07 Arijitd Medicine Results

RESULTS AND OBSERVATIONS

T

he results of the study of the 40 cases of pleural effusions are presented and the relevant observations are made. The age incidence of the 40 cases of pleural effusion are shown

in Table–1 TABLE–1 AGE INCIDENCE OF 40 CASES OF PLEURAL EFFUSION AGE GROUP (IN YEARS)

NUMBER OF CASES (N = 40)

13–23

1

2.5

24–33

12

30.0

34–43

6

15.0

44–53

5

12.5

54–63

8

20.0

64–73

5

12.5

74–83

3

7.5

Total

40

100.0

PERCENTAGE (%)

The age ranges from 13–83 years in the study the commonest age group affected in the present study was found to be third decade. The sex incidence in the 40 cases of pleural effusion are shown in the Table–2 TABLE–2 SEX INCIDENCE OF 40 CASES OF PLEURAL EFFUSION NUMBER OF CASES (N = 40)

PERCENTAGE (%)

Male

30

75.0

Female

10

25.0

SEX

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In the present study 75% cases were male and 25% were females. Pleural effusion affects either one or both sides. From the present study the distribution of affection are shown in the Table–3. TABLE–3 SHOWING THE DISTRIBUTION OF 40 CASES OF PLEURAL EFFUSION AFFECTING ONE OR BOTH SIDES OF CHEST SIDES OF PLEURAL EFFUSION

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

Right

20

50.0

Left

12

30.0

8

20.0

Bilateral

Right sided pleural effusion was found in 50% of cases as compared to 30% on left sides. Bilateral effusion was found in 20% of cases. The patients of the present study were presented with various symptoms which are shown in the following table. TABLE–4 SHOWING PRESENTING SYMPTOMS OF THE 40 CASES OF PLEURAL EFFUSION SYMPTOMS

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

Breathlessness

35

87.5

Chest pain

21

52.5

Dry cough

26

65.0

Cough with expectoration

12

30.0

Fever

24

60.0

Night Sweat

]2

30.0

Hemoptysis

5

12.5

18

45.0

Others

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The commonest symptom of presentation was breathlessness (87.5%). Dry cough and fever were present in 65% and 60% of cases respectively. The erythrocyte sedimentation rates (ESR) were examined in all 40 cases of pleural effusion and the findings are shown in the following table. TABLE– 5 SHOWING ESR OF 40 CASES OF PLEURAL EFFUSION ESR (mmAEFH)

NUMBER OF CASES (N = 40 )

0–10

1

2.5

11–20

3

7.5

21–30

6

15.0

31–40

7

17.5

41–50

4

10.0

51–60

6

15.0

61– 70

2

5.0

71–80

1

2.5

81–90

1

2.5

90–100

4

10.0

> 100

5

12.5

PERCENTAGE (%)

In the present study 90% of patients had an ESR above 20 mm AEFH. Sputum was examined for cytology in all the 40 cases of pleural effusion irrespective of parenchymal lesions present or absent and the results are shown in the following table.

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TABLE–6 SHOWING THE RESULTS OF CYTOLOGICAL EXAMINATION OF SPUTUM NUMBER OF CASES (N = 40 )

SPUTUM EXAMINATION

PERCENTAGE (%)

Positive Gram stain for Pyogenic bacteris

2

5.0

Positive Ziehl–Neelsen Stain for AFB

5

12.5

Positive pap smear for malignant cells

4

10.0

29

72.5

Negative for pyogenic organism, AFB or malignant cells

In the present study only 27.5% of 40 cases of pleural effusion had positive cytological examination of sputum for pyogenic organism, AFB and malignant cells. All other patients had a negative cytology. TABLE–7 SHOWING THE RESULTS OF THE SKIAGRAM OF CHEST OF PARENCHYMAL LESIONS ONLY NUMBER OF CASES (N = 40 )

RESULTS OF THE SKIAGRAM OF CHEST

PERCENTAGE (%)

Tuberculosis

8

20.0

Malignancy

3

7.5

Pneumonic consolidation

2

5.0

27

67.5

No lung parenchymal changes

In the present study 8 patients had tubercular lesions present in chest X–ray and 3 had evidence of malignancy. Pneumonic consolidations were seen in two patients. In 67.5% of the cases (27) had no associated lung parenchymal changes. The pleural fluids from the 40 cases of pleural effusions on gross examination appeared as follows. TABLE–8

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SHOWING THE PLEURAL FLUID APPEARANCES OF THE 40 CASES OF PLEURAL EFFUSION PLEURAL FLUID APPEARANCE

