I.

ETIOLOGY

- Pleural effusion is most commonly caused by congestive heart

failure, cancer, pneumonia, and pulmonary embolism. Pleural fluid

puncture (pleural tap) allows for the distinction of a transudate from an

exudate, which is currently the foundation of further diagnostic work-up.

Pleural effusions are commonly classified as Exudates and

Transudates

The cause of transudative effusions is a combination of increased

hydrostatic pressure and decreased plasma oncotic pressure. The most

common cause is heart failure, which is followed by cirrhosis with ascites

and hypoalbuminemia, which is usually caused by the nephrotic

syndrome.

Local processes that increase capillary permeability result in

exudation of fluid, protein, cells, and other serum constituents, resulting in

exudative effusions. The most common causes are pneumonia, cancer,

pulmonary embolism, viral infection, and tuberculosis.

II. INTRODUCTION
Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-
pleural-disorders/pleural-effusion?query=pleural%20effusion
 - Pleural effusions are common in both respiratory and non-

respiratory specialists' clinical practice. Pleural effusions are fluid

accumulations within the pleural space. They can be caused by a variety

of factors and are typically classified as transudates or exudates. Physical

examination and a chest x-ray are used to detect the condition;

thoracentesis and pleural fluid analysis are frequently required to

determine the cause. Asymptomatic transudates do not necessitate

treatment. Symptomatic transudates and nearly all exudates necessitate

thoracentesis, chest tube drainage, pleurectomy, or a combination of

these procedures.

A. ANATOMY AND PHYSIOLOGY

 - Effusions can constrict space within the pleural cavity,

compressing the lung and reducing its ability

to expand for inspiration. Excess fluid

is likely to collect in the costodiaphragmatic

recess, also known clinically as the

costophrenic angle, due to gravity. The

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-
pleural-disorders/pleural-effusion?query=pleural%20effusion
accumulation of fluid in the pleural space causes the lung on the same

side to be pushed upwards. Because the right and left pleural cavities are

separate, the opposite lung will not be affected unless the surrounding

pleural cavity is also compromised.

When blood, pus, or air accumulate in the pleural cavity, the

condition is known as hemothorax, pyothorax, or pneumothorax.

The pleural cavity is a fluid filled space that surrounds the lungs. It

is found in the thorax, separating the lungs from its surrounding structures

 such as the thoracic cage and intercostal spaces, the mediastinum and

the diaphragm. The pleural cavity is bounded by a double layered serous

membrane called pleura.

B. PATHOPHYSIOLOGY

- In a normal healthy adult, the pleural cavity contains very little

fluid, which serves as a lubricant for the two pleural surfaces. Pleural fluid

is constantly exchanged at a rate of 0.1 ml/kg to 0.3 ml/kg. Pleural fluid is

produced by the vasculature of the parietal pleura surfaces and is

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

MSc, N. G. (2021, October 9). Pleural cavity. Kenhub.

https://www.kenhub.com/en/library/anatomy/the-pleural-cavity

absorbed by lymphatics in the dependent diaphragmatic and mediastinal

parietal pleura surfaces. The interstitial fluid, which has a lower protein

content than serum, is thought to be driven into the pleural space by

hydrostatic pressure from the systemic vessels that supply the parietal

pleura.

Excess fluid can build up if there is an increase in production, a

decrease in absorption, or both, overpowering the normal homeostatic

mechanism. If pleural effusion is primarily caused by increased hydrostatic

pressure, the mechanisms that cause pleural effusion are usually

transudative, and the mechanisms that cause pleural effusion have altered
 the balance between hydrostatic and oncotic pressures (usually

transudates), increased mesothelial and capillary permeability (usually

exudates), or impaired lymphatic drainage (usually exudates).

