ABSTRACT
Effusion is the abnormal accumulation of fluid within a body cavity that can result from a variety of disease processes. This
article reviews the normal production and resorption of body cavity fluid and the pathophysiology of abnormal fluid accumu-
lation. In addition, classification schemes, differential diagnoses, and currently available diagnostic tests for evaluation of effu-
sions are reviewed. (J Am Anim Hosp Assoc 2011; 47:1–11. DOI 10.5326/JAAHA-MS-5558)
From the Emergency & Critical Care (S.D.) and Pathology Departments EDTA ethylenediaminetetraacetic acid; FCoV feline coronavirus; FIP feline
(P.E.), Angell Animal Medical Center, Boston, MA. infectious peritonitis; IV intravenous; PARR PCR for analysis of antigen re-
ceptor rearrangements; PCR polymerase chain reaction; PCV packed cell
Correspondence: sznndmps68@gmail.com (S.D.)
volume; RBC red blood cells; TNCC total nucleated cell counts
TABLE 2
Supportive Diagnostic Tests for Specific Disorders
FCoV, feline coronavirus; PARR, PCR for analysis of antigen receptor rearrangements
than distinct classifications. The three categories are shown in further distinction of protein-poor and protein-rich transudates.7
Table 3. 2
Table 4 lists the categories of effusions modified from the O’Brien
and the Stockham and Stock classification methods.
Classification by Etiology
Other classification schemes have been proposed; however, the Transudates: a Consequence of Altered Fluid
most clinically useful schemes categorize effusions according to Dynamics
their etiology. In 1988, O’Brien described the classification of In the pathophysiology of transudate formation, there is no change
effusions according to their etiology and divided effusions into in endothelial or mesothelial permeability; therefore, as fluid
transudates, exudates (septic or nonseptic), effusions resulting accumulates, there is no concurrent cell leakage. As a result, there
from vessel or viscus disruption, and effusions resulting from cell is a decrease in the cell count through a dilutional effect.1 Tran-
exfoliation.1 Stockham and Scott proposed another scheme with sudative effusions are typically clear and colorless. According to
TABLE 3
Traditional Classification of Effusions2
JAAHA.ORG 3
TABLE 4
Classification of Effusions Modified from O’Brien and Stockham and Scott1,7
the classification system of Stockman and Scott,7 transudates can between hydrostatic and oncotic forces in humans. Specifically,
be either protein-poor or protein-rich depending on whether the higher serum-effusion albumin ratios are associated with portal
effusion is secondary to posthepatic (postsinusoidal) increases in hypertension and lower ratios are more typically associated with
hydrostatic pressure.7 In veterinary patients, hypoalbuminemia is disorders of vascular leakage and inflammation.5 Unfortunately,
the primary cause of protein-poor transudative effusions.2 Other the results of veterinary studies have not been so clear.5 Protein-
pathologic causes of protein-poor transudates include cirrhosis, rich transudates result from increased hydrostatic pressure within
lymphatic obstruction, and noncirrhotic portal hypertension the postsinusoidal vessels of the liver secondary to congestive
(presinusoidal and sinusoidal).7 In contrast, congestive heart heart failure or potentially from mass lesions obstructing blood
failure and postsinusoidal portal hypertension more commonly flow from the hepatic vein or caudal vena cava into the right side
lead to protein-rich transudates.7 of the heart (i.e., a Budd-Chiari-like syndrome).7,13 The increase
Given that hypoalbuminemia is the most common cause of in hydrostatic pressure within the vessels of the liver causes
transudates in veterinary patients, clinicians are encouraged to a protein-rich fluid to leach out of the liver into the abdominal
measure serum total protein and serum albumin concentrations to cavity. Because cell membrane permeability does not change, cells
include or exclude this differential (i.e., hypoalbuminemia) and do not accumulate in the effusion. Thus, a protein-rich transudate
guide further diagnostics. For example, if the serum albumin is formed.7
concentration is normal, then radiographs, abdominal ultrasound,
