Imaging review of pleural effusion: diagnosis and

intervention

Poster No.: P-0058

Congress: ESTI 2014
Type: Educational Poster
Authors: S. Hernandez Muñiz, P. Olmedilla Arregui, A. García de Vicente,
V. Quintana, S. Moron Hodge, S. Alonso Roca, J. C. Albillos
Merino; Madrid/ES
Keywords: Neoplasia, Infection, Drainage, Diagnostic procedure, Ultrasound,
CT, Conventional radiography, Interventional non-vascular,
Management, Thorax
DOI: 10.1594/esti2014/P-0058

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Page 1 of 71
Learning objectives

1. To describe radiologic signs of pleural effusion in chest plain film

2. To emphasize the indications of other imaging methods, mainly US and CT, in the
evaluation of pleural effusion

3. To review common and uncommon causes

4. To highligth the utility of imaging in pleural effusion management, showing illustrative

cases

Page 2 of 71
Background

The pleura is a mesodermal structure composed of visceral and parietal layers. In

physiological conditions the pleural cavity is a potential space occupied by a minimun
amount of fluid. Absorption of pleural cavity contents takes place in the lymphatic system
of the parietal pleura (Fig. 1 on page 6).

Pleural effusion is defined as the accumulation of fluid in the pleural space. It occurs
whenever the rate of fluid formation exceeds the rate of fluid removal.

According to Starling´s law, the turnover of pleural fluid from the subpleural capillaries to
the pleural cavity depends on:

• the balance of hydrostatic and colloidosmotic pressures in the two spaces

• the permeability of capillary and mesothelial membranes

Several potential mechanisms can lead to pleural effusion:

Mechanism Example
Increased hydrostatic microvascular Congestive heart failure
pressure
Decreased plasma oncotic pressure Hypoalbuminemia
Decreased pressure in pleural cavity Atelectasis

Trapped lung (pachypleuritis)

Increased pleural permeability Inflammatory pleural disease

Neoplastic pleural disease

Impaired lymphatic drainage Infection

Malignancy
Movement of fluid from peritoneal space Ascites

Pleural effusion represents a frequent medical problem, with a wide spectrum of causes.

Diagnostic evaluation of pleural effusion begins with obtaining the clinical history and
a physical examination, followed by chest radiography, and analysis of pleural fluid in
appropriate situations.

Page 3 of 71
Signs and symptoms vary depending on the underlying disease, but dyspnea, cough
and pleuritic chest pain are common. Special attention must be paid to previous drug
treatment or contact with asbestos.

Posteroanterior (PA) and lateral chest films usually confirm the presence of a pleural
effusion. Small amounts of pleural fluid, not readily seen on the standard views, may be
recognized in a lateral decubitus film or ultrasound (US) exam.

Once the presence and location of a pleural effusion have been established, the next
step is to investigate its etiology.

In certain circumstances the cause of an effusion is obvious from the clinical history or
radiographic findings.

As a general recommendation, all patients with more than minimal pleural effusion (larger
than 1 cm in height on lateral decubitus x-ray, US or CT) of unknown origin should be
submitted to thoracentesis.

In most cases, analysis of the pleural fluid yields valuable diagnostic information (90%)
or definitively establishes the cause of pleural effusion (25%).

Gross appearance of most aspirates consist of a straw-yellow fluid, a non-specific finding

that occurs in many types of effusion. However, occasionally certain appearances may
suggest a particular cause.

Fluid appearance / odour Cause

Milky /white Chylothorax / pseudochylothorax
Putrid Anaerobic empyema
Turbid Empyema
Urine odour Urinothorax
Black Aspergillus infection
Anchovy brown Amebic liver abscess
Bloodstained Trauma, pulmonary embolism,
malignancy, pneumonia, asbestos-
related, Dressler

The study of pleural fluid sample obtained from the initial thoracentesis
includes biochemical, microbiological and cytological analysis. Routinely performed
determinations are shown in Fig. 2 on page 6.

Page 4 of 71
Depending on its biochemical characteristics, pleural fluid may be catalogued as
transudate or exudate, according to Light´s criteria.

Fluid is an exudate if one or more criteria are met

Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 of upper limit of normal serum LDH
Pleural fluid protein / serum protein > 0.5

After diuretic treatment a trasudate can be classify as exudate. In these cases, additional
biochemical criteria, mainly the serum-effusion protein or albumin gradients*, are useful
to make an accurate diagnosis.

Additional biochemical criteria of exudative fluid

Pleural fluid protein > 3 gr /dl
Pleural fluid cholesterol > 60 mg /dl
Pleural fluid cholesterol / serum cholesterol > 0.3
*Serum protein minus fluid protein < 3,1 gr /dl
*Serum albumin minus fluid albumin < 1,2 gr /dl

The differentiation between exudative and transudative effusions is very important to

narrow the differential diagnosis and decide any further study.

