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Pleural Fluid - Fluid contained between the visceral and parietal membrane of the pleural cavity that encloses

the lungs - Plasma filtrate derived from capillaries of parietal pleura - Produced at a rate that depends on capillary hydrostatic pressure, plasma oncotic pressure, and capillary permeability - Reabsorbed through lymphatics and venules of visceral pleura - Volume: usually less than 30mL Pleural Effusion - Abnormal accumulation of fluid around the lungs which begins at the base - Either transudative or exudative Pleural Fluid Laboratory Differentiation of Transudates and Exudates Transudate Exudate Appearance Clear, pale Cloudy, yellow turbid Pleural Fluid <60 mg/dL >60 Cholesterol mg/dL Pleural Fluid/ Serum <0.3 >0.3 Cholesterol Ratio Pleural Fluid/ Serum <0.6 >0.6 Bilirubin Ratio Pleural Fluid/ Serum <0.5 >0,5 Protein Ratio Pleural Fluid/ Serum <0.6 >0.6 LD Ratio Appearance of Pleural Fluid Pale yellow, clear Normal Turbid, white Presence of WBCs Bacterial infection Tuberculosis Immunologic disorder

Blood Milky Brown Black Viscous

Hemothorax Membrane damage Chylous Material Pseudochylous Material Rupture of Amoebic Liver Abscess Aspergillous Malignant Mesothelioma

*A hemothorax and hemorrhagic exudates can be differentiated by hematocrit level. Fluid hematocrit is >50% of whole blood hematocrit , of blood is from hemothorax. A lower hematocrit is observed in hemorrhagic effusion. *Another differentiation can be made between chylous and pseudochylous pleural effusions. Distinguishing Features in Chylous and Pseudochylouse Effusions Chylous Effusion Pseudochylous Effusion Cause Thoracic duct Chronic leakge inflammation Appearance Milky/ white Milky/ green tinge Leukocytes Predominantly Mixed cells lymphocytes Cholesterol Absent Present Crytals TAGs >110 mg/dL <50 mg/dL Sudan III Strongly positive Negative/ staining weakly positive Lipoprotein Marked Chylomicrons EP elevation of portion is low chylomicrons or absent pH Alkaline Variable Tests Performed A. Hematology Tests Differential Cell Count

- Most diagnostically significant hematology test performed - Routinely peformed - Neutrophil(>50%): bacterial infection, pancreatitis, pulmonary infarction - Lymphocyte with prominent nucleoli and cleaved nuclei (>50%): TB, viral infection, malignancy, autoimmune disorders - Eosinphil(>10%): trauma, allergic reactions, parasitic infections, Hodgkins disease, congestive heart failure, pulmonary infarction - Mesothelial cells: common in inflammatory processes - Malignant cells contain large, irregular adenocarcinoma cells, small carcinoma cells, and clumps of metastatic breast carcinoma cells B. Chemical Tests Glucose - Glucose level of normal pleural fluid, transudates, and most exudates is similar to serum glucose levels - <60 mg/dL glucose level: seen with tuberculosis, rheumatoid inflammation, purulent infection, nonpurulent bacterial infections, lupus pleuritis, and esophageal rupture Lactate - Useful in rapid diagnosis of infectious pleuritis - level in patients with bacterial and tuberculous pleural infections - Moderate elevation observed in malignant effusions Adenosine deaminase (ADA) - Levels over 40 U/L are highly indicative of TB - Frequently elevated with malignancy Amylase

- Elevated AMS levels are associated with pancreatitis - Also elevated in esophageal rupture and malignancy - First to elevate in pleural fluid pH - pH < 7.0 indicates chest tube drainage, administration of drugs - pH at least 0.30 degrees lower than blood pH is significant - pH as low as 6.0 is indicative of esophageal rupture TAGs - Measured to confirm presence of chylous effusion C. Microbiologic and Serological Tests - Examination for S. aureus, M. tuberculosis, Enterobacteriaceae, anaerobes. -Serologic tests include antinuclear antibody and rheumatoid analyses to assess immunologic disease -Detection of tumor markers carcinoembryonic antigen is also performed for diagnostic information in effusions of malignant origin