and/or echocardiography are indicated to assess cardiac function, Exudates: a Consequence of Altered Mesothelial
urinary bladder rupture, and iatrogenic fluid overload (e.g., in and/or Endothelial Permeability
hospitalized patients receiving IV or subcutaneous fluids). Exudates result from a local inflammatory response to foreign
In cases where portal hypertension is suspected, the serum- material within a body cavity. This foreign material can be ex-
effusion albumin ratio has been shown to reflect the balance ogenous (e.g., viral, bacterial, fungal, protozoal, parasitic, or inert),
neoplastic, or endogenous (e.g., urine, pancreatic enzymes, bile patient has been previously treated with antibiotics, intracellular
salts, or immune complexes).1 The inflammatory response releases bacteria (but not extracellular as extracellular bacteria could be
cytokines both locally and systemically that increase mesothelial present in a sample as a result of accidental gastrointestinal as-
and endothelial permeability which permits protein to leak into piration during sample acquisition) may be difficult to find via
the exudate. 1,4
Activated mesothelial cells release a variety of cytologic evaluation.11 Figure 1 provides an example of a septic
chemokines, cytokines, and growth factors and can be phagocytic, effusion.
1
releasing oxidants and proteases into the exudate. Activation of In the past decade, multiple studies have evaluated various
mesothelial cells leads to an influx of inflammatory cells perpet- biochemical parameters as indicators of sepsis. The pH of septic
uating the inflammatory exudative cycle and further increasing peritoneal effusions in cats was significantly lower than nonseptic
vascular and mesothelial permeability.4 Various inflammatory effusions in one study, but there was significant overlap in pH
stimuli modulate the interaction of actomyosin fibers within the measurements between the two groups.11 In another study, an
mesothelial cell membrane to open transcellular pathways via the effusion glucose concentration ,50 mg/dL was specific for septic
fusion of cytoplasmic vesicles with the cell membrane. This results effusions in dogs not previously supplemented with IV dextrose,
in an increased permeability to macromolecules, water, and small but this was not found to be a sensitive test.11 All patients with an
solutes.4 Inflammatory cytokines increase capillary hydrostatic effusion TNCC .13,000 cells/mL had septic peritoneal effusions,
pressure and induce chemotaxis of inflammatory and phagocytic but not all dogs with septic effusions met this criteria.11 Differ-
cells into the effusion.1,4 As the inflammatory cells and fibrin ences in blood and fluid glucose and lactate concentrations were
accumulate within the effusion, lymphatic stomata become ob- significantly different in dogs with septic effusions compared with
structed by fibrin which impairs drainage, further exacerbating dogs with nonseptic effusions. Evaluation of these differences was
the accumulation of fluid.4 considered more accurate than either TNCC or cytology.11 Spe-
Cytology will determine the predominant cell type(s) in the cifically, if a dog’s effusion lactate concentration was 1.5 mmol/L
exudate. Exudates are often primarily composed of neutrophils. If greater than the concurrent peripheral blood lactate concentra-
neutrophils appear degenerate, critical evaluation of the fluid cy- tion and/or if a dog’s effusion glucose concentration was more
tology for a bacterial etiology is indicated. Atypical cells suggestive than 20 mg/dL less than a concurrent blood glucose concentration
of neoplasia may be present but neoplastic cells and reactive (prior to IV dextrose supplementation) then a septic effusion was
mesothelial cells may share common cytomorphologic features strongly suspected (Table 2).11,17 These studies were limited by
and can be easily confused (e.g., reactive mesothelial cells are most small sample sizes and lack of comparison between samples with
likely to be confused for cells from a mesothelioma or cells from septic inflammation and samples with sterile inflammation of
1
a carcinoma). Common diseases, septic and nonseptic, associated
with exudative effusions are presented in the next few paragraphs
and useful diagnostic techniques to differentiate among these causes
are discussed.