C. SIGNS AND SYMPTOMS

- Some pleural effusions are asymptomatic and are discovered by

chance during a physical exam or on a chest x-ray. Many are responsible

for dyspnea, pleuritic chest pain, or both. Pleuritic chest pain, which is

characterized by a vague discomfort or sharp pain that worsens during

inspiration, is caused by inflammation of the parietal pleura. Pain is usually

felt over the inflamed area, but referred pain can occur. The lower 6
Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-
pleural-disorders/pleural-effusion?query=pleural%20effusion
intercostal nerves supply the posterior and peripheral portions of the

diaphragmatic pleura, and irritation there may cause pain in the lower

chest wall or abdomen that mimics intra-abdominal disease. Pain referred

to the neck and shoulder is caused by irritation of the central portion of the

diaphragmatic pleura, which is innervated by the phrenic nerves.

Although uncommon, a pleural friction rub is the classic physical

sign. The friction rub ranges from a few intermittent sounds that may

mimic crackles to a fully developed harsh grating, creaking, or leathery

 sound that is heard during inspiration and expiration and is synchronous

with respiration. Friction sounds adjacent to the heart (pleuropericardial

rub) may vary with heartbeat and be confused with pericarditis friction rub.

Pericardial rub is best heard over the left border of the sternum in

the third and fourth intercostal spaces, is a to-and-fro sound synchronous

with the heartbeat, and is unaffected by respiration. The physical

examination's sensitivity and specificity for detecting effusion are most

likely low.

III. PATIENT HISTORY

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-

- A 33-year-old man presented to our hospital with a 2-day history

of sudden onset, pleuritic, right-sided chest pain. It was not linked to fever,

cough, dyspnea, wheezing, or hemoptysis. There was no history of lower

extremity swelling, weight loss, or anorexia. There was no history of major

comorbidities. He smoked for 8 pack-years. He had no history of

substance abuse.

IV. BRIEF DESCRIPTION OF THE PROCEDURE

 - Chest radiographs are the most commonly used examination to

detect pleural effusion; however, it should be noted that on a routine erect

chest x-ray, as much as 250-600 mL of fluid is required before it is visible.

An electrocardiogram revealed the classic triad of findings for

pericardial effusion with cardiac tamponade, which included sinus

tachycardia, low QRS voltages, and electrical alternans.

Thoracentesis is a procedure that involves inserting a needle into

the pleural space between the lungs and the chest wall. This procedure is

used to remove excess fluid from the pleural space, allowing you to

breathe more easily. It could be used to rule out the cause of pleural

effusion.

The blood vessels that run from the heart to the lungs are

photographed during a CT pulmonary angiogram (the pulmonary

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.

arteries). A dye will be injected into a vein in your arm that leads to your

pulmonary arteries during the test. This dye causes the arteries to appear

bright and white on scan images.

V. PRELIMINARY OBSERVATION TO RADIOLOGICAL AND FINAL

DIAGNOSIS MADE BY RADIOLOGIST

Investigations revealed a haemoglobin level of 16.4 gdL1 and a

total leukocyte count of 8870 cellsmm3 with a differential count of 62%

neutrophils, 28% lymphocytes, 7% monocytes, 2% eosinophils, and 1%

basophils. The platelet count was 160 000 cells per millimeter3.

Creatinine, electrolytes, and liver function tests were all within normal

limits. The electrocardiogram was unremarkable, and cardiac enzymes

were within normal ranges.

He underwent a diagnostic thoracentesis, which revealed 6.5 gL1

protein (corresponding serum proteins were 7.3 gL1), 820 UL1 lactate

dehydrogenase (LDH) concentration (corresponding serum LDH was 563

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

UL1), and 7 mmolL1 glucose. The erythrocyte count was 2 700 000
 cellsL1 and the leukocyte count was 3400 cellsL1 with 53% neutrophils,

42% lymphocytes, and 5% monocytes. Gram stain and cultures were both

sterile. Smears revealed no acid-fast bacilli, and real-time PCR for

Mycobacterium tuberculosis was negative. There were no malignant cells

found during the cytological examination.