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

Pale Yellow

30

75.0

Hemorrhagic

7

17.5

Turbid

3

7.5

The pleural fluid appeared pale yellow coloured in 75% of cases and hemorrhagic in 17.5% of cases. In other 7.5% cases the pleural fluid was turbid. The pleural fluid was examined for cytology in all 40 cases of pleural effusion and the results obtained are shown in table 10. TABLE– 9 SHOWING THE RESULTS OF CYTOLOGICAL EXAMINATION OF PLEURAL FLUID OF 40 CASES OF PLEURAL EFFUSION Cells

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

Lymphocytes: 

Few



Plenty

29

72.5

7

17.5

12

30.0

2

5.0

Pus Cells: 

Few



Plenty

RBC's: 

Few

6

15.0



Plenty

7

17.5

In majority of cases (72.5%) the pleural fluid contained few lymphocytes. Plenty of RBC's and pus cells were present in 17.5% and 5% cases respectively.

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The pleural fluid was examined for AFB, malignant cells and culture for pyogenic organism and result are shown in the following table. TABLE–11 RESULTS OF POSITIVE PLEURAL FLUID EXAMINATION FOR AFB, MALIGNANT CELLS AND CULTURE FOR PYOGENIC ORGANISMS Pleural fluid for

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

Acid fast bacilli

4

10.0

Malignant cells

3

7.5

Culture for pyrogenic organism

2

5.0

The etiologic diagnosis could be made in 22.5% of cases. Acid fast bacilli and malignant cells were demonstrated in 10% & 7.5% each and pyogenic organism was isolated in 5% of cases. In 31 cases (77.5%) all the smear studies were negative for AFB, malignant cells and culture for poygenic organism. Pleural biopsy was done in 11 cases of pleural effusion in the present study and the results are shown in the Table–12. TABLE– 12 RESULTS OF THE PLEURAL BIOPSY IN SELECTED CASES OF PLEURAL EFFUSION PLEURAL BIOPSY RESULTS

NUMBER OF CASES

PERCENTAGE (%)

Tuberculosis

8

20.0

Adenocarcinoma

2

5.0

Non Hodgkin's lymphoma

1

2.5

11

27.5

TOTAL

Pleural Biopsy was done in 11 cases & on comparing with the etiological diagnosis of 40 cases of pleural effusion, 20% of biopsy came out to be tuberculosis & 7.5% were malignancies.

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TABLE– 13 THE CAUSES OF THE 40 CAUSES OF PLEURAL EFFUSION CAUSES

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

Transudates: 

Heart failure

6

15.0



Cirrhosis

4

10.0



Nephrotic syndrome

3

7.5



Pericardial effusion

1

2.5

15

37.5

Exudates : 

Tuberculosis



Neoplasm

8

20.0



Parapneumonic effusion

2

5.0



Rheumatoid Arthritis

1

2.5

Among the transudates 15% cases are caused by congestive heart failure and 37.5% of exudates are caused by tuberculosis. TABLE– 14 PLEURAL FLUID PROTEIN CONCENTRATION OF THE 40 CASES OF PLEURAL EFFUSION PROTEIN CONCENTRATION IN PLEURAL FLUID (g/dl)

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

1.0—2.0

3

7.5

2.1—3.0

15

37.5

3.1—4.0

0

0.0

4.1—5.0

22

55.0

In 55% of cases pleural fluid protein concentrations were above 3 g/dl & in 45% the protein concentration was 3 or below 3 g/dl. The graphical representation of the above table is shown in Fig. 1.

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TABLE– 15 SHOWING THE DISTRIBUTION OF PLEURAL FLUID TO SERUM PROTEIN RATIO PLEURAL FLUID TO SERUM PROTEIN RATIO

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

0.01—0.25

0

0.0

0.26—0.50

17

42.5

0.51—0.75

17

42.5

0.76—1.00

6

15.0

In 57.5% of cases pleural fluid protein to serum protein was above .5 & in 42.5% cases it was 0.5 or below 0.5 The graphical representation of the above table is shown in Fig. 2. TABLE–16 SHOWING THE DISTRIBUTION OF PLEURAL FLUID LDH PLEURAL FLUID LDH (U/L)

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

0—200

16

40.0

201—400

3

7.5

401—600

16

40.0

601—800

5

12.5

In 60% of cases Pleural Fluid LDH is greater than 200 U/L & in 40% cases it is equal or less than 200 U/L. The graphical representation of the above table is shown in Fig. 3. TABLE– 17

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SHOWING THE DISTRIBUTION OF PLEURAL FLUID LDH TO SERUM LDH PLEURAL FLUID LDH/SERUM LDH

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

0.00—0.30

2

5.0

0.31—0.60

11

17.5

0.61—0.90

10

25.0

0.91—1.20

6

15.0

1.21—1.50

11

27.5

In 67.5% of cases Pleural fluid LDH to serum LDH is above 0.6 & in 32.5% it is equal or less than 0.6 The graphical representation of the above table is shown in Fig. 4. TABLE– 18 SHOWING DISTRIBUTION OF SEAG [SERUM–EFFUSION ALBUMIN GRADIENT] IN 40 CASES OF PLEURAL EFFUSION SEAG