Several additional tests can be performed when clinical setting requires it (Fig. 3 on page
7).

Recommended algorithm for the evaluation of patients with pleural effusion (Fig. 4 on
page 8).

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Images for this section:

Fig. 1: Pleural anatomy

© Radiologia, Infanta Sofía - Madrid/ES

Page 6 of 71
Fig. 2: Routinely analysis of pleural fluid

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 3: Further tests of pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

Page 8 of 71
Fig. 4: Algorithm for investigation of pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

Page 9 of 71
Imaging findings OR Procedure details

A. MANIFESTATIONS OF PLEURAL EFFUSION IN PLAIN CHEST FILM

1. Menisc sign describes the classic appearance of free pleural fluid in erect films; it
consists in a homogeneous opacity with a concave upper border, higher laterally than
medially (Fig. 5 on page 30).

Pleural fluid volume X-ray view Finding (obliteration)

50 ml Lateral Posterior costophrenic
angle
175-200 ml PA Lateral costophrenic angle
500 ml PA Ipsilateral hemidiaphragm

2. Subpulmonic effusion: describes pleural fluid located in the subpulmonic region in

upright patients. Lung floats on a layer of fluid. The hemidiaphragm is flattened and
inverted, without significant blunting of lateral costophrenic angle (Fig. 6 on page 30).

Subpulmonary effusions are difficult to diagnose on erect films, and lateral decubitus view
or US may be required.

Main finding : elevated pseudodiaphragm

PA view Lateral view
Lateral position of apex Rectification of anterior
margin
Ill defined costophrenic angle
Lower lung vessels not seen
> 2 cm between hemidiaphragm and gastric bubble

3. Free pleural fluid within the fissures: interlobar fluid shows variable appearance
depending on the the fissure and direction of x-ray beam (Fig. 7 on page 31) , (Fig.
8 on page 32) , (Fig. 9 on page 33).

Sign PA view Lateral view

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Incompete fissure sign Faint opacity: laterally more
(major) dense and medially sharp
Middle lobe step (minor) Steplike shape of fluid
below fissure
Thorn sign (minor) Small fluid in lateral part
Vanishing tumor (minor) Sharp rounded or oval Sharp lenticular opacity
opacity (masslike)
Vanishing tumor (major) Partly hazy margin (no Sharp lenticular (flat
masslike shape) superior margin)

4. On supine radiographs pleural fluid often produces a hazy opacity of the hemithorax
with preserved vascular shadows. A supine film underestimates the volumen of fluid
(usually not detected under 175 ml) (Fig. 10 on page 34).

Signs on AP view
Hazy diffuse opacity (preserved underlying lung)
Ill defined hemidiaphragm
Apical cap
Widening of paraspinal soft tissues
Apparent elevation of hemidiaphragm

5. Large and loculated effusions:

Massive effusions obscure the heart border and shift the mediastinum, airways and
diaphragm. They can have significant hemodynamic effects and, depending on the
position of the patient, may influence the gas exchange (Fig. 11 on page 35).

In a loculated effusion the fluid does not shift freely in the pleural space, usually due to
adhesions between the visceral and parietal pleural (Fig. 12 on page 36).

Finding PA view Lateral view

Large Obscured heart border Anterior shift of central
airways
Mediastinum and
diaphragm shifted

Radiolucent margin of
pericardial fat

Page 11 of 71
Loculated Lentiform opacity against chest wall (convex to the lung)

Sharp margins if tangentially viewed

Pseudomass
Pseudoloculated Same appearance as loculated fluid, but it moves freely
(shifts changing patient position)

6. Unusual or atypical fluid distribution (Fig. 13 on page 37).

B. WHEN FURTHER IMAGING METHODS SHOULD BE USED?

Other imaging modalities may be needed to diagnose the patient with pleural effusion.
Depending on the clinical context, the optimal imaging technique for further evaluation
may be CT or US.

1. Ultrasound (US)

It has been established the usefulness of chest US in the diagnosis of different

pleuropulmonary disease. It is also highly useful in guiding diagnostic and therapeutic
procedures.

Advantages:

• lack of ionising radiation

• low cost and easy to repeat
• real-time bed side applications
• best method to detect small pleural effusions (from 5 ml) and in volume
measurement
• more sensitive than CT to depict the internal structure (septa) of pleural
collections

Examination technique: It should be performed with plane or convex probes (3.5, 6.0
or even 10.0 MHz), using intercostal space as an acoustic window.

Normal findings:

• Pleural band: Highly reflective line created by the pleural-lung interface

• Reverberation echoes (A lines): Located distal to the pleural band and
elicitated by the reflection of sound waves at the lung surface (Fig. 14 on
page 38).

