Today’s morning report featured a fascinating case of eosinophilic pleural effusion from second year fellow Ted Cybulski
Second year PCCM fellow Ted Cybulski | http://tedc.cc/ | Twitter: @tdwck
First thing’s first – how do we define pleural fluid eosinophilia (PFE), and what are classic associations to be familiar with?
Some more quick facts:
- Incidence estimated between 5-16% of all pleural effusions
- More common in men (ratios reported between 2:1 and 9:1)
- Malignant in roughly 35% of cases, of which 50% are lung ca.
Here a closer look at the broad categories on the differential diagnosis of PFE:
In our discussion, Dr. Sporn added that pleural fluid protein <4 and effusion size >1/3 hemithorax are suggestive against tuberculous effusion. A couple of other important points about TB effusion:
- Can occur with primary or reactivation of infx
- Pleural fluid ADA >40 u/L argue strongly for TB especially in lymphocytic exudative effusions (90% of cases)
- Eosinophilic effusions are relatively rarer presentation
Below Ted details the association of eosinophil count in PFE with malignancy – while a lower count (<40%) is MC in malignancy, a higher count is not necessarily reassuring. Other characteristics which carry higher risk for malignant effusion include advanced age and higher pleural fluid LDH (cutoff >900 suggested)
Takeaways
- Pleural fluid eosinophilia = >10% eos, found in 6-14% of pleural effusions
- Classic association with trauma, repeated taps, asbestos.
- MC etio malignant
- Lower eos (10-40%), higher LDH (>900) and advanced age associated with higher probability of malignancy
- TB can present with eosinophilic effusion, but classic presentation is lymphocytic exudate with high ADA (>40)
Thanks for leading a great discussion, Ted!
Sources cited
- Krenke et al. ERJ 2009; 34(5):1111-1117 (https://pubmed.ncbi.nlm.nih.gov/19386682/)
- JM Porcel. Lung 2009; 187:263-70 (https://pubmed.ncbi.nlm.nih.gov/19672657/)