NUMBER OF CASES (N = 40 )

PERCENTAGE (%)

0.30—0.60

3

7.5

0.61—0.90

4

10

0.91—1.20

19

47.5

1.21—1.50

10

25

1.51—1.80

3

7.5

1.81—2.10

0

0

2.11—2.40

1

2.5

In 35% of cases Serum–Effusion Albumin gradient is above 1.2 g/dl & in 65% of cases it is equal or less than 1.2 g/dl. The graphical representation of the above table is shown in Fig. 5. TABLE– 19

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SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL FLUID PROTEIN OF 3 gms/dl IN COMPARISON TO THE ESTABLISHED DIAGNOSIS OF TRANSUDATES & EXUDATES

TYPES OF PLEURAL FLUID

NUMBER OF CASES NUMBER NUMBER OF ETIOLOGICALLY DIFFERENTIATED OF CASES CASES DIAGNOSED BY PLEURAL TRULY FALSELY (N = 40) FLUID PROTEIN CLASSIFIED CLASSIFIED OF 3 g/dl

Exudate

26

22

16

6

Transudate

14

18

14

4

The Pleural fluid Protein of 3g/dl separated 22 cases (55%) as exudates & 18 (45%) as transudate. When etiology was reviewed 6 of the exudates

&

4

of

the

transudates

were

falsely

classified.

A total

misclassification of 25% occurred. The graphical representation of the above table is shown in Fig. 6. TABLE– 20 SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL FLUID PROTEIN TO SERUM PROTEIN OF .5 IN COMPARISON TO THE ESTABLISHED. DIAGNOSIS OF TRANSUDATES & EXUDATES TYPES OF PLEURAL FLUID

NUMBER OF NUMBER NUMBER OF ETIOLOGICALLY CASES OF CASES CASES DIAGNOSED. DIFFERENTIATED TRULY FALSELY (N = 40) BY P/S PROTEIN CLASSIFIED CLASSIFIED OF 0.5

Exudate

26

23

18

5

Transudate

14

17

14

3

The pleural fluid to serum protein ratio of .5 separated 23 cases (57.5%) as exudates & 17 (42.5%) as transudates. When etiology was reviewed 5 of the exudates & 3 transudates were falsely classified. Total misclassification of 20% occurred. The graphical representation of the above Table–20 is shown in

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Fig. 7. TABLE– 21 SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL FLUID PROTEIN OF 3g/dl & PLEURAL FLUID TO SERUM PROTEIN RATIO OF .5 IN COMPARISON TO THE ESTABLISHED. DIAGNOSIS OF EXUDATES & TRANSUDATES TYPES OF PLEURAL FLUID

NUMBER OF NUMBER OF NUMBER OF ETIOLOGICAL CASES CASES CASES DIAGNOSIS DIFFERENTIATED TRULY FALSELY (N = 40) BY P.F. PROTEIN CLASSIFIED CLASSIFIED 3g/dl & P/S OF 0.5

Exudate

26

22

18

4

Transudate

14

18

15

3

Pleural fluid protein of 3g/dl & p/s of .5 separated 22(55%) cases as exudates & 18(45%) as transudates. When the etiology was reviewed 4 of the exudates & 3 of the transudates were falsely classified. Total misclassification rate of 17.55% occurred. The graphical representation of the above table is shown in Fig. 8. TABLE– 22 SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL FLUID LACTATE DEHYDROGENASE (LDH) OF 200 U/L NUMBER OF CASES NUMBER OF TYPES OF AETIOLOGICAL DIFFERENTIATED CASES PLEURAL DIAGNOSIS BY PLEURAL TRULY FLUID (N = 40) FLUID LDH OF CLASSIFIED 200 U/L

NUMBER OF CASES FALSELY CLASSIFIED

Exudate

26

24

20

4

Transudate

14

16

13

3

Pleural fluid LDH of 200 U/L separated 24 (60%) as exudates & 16 (40%) as transudates. When etiology was reviewed 4 of exudates & 3 of transudates were falsely classified. Total misclassification of 17.5% occurred. The graphical representation of the above Table–22 is shown in

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Fig. 9. TABLE– 23 SHOWING EXUDATES AND TRANSUDATES SEPARATED BY PLEURAL FLUID LDH TO SERUM LDH OF O.6 IN COMPARISON TO THE ESTABLISHED DIAGNOSIS OF EXUDATES & TRANSUDATES TYPES OF PLEURAL FLUID