Page 12 of 71
 • Sliding lung: Visceral pleura sliding during respiratory movements (Fig. 15
on page 39).

Pathological findings:

The majority of pleural effusions are identified as anechoic or hypoechoic collections

delineated by the echogenic line of the visceral pleura and lung.

US appearance can help to distinguish between a trasudate and an exudate (Fig. 16 on

page 40).

US appearance US finding Nature of effusion

Anechoic Echo-free spaces between Transudate
pleural layers
Exudate (sometimes)
Complex non septated Ecoghenic material in Exudate
anechoic fluid
Complex septated Fibrin strands or septa Exudate
floating in anechoic fluid
Echogenic Homogeneously echogenic Exudate
fluid
Hemorrhage

Empyema

Chylothorax
Anechoic (usually) Hypoechoic masses
forming obtuse margins Malignant fluid
+ other findings with chest wall

Swirling pattern (internal

echoes with whirling motion
in pleural fluid)

2. Computed tomography (CT)

Advantages:

• Differentiates pleural from parenchymal lesions and may characterize

underlying lung disease
• Determines the precise location and extent of pleural disease
• Differentiates between free and loculated fluid

Page 13 of 71
 • Helps to diagnose the specific fluid cause (pleural nodules, calcified
plaques…)
• More sensitive than US for differentiating pleural fluid from pleural
thickening
• Facilitates the exact placement of chest tubes and percutaneous
biopsy

Examination technique: CT should be performed with contrast enhancement and

before complete aspiration of fluid (pleural abnormalities will be better visualised).

Normal findings:

At the fissures, the pleura has a thickness of less than 1 mm and is sharply defined.

Visceral and parietal pleura are not visualized along the chest wall (normal pleura
cannot be separated from adjacent structures).

Pathological findings:

* Free flowing pleural effusion: sickle-shaped o crescentic opacity in the most

dependent part of the pleural cavity.

* Loculated effusions: lenticular shape with smooth margins and relatively homogeneous
attenuation (Fig. 17 on page 41).

* Attenuation values:

- typically 10-20 HU: between those of water (0 HU) and soft tissue (100 HU)

- not reliable in differentiating exudates from transudates, or in the diagnosis of

chylothorax

- characterization of acute pleural hemorraghe may be done: high density or a fluid-fluid

level (Fig. 18 on page 42).

* Ancillary findings more common in exudative effusions:

- pleural thickening

- pleural nodules

- loculation of fluid

- increased attenuation of extrapleural fat

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* Split pleura sign : thickening and increased contrast enhancement of the visceral and
parietal pleura separated by pleural fluid (usually empyema or exudate) (Fig. 18 on page
42).

* Findings that favour a malignant disease:

- nodular pleural thickening,

- mediastinal pleural thickening,

- parietal pleural thickening > 1 cm

- circumferential pleural thickening

* Signs to distinguish small pleural effusion from ascites:

Sign Ascites Pleural effusion

Displaced crus sign No displacement Anterolateral displacement
(away from the spine)
Interface sign Sharp Indistinct
Diaprhagm sign Inside the diaphragmatic Outside the diaphragm
contour
Bare area sign Does not extend behind the May extend behind liver at
bare area of the liver the bare area

3. Other imaging techniques

• MRI : limited role in the evaluation of pleural effusions. In general, fluid

collections show low signal intensity on T1-w images and high relative signal
on T2-w images. Subacute or chronic hemorrhage can show very high
signal intensity on T1 and T2 images.
• PET-CT: accurate tool in differentiating benign from malignant pleural
effusion in oncologic patients (sensitivity 88-100% and specificity 67-94%).
Focal increased uptake within the posterior portion of the effusion
(presumably resulting from accumulation of malignant cells in the dependent
location) is considered highly specific for malignancy. A negative PET can
be useful to rule out metastatic disease. False positive uptake of FDG
by the pleura may be seen in pleural infection or inflammation after talc
pleurodesis.

Page 15 of 71
C. ETIOLOGIC CLASSIFICATION OF PLEURAL EFFUSION

There are many causes of pleural effusion (Fig. 19 on page 43). In adults, the most
common are cardiac faliure, pneumonia, malignant neoplasm and pulmonary embolism,
whereas pneumonia is the leading cause in children.

The division of pleural effusion in trasudates and exudates usually reflects its mechanism
of formation:

• transudates result from imbalances in hydrostatic and oncotic forces,

with a normal pleural membrane. In general, they respond to treatment of
underlying disease.
• exudates occur when the pleural surface is damaged (usually result from
pleural or lung diseases).

1. Congestive heart faliure

Transudative pleural effusions are common in left heart faliure.

Most often are bilateral, larger on the right side; when unilateral, are most commonly
right-sided.

Usually, associated cardiac enlargement, with or without pulmonary venous hipertensión,

makes the diagnosis easy (Fig. 20 on page 44).

