and (4) none of the pulmonary artery identified. Then, the possible failed reasons in PE segmentation were analyzed and determined based on the image characterization of the diseases and the applied CTPA scanning protocols.

RESULTS

In the study, 143 (47.0%., 30 (9.9%., 110 (36.2%. and 21 (6.9%. examinations were classified into groups A, B, C and D, respectively. Group C and D included the cases with failed segmentation. Fifteen failure reasons, including intrapulmonary abnormalities, extra-pulmonary abnormalities, diffuse pulmonary diseases, enlarged heart, absolute occluded vessels, embolism attached to artery wall, delayed scan time, skewed location, low scan dose, obvious artifact of superior vena cava, previous chest surgery, congenital deformities of the chest, incorrect positioning, missed images and other unknown reasons, were determined with corresponding case percentages ranging from 0.3%.o 9.2%.

CONCLUSIONS

Automated segmentation failures were caused by specific lung diseases, anatomy varieties, improper scan time, improper scan dose, manual errors or other unknown reasons. Realization of those limitations is crucial for developing robust automated schemes to handle these issues in a single pass when a large number of CTPA examinations need to be analyzed.

To immunosuppress or not: Behcet's syndrome presenting as an eosinophilic pleural effusion

Etiologic diagnosis of an eosinophilic pleural effusion (EPE) presents a diagnostic challenge when intrapleural air and blood have been ruled out as its proximate causes. Among the causes of EPE, those that require immunosuppression for the underlying disease include connective tissue diseases, sarcoidosis, vasculitis, and eosinophilic pneumonia. We present a case of clinically suspected Behcet's syndrome based on a 10-year history of recurrent multiple oral ulcers and human leukocyte antigen-B51 positivity who presented with only an EPE. Computed tomography pulmonary angiogram ruled out central thoracic vein thrombosis but was inconclusive in ruling out a subsegmental pulmonary embolism. The patient declined immunosuppressants and while on follow-up developed bilateral extensive acute lower limb deep venous thrombosis and pulmonary embolism. Upper infrarenal inferior vena cava demonstrated chronic thrombosis suggestive of its antecedent role in pulmonary embolism-related EPE during the first instance. Behcet's syndrome-related EPE can be associated with venous thromboembolism, and immunosuppressive therapy prevents the subsequent thrombotic episodes.

An interesting case of undiagnosed pleural effusion

Pleural effusions are commonly encountered in the clinical practise of both respiratory and nonrespiratory specialists. An estimated 1–1.5 million new cases in the USA and 200 000–250 000 new cases of pleural effusions are reported from the UK each year [1]. Analysis of the relevant clinical history, physical examination, chest radiography and diagnostic thoracentesis is useful in identifying the cause of pleural effusion in majority of the cases [2]. In a few cases, the aetiology may be unclear after the initial assessment. The list of diseases that may account for a persistent undiagnosed pleural effusion is long [3]. We present an interesting case of undiagnosed pleural effusion that was encountered in our hospital.

Pulmonary embolism is an important cause of undiagnosed pleural effusionhttp://ow.ly/HDLx30bVVa7

Prognostic impact of pleural effusion in acute pulmonary embolism

Background Pulmonary embolism (PE) is a common and life-threatening condition associated with considerable morbidity and mortality. Pleural effusion occurs in about one in three cases; however, data on its prognostic value are scarce. Purpose To investigate the association between pleural effusion and both 30-day and long-term mortality in patients with acute PE. Material and Methods We retrospectively evaluated 463 patients diagnosed with acute PE using computed tomography pulmonary angiography (CTPA). Echocardiographic, demographic, and laboratory data were collected. The study population was divided into two groups: patients with and without pleural effusions. Pleural effusion detected on CT was graded as small, moderate, and large according to the amount of effusion. The predictors of 30-day and long-term total mortality were analyzed. Results Pleural effusions were found in 120 patients (25.9%). After the 30-day follow-up, all-cause mortality was higher in acute PE patients with pleural effusions than in those without (23% versus 9%, P < 0.001). Also, patients with pleural effusions had significantly higher incidence of long-term total mortality than those without pleural effusions (55% versus 23%, P < 0.001). In a multivariate analysis, pleural effusion was an independent predictor of 30-day and long-term mortality (odds ratio [OR], 2.154; 95% confidence interval [CI], 1.186-3.913; P = 0.012 and OR, 1.591; 95% CI, 1.129-2.243; P = 0.008, respectively). Conclusion Pleural effusion can be independently associated with both 30-day and long-term mortality in patients with acute PE.

Pleural effusions as a predictive parameter for poor prognosis for patients with acute pulmonary thromboembolism

The incidence, characteristics of pleural effusions due to pulmonary thromboembolism (PTE) have been reported previously. However, the impact of pleural effusions on the prognosis of acute PTE patients and the involved influencing factors remain unclear. A total of 518 consecutive PTE patients were enrolled in Beijing Chao-Yang Hospital from January 2009 to April 2014. The diagnosis was confirmed with Spiral computer tomography pulmonary angiography or/and high-probability ventilation and perfusion scans. All patients finished one-year clinical follow-up. Among 518 patients with acute PTE, pleural effusions were found in 120 patients (23.2 %). No strictly tight association between side of pleural effusions and location of thrombus was observed. The diagnosis time between patients of PTE with pleural effusions and without pleural effusions had no statistically significant difference. During the 3-month follow-up, the all-cause mortality of PTE patients with pleural effusions was significantly higher than those without pleural effusions [10/120 (8.3 %) vs. 8/398 (2.0 %)]. During the 1-year follow-up, analysis of survival also showed that all-cause mortality was significantly higher in PTE patients with pleural effusions than those without pleural effusions. In both univariate Cox-regression analysis [P < 0.001, HR 3.044, 95 % CI (1.647, 5.625)] and multivariate Cox-regression analysis [P < 0.05, HR 2.040, 95 % CI (1.038, 4.009)] pleural effusions showed to be risk factor of poor prognosis. Pleural effusions in patients with acute PTE were significantly correlated with higher mortality. Pleural effusions in acute PTE patients might be used as a predictive parameter for prognosis.