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Rapid Diagnosis and Treatment of a Pleural Effusion in a 24-Year-Old Man

Article  in  Chest · April 2019

DOI: 10.1016/j.chest.2018.09.036

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[ Ultrasound Corner ]

Rapid Diagnosis and Treatment of a

Pleural Effusion in a 24-Year-Old Man
Joseph M. Carrington, DO, MHA; and Derek A. Kruse, MD

CHEST 2019; 155(4):e83-e85

A 24-year-old man with prior history of seizure disorder

presented with a nonproductive cough and dyspnea for
2 weeks. The patient reported to be a never-smoker, but
was exposed to second-hand smoke daily in his home.
He worked in a factory that produced kerosene and had
previously worked in a foundry. His only medication
was carbamazepine. He was initially treated as an
outpatient with azithromycin, but his dyspnea worsened.
On presentation to our ED, he was noted to be hypoxic;
a radiograph (Fig 1) revealed a right-sided pleural
effusion. He was admitted and pulmonary medicine was
consulted.
On our examination, he was noted to be afebrile and
normotensive. He was tachycardic at 104 beats/min and
hypoxic to 87% saturation of peripheral oxygen on room
air. His respirations were nonlabored. Lung auscultation
was notable for decreased sounds on the right, but clear
respirations on the left without any wheezing or rhonchi.
Figure 1 – Anteroposterior chest radiograph showing a right pleural
Percussion of his posterior chest revealed dullness effusion.
halfway up his right lung. The remainder of his physical
examination was without significant abnormality. Initial
laboratory workup was significant only for a mild Question: Based on the ultrasound in Video 1,
leukocytosis. Lung ultrasound was performed to assess what is the most likely cause of this patient’s
the pleural effusion and to guide thoracentesis. pleural effusion?

AFFILIATIONS: From the Department of Internal Medicine, Division

of Pulmonary, Critical Care, Sleep, and Allergy, University of Nebraska
Medical Center, Omaha, NE.
CORRESPONDENCE TO: Joseph M. Carrington, DO, MHA, Division of
Pulmonary, Critical Care, Sleep & Allergy, University of Nebraska
Medical Center, 982465 Nebraska Medical Center, Omaha, NE 68198;
e-mail: joe.carrington@unmc.edu
Copyright Ó 2019 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
DOI: https://doi.org/10.1016/j.chest.2018.09.036