Effusions improve quickly once diuretic therapy is started.

Key points:

- Patients with clinical and /or radiological evidence of heart faliure, do not need further
diagnostic tests.

- Diagnostic thoracentesis is required only if:

• effusion does not respond to therapy,

• fever or chest pain are present,
• cardiomegaly is absent

- In 20% of patients: exudative effusion after diuretics.

2. Infection

a) Non-tuberculous parapneumonic effusion and empyema

Page 16 of 71
Parapneumonic effusion is an effusion associated with lung infection (pneumonia,
abscess or bronchiectasis). It develops in 40% of patients with a community-acquired
pneumonia. The majority of cases resolve with anti-microbial therapy, but in 10-15% it
becomes infected and requires chest tube drainage.

An empyema is a pleural collection that contains pus or organisms (positive Gram stain
or culture).

Pleural infection is more common in the paediatric and elderly populations.

It increases the morbi-mortality associated with lung infections (in adults mortality
approaching 20%).

Etiology of parapneumonic effusion and empyema

Community-acquired Streptococcus pneumoniae

Streptococcus pyogenes

Staphilococcus aureus
Nosocomial MRSA (meticillin resistant
S. aureus) Enterobacteriae

Anaerobes

The development of empyema is a progressive process that moves from a simple exudate
to a fibrinopurulent stage and later to an organising state with scar tissue formation.

Patients may present with a pleural effusion on chest X-ray in the setting of pneumonia,
without the expected clinical improvement (Fig. 21 on page 45).

A common clinical dilemma is distinguising an empyema from a peripheral lung abscess.

Several imaging findings can help to make the correct diagnosis.

Feature Empyema Lung abscess

shape Oblong configuration Round
angle with chest wall Obtuse Acute
relationship with lung Adjacent lung and airways Often consolidated
displaced and comprised surrounding lung

Page 17 of 71
 Pulmonary vessels and
bronchi extend toward
abscess
size in PA and lateral Different Similar
films
pleural enhancement Present Absent
wall Thin and uniformly smooth Thick and irregular

In a patient with a parapneumonic effusion, a sample of fluid is often required. Current

guidelines recommend the sampling of effusions with a thickness > 10 mm.

Biochemical analysis of fluid helps to separate non-complicated (ph >7.2, LDH < 1000 u/
l and glucose > 40 mg/dl) from complicated parapneumonic effusions.

The American College of Chest Physicians classifies pleural effusion in four categories.

Category Imaging Fluid Risk of poor Management

characteristics outcome
1. Minimal < 10 mm -------- Very low Observation
without
diagnostic
sampling
2. Simple Small to ph > 7.2 Low Usually
parapneumonic moderate free resolves with
flowing fluid Negative Gram antibiotics
(>10mm and and culture
<½ hemithorax)
3. - Large free Positive Gram Moderate Drainage
Complicated flowing (>½ or culture,
parapneumonic hemithorax)
or ph < 7.2
- Loculated
effusion

- Fluid +
thickened
pleura
4. Empyema Usually Pus High Drainage
loculated or

Page 18 of 71
 complex fluid
collection

In complicated effusion and empyema US may help to detect septa. In a complex

septated collection pleural drainage is difficult, and intrapleural administration of
fibrinolytics may be useful.

Proposed algorithm for the management of patients with parapneumonic effusion (Fig.
22 on page 46).

Key points:

- in nonpurulent fluid ph < 7.2 is the most useful index predicting the need for chest tube
drainage

- early diagnosis and prompt drainage appear to reduce morbi-mortality of infected pleural
effusion.

b) Tuberculous pleuritis is still an important cause of pleural effusion all over the world
and constitutes one of the most common extrapulmonary manifestations of tuberculosis.

It occurs 3-7 months after the primary infection, when a subpleural caseous focus empties
into the pleural space.

The majority of patients are adolescent and young adults, and pleural effusion is often
the solely manifestation of tuberculosis. It is unilateral and may be large (Fig. 23 on page
47).

Fluid analysis reveals a lymphocytic exudate.

Definitive diagnosis requires the identification of mycobacteria by microscopy or culture

of the pleural fluid or tissue.

Tuberculous pleuritis may progress to chronic persistent effusion or empyema.

Empyema necessitatis is due to rupture of the tuberculous empyema through the parietal
pleura, forming a subcutaneous abscess. CT shows well demarcated thick walled fluid
collections in intra and extrathoracic locations.

Key points:

- Consider tuberculosis when an unilateral pleural effusion is seen in a young patient, for
which no cause is found by means of clinic, radiology and fluid analysis

Page 19 of 71
- Frequently pleural biopsy is required to establish the diagnosis

- New diagnostic parameters in pleural fluid: ADA, interferon and PCR.