VI. PATIENT INFORMATION

AGE: 33 years old
GENDER: Male

VII. CASE REPORT

- A 33-year-old man arrived at our hospital with a 2-day history of

pleuritic, right-sided chest pain. It was not associated with a fever, cough,

dyspnea, wheezing, or hemoptysis. There was no history of swelling in the

lower extremities, weight loss, or anorexia. There was no history of

significant comorbidities. He had smoked for eight pack-years. He didn't

have a history of substance abuse.

VIII. DIAGNOSIS

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117
 - A mild right-sided pleural effusion, blunting of the left costophrenic

angle, no shift in mediastinal position, and no lung parenchymal opacities

were seen on a chest radiograph.

An ECG was taken, which revealed a normal sinus rhythm with an

S-wave in lead I and a Q-wave and an inverted T-wave in lead III. This is

known as the S1Q3T3 pattern. In V1, there was an inverted T-wave.

A computed tomographic pulmonary angiography revealed

filling defects in both the lower and upper lobar arteries, as well as the

right middle lobe and lingular arterial branches, indicating an acute PE.

CTPA revealed no right ventricle enlargement in the four-chamber view of

the heart, implying that there was no right ventricular dysfunction

The diagnostic thoracentesis showed the protein concentration

was 6.5 gL1 (corresponding serum proteins were 7.3 gL1), the lactate

dehydrogenase (LDH) concentration was 820 UL1 (corresponding serum

LDH was 563 UL1), and the glucose concentration was 7 mmolL1.

IX. TREATMENT OPTIONS

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-
 - If the effusion is asymptomatic, it usually does not require

treatment because many effusions resorb spontaneously when the

underlying disorder is treated, particularly effusions caused by

uncomplicated pneumonias, pulmonary embolism, or surgery.

Nonsteroidal anti-inflammatory drugs (NSAIDs) or other oral

analgesics are commonly used to treat pleuritic pain. A short course of

oral opioids is sometimes required.

Thoracentesis is an effective treatment for many symptomatic

effusions and can be repeated if the effusion recurs. There are no arbitrary

limits to how much fluid can be removed. Fluid removal can be continued

until the effusion has been drained or the patient develops chest tightness,

pain, or severe coughing.

Chronic, recurrent effusions that cause symptoms can be treated

with pleurodesis or intermittent drainage with an indwelling catheter.

Effusions caused by pneumonia and cancer may necessitate additional

measures.

Pleural effusion associated with PE is treated in the same way as

any other PE patient, with risk stratification and subsequent management.

In all cases, anticoagulation is the mainstay of treatment. The presence of

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-
 hemorrhagic effusion does not preclude anticoagulation or thrombolysis.

As in our case, anticoagulant therapy gradually resolves the pleural

effusion. If the pleural effusion grows in size or appears on the

contralateral side, it indicates recurrent thromboembolism, pleural

infection, or hemothorax.

X. REFERENCES

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting

case of undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:

10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed

pleural effusion. Breathe, 13(2), e46–e52.

https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual

Professional Edition.

https://www.msdmanuals.com/professional/pulmonary-

disorders/mediastinal-and-pleural-disorders/pleural-effusion?query=pleural

%20effusion

MSc, N. G. (2021, October 9). Pleural cavity. Kenhub.

https://www.kenhub.com/en/library/anatomy/the-pleural-cavity

Clinical case report by Panjwani, A., & Zaid, T. (2017). An interesting case of
undiagnosed pleural effusion. Breathe, 13(2), e46–e52. DOI:
10.1183/20734735.001117

Panjwani, A., & Zaid, T. (2017). An interesting case of undiagnosed pleural effusion.
Breathe, 13(2), e46–e52. https://doi.org/10.1183/20734735.001117

Light, R. W. (2021, November 4). Pleural Effusion. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/pulmonary-disorders/mediastinal-and-
pleural-disorders/pleural-effusion?query=pleural%20effusion