chestjournal.org e83

Answer: Malignant effusion.
Discussion
As early as 1976, lung ultrasound has been used to detect
and characterize pleural effusions.1 Ultrasound has proven
more accurate in detecting pleural effusions than physical
examination2 and chest roentgenogram,3 with a sensitivity
of 93% (95% CI, 89% to 96%) and a specificity of
96% (95% CI, 95% to 98%).4 When identifying a pleural
effusion, we begin by locating anatomical landmarks: the
diaphragm, the liver or spleen, and the chest wall. Within
these borders, one can find an anechoic space, which can
represent pleural fluid. Normal or atelectatic lung is
frequently seen, which moves with respiration and is often
referred to as lung flapping or the jellyfish sign.5 The
pleural fluid can be purely anechoic (most often
representing a transudative effusion) or may have cellular
debris causing echogenic foci (complex nonseptated),
fibrin strands (complex septated), or almost completely
cellular (homogenous echogenicity).4,5 These latter three
types of effusions may represent a hemothorax, a complex
parapneumonic effusion, a chronic inflammatory effusion
(such as a rheumatoid effusion), or a malignant effusion.4,5
Ultrasound has proven superior at characterizing these
effusions compared to computed tomography.6
In the patient in our study, there was a pleural effusion
with lung flapping and heterogeneous echogenicity with a
positive plankton sign (Discussion Video). A plankton
sign describes the cellular debris content within the
pleural effusion, which flows back and forth with
respiratory and cardiac pulsation.5 This may represent a
malignant effusion, hemothorax, or early formation of
empyema. When this cellular debris settles at the
costophrenic angle, creating a layering effect, it is often
suggestive of hemothorax and is referred to as a
hematocrit sign. The patient in our study did not have
layering of this cellular debris, but did have pleural
thickening and nodularity present. Normal pleura should
be 0.2 to 0.3 mm thick.7 Whereas parietal pleura > 10 mm,
pleural nodularity, or diaphragmatic thickness > 7 mm
predicts a malignant effusion with 73% sensitivity,
100% specificity, and 100% positive predictive value.8
These pleural-based masses are often hidden by pleural
effusions on chest roentgenogram; lung ultrasound can
provide clear visualization and accurate diagnosis.
Malignant pleural effusions can represent 15% to 35% of
all pleural effusions.9 Lung ultrasound can assist in rapid
and accurate diagnosis malignant effusions. By quickly
assessing the patient, we were able to rule out significant
e84 Ultrasound Corner
pathology on his contralateral lung. In Video 2, we
demonstrate normal lung sliding with A-line
predominance and a curtain sign. The presence of lung
sliding with A-line predominance (< 3 B-lines)
throughout the contralateral lung effectively rules out
pneumothorax and pulmonary edema as potential
causes of this patient’s lung disease.10 A curtain sign
rules out a pleural effusion and consists of two
characteristics found at the level of the diaphragm: (1)
the lung must move in and out of the field of view with
respirations and (2) the lung field always hides the
lateral diaphragm from view.10
Ultrasound-guided thoracentesis with cytological
evaluation is standard of care when a malignant pleural
effusion is suspected.9 A pleural fluid sample of at least 50
to 60 mL can have a diagnostic yield up to 60%.9 Repeating
thoracentesis a second time can increase yield by 27%, but a
third time has no effect.9 A closed pleural biopsy has
minimal complications, but often lacks increased yield
because of blind sampling.9 Medical pleuroscopy increases
yield because of direct visualization of biopsy sites.9 In this
patient, we were able to visualize an area of thickened
parietal pleura with ultrasound. After complete lung
ultrasound examination revealed no contralateral area of
concern, we chose the area with thickened pleura because it
provided the highest likelihood of diagnosis. Ultrasound-
guided thoracentesis resulted in 100 mL of amber-colored
pleural fluid with mixed cellularity (67% monocytes,
16% polymorphonuclear cells, 15% lymphocytes,
1% eosinophils). Cytology revealed malignant cells
consistent with adenocarcinoma. During initial puncture
of the thickened pleura, a small piece of pleura was
aspirated through the needle. This tissue revealed
neoplastic cells that stained positive for TTF-1, monoclonal
CEA, EpCAM, and high PD-L1 expression. The tissue
stained negative for calretinin and WT1 (consistent with
primary lung adenocarcinoma). Further testing revealed
ALK (2p23) rearrangement, and the patient was started on
crizotinib immediately. Before hospital discharge, an
indwelling pigtail catheter was placed and confirmed with
ultrasound guidance. Indwelling pleural catheters are
proven to be as effective as sclerotherapy for treatment of
malignant pleural effusion in approximating the pleura
and reducing the risk of trapped lung.9
Our case highlights the importance of ultrasound in
characterizing and treating malignant pleural effusions.
By identifying classic signs of a malignant pleural
effusion and locating an area with thickened pleura, we
were able to perform a safe thoracentesis that lead not
only to diagnosis of stage IV adenocarcinoma of the
[ 155#4 CHEST APRIL 2019 ]
 lung, but also provided tissue for staining and genetic
testing. Furthermore, we provided safe bedside insertion
of a pigtail catheter that relieved the patient’s symptoms
and approximated his pleura causing natural
pleurodesis. The patient was able to begin treatment of
his malignancy before hospital discharge. On follow up,
his pleural effusion had minimal reaccumulation.
Reverberations
1. Point-of-care thoracic ultrasound provides a low-cost
and effective characterization of pleural effusions with
more accuracy than physical examination or chest
roentgenogram.
2. The plankton sign represents heterogeneous echogenic
foci within an effusion that may be blood or cellular
debris from an infection or malignancy.
3. The curtain sign rules out a pleural effusion when the
lung moves in and out of the field of view with respi-
rations and always hides the lateral diaphragm.
4. Findings of parietal pleura > 10 mm, pleural nod-
ularity, or diaphragmatic thickness > 7 mm predicts a
malignant effusion with 73% sensitivity, 100% speci-
ficity, and 100% positive predictive value.
5. Point-of-care thoracic ultrasound improves safety and
efficacy of thoracentesis and interpleural catheter
insertion.
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Acknowledgments
Financial/nonfinancial disclosure: None declared.
Other contributions: The authors thank Melissa Carrington, BA, for
assistance with video editing. CHEST worked with the authors to
ensure that the Journal policies on patient consent to report
information were met.
Additional information: To analyze this case with the videos, see the
online version of this article.
References
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