3. Malignant effusion

Malignant pleural disease is a common clinical problem. About 25% of all pleural effusions
in older patients are malignant. The pleura may be involved by primary or secondary
tumors.

a) Secondary tumors account for about 90% of pleural neoplasms. Tumoral invasion
of the pleura is produced by hematologic route (through pulmonary arteries), lymphatic
invasion or by contiguity spread.

Metastasic pleural effusion should be suspected in: elderly patients, massive or

serosanguineous effusions, or when chest X-ray or CT suggest neoplastic disease (Fig.
24 on page 48).

Main primary sites causing metastasic pleural effusion:

Primary tumour %
Lung 36
Breast 25
Lymphoma 10
Ovary 5
Stomach 2
Unknown primary 7
Other neoplasms* 14

* They include other tumors like thymoma (Fig. 25 on page 49) and lymphoma (Fig.
26 on page 50).

Diagnosis of metastasic pleural effusion is based on the finding of malignant cells in

pleural fluid or neoplastic infiltration in a pleural biopsy.

Page 20 of 71
Features of metastastasic pleural effusion
Size and location Large and unilateral (often)
Type Serous bloody exudate (usually)

Transudate (uncommon)
Biochemical analysis Proteins #4 g/Dl

Normal glucose level

ph > 7.3
Cytologic examination Rich in lymphocytes (50-70% range)

Malignant cells (positive in 60% )

Tumoral markers CEA > 50 ng/ml or CA15-3 > 75 U/ml
Specific in 100 % (only present in 30%)

Key points:

- If cytologic analysis is negative, it is mandatory to obtain a second sample

- Sensitivity of tumoral markers is low (30%)

- In a persistent unexplained exudative effusion (not diagnosed by fluid analysis and

radiology) a pleural biopsy is indicated

b) Primary neoplasms:

Malignant pleural mesothelioma is the most common primary malignancy of the pleura.
It has been established that exposure to asbestos is the main cause of this aggressive
tumor.

The most usual presentation is nodular or lobular extensive pleural thickening, associated
with ipsilateral pleural effusion (Fig. 27 on page 51), (Fig. 28 on page 52).

A large unilateral pleural effusion is present in 60% of patients at diagnosis and it may
obscure the underlying pleural thickening on chest-X ray.

Fluid analysis shows an exudate with low pH (lower than other malignant effusions).
Mesothelin is a tumoral marker that can help in diagnosis (< 20 nM in pleural fluid is
related to low probability).

Page 21 of 71
When there is suspicion of mesothelioma, sufficient tissue samples must be obtained.
Pleural biopsy guided by imaging techniques (US or CT) is the recommended procedure.
Diagnosis should be always confirmed by inmunohistochemistry.

Key points:

- Unilateral large pleural effusion without contralateral shift of mediastinum

- Preserving a cell block from pleural fluid and using inmunohistochemistry reach
diagnosis in about 84% of patients

Other primary pleural tumors are rare. They include localized fibrous tumor, primary
lymphoma and liposarcoma.

4. Pulmonary embolism

Pleural effusions occurs in 30-50% of patients with pulmonary embolism (PE). Pleural
fluid is more common in PE associated with infarction.

Main features:

• small size, occuping 15 % of a hemithorax on average (very uncommon

more than one third).
• unilateral in most cases, with no side predilection (Fig. 29 on page 53)
• associated with other radiographic signs of embolism, such as basal
pulmonary opacity or diaphragmatic elevation
• painful and maximal volume within the first 3 days of illness
• disappears in around one week, but if acompanied by lung consolidation
takes longer to clear
• if the effusion progresses during therapy, recurrent embolism, secondary
infection or pleural hemorrhage due to anticoagulation should be suspected
• usually exudate, but transudate is also possible

5. Benign asbestos related pleural effusion

Asbestos exposure can lead to pleural irritation and development of an exudative

effusion. Around 3% of asbestos workers will suffer an otherwise unexplained effusion
within the first decade of exposure.

Benign asbestos effusion is defined by:

• history of exposure to asbestos

• confirmation by radiography or thoracentesis

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 • no other disease related to pleural effusion
• no malignant tumor within 3 years after the onset of the effusion

Most patients are asymptomatic, but some of them complain of pleuritic chest pain.

Usually the effusion is unilateral and small (Fig. 30 on page 54).

In general, pleural effusion resolves spontaneously after 3-4 month, but it recurs in 30%,
and 5% of patients will develop a malignant mesothelioma.

6. Pericarditis

It is an inflammation of the pericardium that can be acute, subacute or chronic. This entity
has many etiologies, being viral infection or idiopathic the main causes (90%).

Usually a variable amount of pericardic and pleural fluid is present.

Pleural effusion is an exudate commonly bilateral, predominantly on the left side.

The diagnosis is based on clinical symptoms, changes on the ECG and laboratory
findings. Imaging techniques are used to support and reassured the clinical suspicion
(Fig. 31 on page 55).