NUMBER OF NUMBER NUMBER OF AETIOLOGICAL CASES OF CASES CASES DIAGNOSIS DIFFERENTIATED TRULY FALSELY (N = 40) BY P/S LDH OF 0.6 CLASSIFIED CLASSIFIED

Exudates

26

27

24

3

Transudates

14

13

11

2

Pleural fluid LDH to Serum LDH of .6 separated 27 (67.5%) as exudates & 13 (32.5%) as transudates. When the etiology was reviewed 3 of the Exudates & 2 transudates were falsely classified. Total misclassification of 12.5% occurred. The graphical representation of the above table is shown in Fig. 10. TABLE– 24 SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL FLUID LDH OF 200 U/L & PLEURAL FLUID LDH TO SERUM LDH OF 0.6 IN COMPARISON TO THE ESTABLISHED DIAGNOSIS OF EXUDATE & TRANSUDATE NUMBER OF CASES NUMBER NUMBER OF TYPE OF ETIOLOGICAL DIFFERENTIATED BY OF CASES CASES PLEURAL DIAGNOSIS PLEURAL FLUID LDH TRULY FALSELY FLUID ( N = 40 ) OF 200 U/L & CLASSIFIED CLASSIFIED P/S LDH OF 0.6 Exudate

26

28

26

2

Transudate

14

12

10

2

Pleural fluid LDH of 200 U/L & pleural fluid LDH to serum LDH of .6 seperated 28 ( 70% ) cases as exudates & 12 ( 30% ) as transudates

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when etiology was reviewed 2 of the exudates & 2 of the transudates were falsely classified. Total misclassification of 10% occurred. The graphical representation of the above table is shown in Fig. 11.

TABLE– 25 SHOWING NUMBER OF CASES SEPARATED BY SERUM–EFFUSION ALBUMIN GRADIENT OF 1.2 g/dl IN COMPARISON TO THE ESTABLISHED DIAGNOSIS OF EXUDATES & TRANSUDATES TYPE OF AETIOLOGICAL PLEURAL DIAGNOSIS FLUID

NUMBER OF CASES NUMBER NUMBER OF DIFFERENTIATED OF CASES CASES BY SEAG TRULY FALSELY OF 1.2 G/DL CLASSIFIED CLASSIFIED

Exudate

26

26

25

1

Transudate

14

14

13

1

Serum–Effusion Albumin gradient of 1.2 g/dl separated 26 (65%) cases as exudates & 14 (35%) as transudates when etiology was reviewed only 1 exudate & 1 transudate was falsely classified. Total misclassification of 5% occurred. The graphical representation of the above table is shown in Fig. 12.

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TABLE– 26 MEAN (M) VALUES, RANGES (R), STANDARD DEVIATIONS (SD), OF PARAMETERS STUDIED IN 40 CASES OF PLEURAL EFFUSIONS Parameter Character Pleural Fluid Protein of 3g/dl P/S Protein of 0.5 Pleural Fluid LDH of 200 U/L P/S LDH of 0.6 SEAG of 1.2g/dl

Non– Transudates Exudates Tubercular Neoplasm Tubercular (N = 14) (N = 26) (N = 15) (N = 8) (N = 2)

M

2.534

4.344

3.33

3.78

R

1.92–3

SD

0.344

0.143

0.946

1.34

0.898

M

0.45

0.699

0.545

0.56

0.64

R

0.39–.5

0.5–.8

0.39–.8

0.44–.68

0.45–.8

SD

0.03

0.074

0.14

0.17

0.14

M

101.25

483.92

333.4

348

402.38

R

399–680

73–131

83–73

123–573

73–680

SD

19.15

109.38

214.49

318.2

216.5

M

0.39

1.01

0.87

0.66

0.83

R

0.11–2.6

0.4–.92

0.37–1.25

SD

0.11

0.25

0.36

0.38

0.35

M

1.45

0.999

1.13

0.82

1.08

R

1.21–2.24

0.51–1.2

SD

0.29

0.23

0.59–2.24 0.51–1.12 0.39

0.43

“p” value

4.22

<.01 (S*)

0.69

<.01 (S*)

412

<.01 (S*)

1.24

<.001 (H.S.**)

1.01

<.001 (H.S.**)

3.69

4.18–4.69 1.92–4.69 2.73–4.63 2.41–4.52

0.61–1.27 0.31–1.27

Others (N = 1)

0.63–1.7 0.31

(* S : Significant; ** H.S. : Highly Significant)

The differences in the means of the transudates & exudates were significant (p < 0.01) for the parameters–pleural fluid protein, pleural fluid protein to serum protein ratio & pleural fluid LDH. The differences of the means of pleural fluid to serum LDH & serum–effusion albumin gradient were highly significant (p < 0.001) indicating the usefulness in the differential diagnosis of pleural effusion.

usu