Acute pericarditis usually has a good prognosis and it responds to non-esteroideal

antiinflammatory drugs.

Chronic pericarditis when is constrictive may requiere surgery.

7. Dressler´s syndrome

Pericarditis due to inmunopathologic origin. It is associated to several myocardial injuries,

such as cardiac surgery, pacemarker implantation and coronary angioplasty.

Symptoms are usually mild and appear days or weeks after precipitating event. Pleural
effusion may be uni or bilateral; when unilateral, it is more common on the left side. It is
a serous or hemorrhagic exudate.

This entity responds very well to steroids and non-steroideal antiinflammatory drugs,
resolving in a few days (Fig. 32 on page 56).

8. Connective tissue diseases

In these disorders pleural pathology is often a reflection of the underlying pulmonary

process. Systemic lupus eritematosus (SLE) and rheumatoid arthritis are the most
common that affect pleura (effusion and thickening).

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In SLE, pleural effusion is the presenting manifestation in 5% of patients, and it occurs
in 70% of them.

It is typically unilateral and small, although may be bilateral.

Fluid is a serous or seosanguineous exudate. The demonstration of lupus erythematous

cells in pleural fluid is diagnostic. Antinuclear antibody (ANA) titer # 160 is sensitive for
lupus serositis, but nonspecific (Fig. 33 on page 57).

Key point: when cardiac enlargement with bilateral pleural effusion in young women is
found, the diagnosis of SLE should be rule out.

Pleural abnormalities are the most frequent intrathoracic manifestation of rheumatoid

arthritis. Although the disease occurs predominantly in women, pleural effusions are
more commonly observed in middle-aged men with positive rheumatoid factor.

Pleural fluid is an exudate; a low glucose level suggests rheumatoid arthritis, especially
when fluid is non-purulent and contains no bacteria nor malignant cells.

Chest x-ray usually shows a small to moderate unilateral effusion, which may be transient,
chronic or relapsing. Chronic effusion may lead to fibrothorax requiring decortication.

9. Drugs

A number of drugs may cause pleural effusions or pleural thickening.

Relevant drugs are listed in the following table.

Cytotoxic drugs Bleomycin, busulfan, methotrexate

mitomycin, procarbazine, interleukin-2

Antimigraine drugs Ergotamine, methysergide
Antiarrhythmic drugs Amiodarone
Antithyroid drugs Propylthiouracil
Skeletal muscle relaxants Dantrolene
Vasodilatator antihypertensive Minoxidil
Dopaminergic receptor stimulants Bromocriptine
Beta-adrenergic blockers Acebutolol, practolol, propranolol

Page 24 of 71
Antibacterial drugs Nitrofurantoin
Gonadotrophin

10. Radiation therapy

Pleural thickening and effusion following radiation are unusual.

Two pathogenic mechanisms have been proposed:

a) radiation pleuritis

b) lymphatic and venous obstruction due to mediastinal fibrosis

Pleural effusions are usually small, decrease gradually and often disappear in an indolent
fashion (Fig. 34 on page 58).

Proposed criteria for the diagnosis of radiation pleuritis includes:

• effusion within 6 months of completing radiotherapy

• coexisting radiation pneumonitis
• spontaneous resolution

Reaccumulation or rapid increase of pleural fluid suggest metastasis.

11. Abdominal diseases

Many intra-abdominal and pelvic disorders are associated with pleural effusion.

Hepatic Cirrhosis, hepatitis

Pancreatic Pancreatitis (acute, chronic)
Renal Uremic pleuresy, neprhotic syndrome,
renal infection, acute nephritic syndrome,
renal tract obstruction, peritoneal dialysis
Splenic Abscess, infarct, hematoma
Ovarian Ovarian hyperstimulation syndrome, Meig
´s syndrome
Other Subphrenic abscess, ascites, abdominal
surgery

We´ll review briefly some of them:

Page 25 of 71
a) Peritoneal dialysis : Some patients develop a pleural acute hydrothorax during
peritoneal dialysis. The effusion most commonly develops within hours of the initiation
of dialysis. Like ascites-related pleural effusions, they are ussually on the right side.
Elevated levels of glucose confirm the presence of dialysate in the pleural fluid.

Mechanism of production is direct transfer of fluid from peritoneal cavity into pleural space
through diaphragmatic defects.

Key point: when these effusions appear, peritoneal dialysis has to be stopped (Fig. 35
on page 59).

b) Pancreatitis: Acute or chronic pancreatitis may be associated with pleural effusion,

usually without other intrathoracic abnormality. Effusion is predominantly left sided, and
often recurrent. Diagnosis is confirmed by demonstrating a high amilase content in the
fluid (Fig. 36 on page 60).

c) Meig´s syndrome consists of four components:

• pleural effusion, more commonly right sided

• ascites
• benign tumor of the ovarian, usually fibroma or fibrothecoma, but also
teratoma or leiomyoma
• resolution of ascites and hydrothorax with removal of tumor.

d) Ovarian hyperstimulation syndrome : rare and potentially life threatening

complication. It is due to follicular growth medically induced using gonadotrophins. There
is a massive ovarian enlargement with a fluid shift into extravascular compartment
(increased capillary permeability of the ovarian vessels). This results in ascites, pleural
or pericardial effusion, oliguria, hemoconcentration and thromboembolic phenomena.

Radiologic findings include: bilateral or unilateral (most right sided) pleural transudate,
bilaterally elevated hemidiaphragm and atelectasis (Fig. 37 on page 61).

e) Urinothorax : Pleural effusion may be due to retroperitoneal leakage of urine, that

probably enters in the pleural cavity via diaphragmatic lymphatics. It is a rare complication
of an obstructed urinary tract, followed by rupture and urinoma formation. The diagnosis
is confirmed by showing a low pH transudate with a high level of creatinine (Fig. 38 on
page 62).

12. Hemothorax

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A bloody pleural effusion is an hemothorax if its hematocrit level is at least half that of
the peripheral blood.

Most hemothoraces are caused by trauma, although on rare occasions they may be
produced by pulmonary embolism, metastatic disease, ruptured aortic aneurysm or
anticoagulant therapy.

Traumatic hemothorax may be related to blunt or penetrating (including iatrogenig)

trauma. Usually there is a disruption of a systemic vessel in chest wall, mediastinum or
diaphragm, or a pulmonary vessel.

Sometimes initial radiograph does not show significant effusion, and delayed films are
necessary.

Hemothorax often manifests as a rapidly enlarging pleural effusion.

On CT fresh blood displays high attenuation values or a fluid-fluid level (Fig. 39 on page
63). When pleural blood becomes defibrinated, it is indistinguishable from any other
exudate.

Complications of hemothorax include:

• retention of clotted blood in the pleural space and secondary empyema

• calcified fibrothorax

Tube drainage is often indicated.

13. Chylothorax and pseudochylothorax

Chylothorax is due to extravasation of the fatty content of the thoracic duct.

Most common causes are malignancy, particularly lymphoma, and traumatism, especially
during surgery.

Congenital chylothorax, generally due to malformation of the thoracic duct, is one of the
most frequent causes of fetal pleural effusion.

Chyle is characteristically a milky white opalescent fluid. Gross appearance of pleural

fluid can be misleading, because milky effusions are not always chylous in nature.

Pseudochylothorax is produced by cell rupture in cases of long term pleural effusions,

such as in tuberculosis or rheumatoid arthritis.

The distinction between both types is clinically relevant. It can be made with lipid analysis
of the fluid (Fig. 40 on page 64).

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14. Idiopathic effusion

In aproximately 15% of reported cases, the cause of pleural effusions is not established
after an exhaustive study. These are called idiopathic or non-specific pleural effusions.

If the patient is improving and there are no parenchymal lesions or pleural nodules,
observation is probably the best option, because most undiagnosed effusions are benign
(85%). However, in patients with no improvement or progression of the effusion, invasive
diagnostic procedures, including thoracoscopy, should be performed.

In those cases with persistent negative results, a follow-up is recommended.

D. IMAGE GUIDED PLEURAL INTERVENTIONAL PROCEDURES

Interventional image guided techniques include thoracentesis (both diagnostic and

therapeutic), drainage of pleural collections and pleural biopsies. They are commonly
performed with US or CT guide. The modality employed depends on different factors,
such as user preference, site and size of the lesion, availability of equipment and whether
the lesion can be seen more easily on CT or US.

1. US can provided guidance for aspiration of pleural fluid, especially when small
effusion, loculated fluid or blind failed thoracentesis attempt.

2. In malignant effusion, therapeutic thoracentesis is either for symptomatic benefit or

as precursor to pleurodesis.

3. In general, US is the primary guidance modality employed for chest catheter

insertion. CT could be reserved for more difficult cases (small empyema, loculated
collection and large patient).

Entry site should be chosen close to the dependent portion of the effusion. It is advisable
to avoid a posterior entry site (it may cause discomfort).

With advances in imaging methods and catheter technology, interventional radiology is

playing an increasing role in the management of infected effusions.

At the present, there is no consensus about the optimal size of tubes for treating both
parapneumonic effusion and empyema. Some studies have found that small bore (# 14F)
catheters inserted under imaging guide were at least as effective as larger catheters
inserted without imaging. Small tubes are safer, better tolerated and technically easier

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to insert. They are successful in a high percentage of cases and complications are
uncommon (hematoma and neumothorax) (Fig. 41 on page 65).

What to do after placement of a drainage catheter?

• conect to 20 cm water suction

• irrigate with sterile saline regularly (every 6-8 hours)
• follow-up: daily by chest X-ray or US. CT limited when suboptimal response
(to detect loculations and undrained collections)
• remove when the collections are drained, drainage drops below 20 cc/day,
and objective evidence of sepsis resolution

What to do when drainage is unsatisfactory?

US or CT should be performed to rule out: wrong location of the tube, septated or

loculated fluid and fibrinous coating of the visceral pleura, which prevents the underlying
lung from expanding.

Intrapleural therapy: Current evidence does not support the routine use of intrapleural
fibrinolytic agents. In clinical practice, intrapleural urokinase can be used when the
drainage of infected fluids is not successful. It improves radiological outcome, but is not
associated with reduction of mortality nor frequency of surgery.

Organizing hemothoraces may be also successfully treated with instillation of fibrinolytic

agents.

The majority of patients with infected pleural effusion can be managed with antibiotics
and chest tube drainage. Surgery should be considered in cases with persistent sepsis
and residual pleural collection despite adequate treatment. Contact to thoracic surgeon
should not be delay more than 5-7 days after placement of drainage.

VATS (video-assisted thoracoscopic surgery) is the first-line modality. Open thoracic

drainage and thoracotomy with decortication are alternative techniques.

4. Image guided pleural biopsy in patients with suspected malignant pleural thickening
reaches high sensitivity (>85%) and specificity (100%) (Fig. 42 on page 66).

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Images for this section:

Fig. 5: Free pleural effusion: menisc sign.

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 6: Free pleural fluid: subpulmonic effusion.

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 7: Interlobar fluid: incomplete fissure sign.

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 8: Interlobar fluid: middle lobe step sign.

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 9: Vanishing tumor

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 10: Pleural effusion on supine radiograph

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 11: Massive pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 12: Loculated pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 13: Atypical radiographic finding

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 14: US: normal pleura

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 15: US video of normal pleura

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 16: US findings in pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 17: CT: free and loculated effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 18: Split pleura sign. Hemothorax.

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 19: Causes of pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 20: Congestive heart failure

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 21: Pneumococcic empyema

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 22: Management of pleural infection

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 23: Pleural tuberculosis

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 24: Metastasic pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 25: Invasive thymoma

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 26: Non-Hodgkin´s lymphoma

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 27: Malignant pleural mesothelioma

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 28: Malignant mesothelioma

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 29: Pulmonary embolism

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 30: Benign asbestos-related pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 31: Pericarditis

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 32: Dressler´s syndrome

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 33: Systemic lupus eritematosus

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 34: Radiation therapy

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 35: Peritoneal dialysis related pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 36: Acute pancreatitis

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 37: Ovarian hyperstimulation syndrome

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 38: Urinothorax

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 39: Hemothorax due to blunt chest trauma

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 40: Causes and fluid characteristics of chylothorax and pseudochylothorax

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 41: CT-guided drainage of infected pleural effusion

© Radiologia, Infanta Sofía - Madrid/ES

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Fig. 42: US-guided pleural biopsy

© Radiologia, Infanta Sofía - Madrid/ES

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Conclusion

The differential diagnosis of pleural effusion is wide, therefore a systematic approach to

investigation is mandatory.

The chest X-ray remains the mainstay of pleural effusion imaging; it is often the initial
examination performed and the most used in the follow-up.

Pleural US is fast, safe and effective in confirming the presence of pleural fluid. It localizes
the optimal site for diagnostic and therapeutic intervention in real time.

CT is the imaging tool of choice in order to asses the pleura and parenchymal or
endobronchial lesions. It is also the best method to evaluate tube position and fluid
loculations.

Image-guided pleural interventions are becoming increasingly frequent in the day-to-

day work of the radiologist. These pocedures have been proven to be both safe and
efficacious.

Management of pleural disease often requires a multidisciplinary working team.

Radiologists play an active role and should be updated, not only in diagnosis but also
in interventional techniques.

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3. McGrath EE, Anderson PB. Diagnosis of pleural effusion: A systematic approach.

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12. Davies HE, Davies RJ, Davies CW. Management of pleural infection in adults: British
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of Thoracic Disease 2012; 4: 186-193.

14. Keeling AN, Leong S, Logan PM, Lee MJ. Empyema and Effusion: Outcome of Image-
Guided Small-BoreCatheter Drainage. Cardiovasc Intervent Radiol 2008; 31:135-141

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Personal Information

Susana Hernández Muñiz

Radiology department. Hospital Infanta Sofía. San Sebastián de los Reyes. Madrid.
Spain

susana.hernandezm@madrid.salud.org

Pilar Olmedilla Arregui

Radiology department. Fundación Hospital Alcorcón. Madrid. Spain

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