Septic Exudates
Exudates caused by septic inflammation usually result from bac-
terial contamination of a body cavity secondary to gastrointestinal
tract leakage or penetrating wounds. They can also result in
neonates from transplacental infections secondary to maternal
bacteremia or from migrating foreign bodies, disruption or in-
fection of the urogenital tract, bacterial translocation through
diseased pulmonary tissue or hypoperfused gastrointestinal tissue,
and hematogenous spread secondary to distant infections.11,12,14–16
Patients with septic exudates require immediate therapy; there-
fore, if sepsis is suspected, cytologic evaluation of the effusion FIGURE 1 Septic exudate. Microscopic appearance of abdominal
should be a priority and submitting a sample of the exudate for effusion from a dog with intestinal perforation. Note the neutrophils
anaerobic and aerobic cultures is indicated. Cytology is often and the intracellular bacterial rods (arrow). Wright-Giemsa stain,
diagnostic (i.e., identification of intracellular bacteria), but if the original magnification 31000.
JAAHA.ORG 5
similar cell counts. Since the differences in glucose and lactate sensitivity and specificity are only between 75% and 85%.18 A
concentrations between effusion and blood were not as sensitive Rivalta’s test (described below), which tests the fluid’s globulin
in cats, cytology and TNCC were found to be more reliable in content, is very sensitive but only 80% specific, and effusion total
feline patients.11 protein .8.0 g/dL or immunofluorescent staining of FCoV anti-
Regardless of the blood or effusion glucose and lactate levels, gens in the effusion are very specific but not very sensitive.18 To
the clinical presentation and history of the patient along with the perform the Rivalta’s test, one drop of acetic acid (98%) is added
results of other diagnostic tests need to be considered. Finding to 5 mL of distilled water. This fluid is mixed thoroughly and then
intracellular bacteria on effusion cytology remains the gold one drop of effusion is gently placed on the surface of the mix-
standard for initial diagnosis of a septic effusion while cultures are ture. If the drop stays at the top of the fluid or slowly floats to the
pending. Only 1 cat and 1 dog out of 18 cats and 19 dogs in the bottom, the test is considered to be positive. This test can give
studies by Bonczynski et al. (2003) and Levin et al. (2004) had inaccurate results if inappropriate technique is used or if there is
sterile effusions that were not that were not classified as modified a significant temperature difference between the fluid sample and
transudates. Modified transudates are effusions of moderate cel- the acetic acid solution. A positive Rivalta’s test can result from
lularity and protein content.11,17 Further comparison of sterile lymphosarcoma, septic, or FIP effusions. Lymphosarcoma and
suppurative exudates to septic exudates is necessary to ensure that septic effusions can usually be differentiated from FIP by cytology
the glucose and lactate measurements in dogs and total nucleated and culture, respectively.18 Reverse transcription PCR testing of
cell counts in cats are reliable indicators of sepsis and do not apply effusions, blood, or tissue aspirates documents ongoing infection
when a sterile inflammatory effusion is present. with pathogenic FCoV variants and is more accurate when testing
effusion than when testing serum.14,18
Nonseptic Exudates
Pancreatitis. Pancreatitis causes intra-abdominal inflammation Effusions Caused by a Ruptured Vessel or Viscus
and exudate formation that can lead to a sterile suppurative in- Another category of effusions presented by O’Brien is effusions
flammation. In these cases, differentiating the clinical signs and that result from disruption of a vessel or viscus (Table 4).1 The
cytology of a septic abdomen from severe pancreatitis can be most common effusion in this category is hemorrhagic effusions,
difficult as both can have degenerate neutrophils and lead to but chylous effusions, effusions secondary to Bartonella spp.
hyperbilirubinemia and hypoglycemia. This underscores the im- infections, and effusions that result from disruption of the uro-
portance of diligent evaluation of effusion cytology for the presence genital, hepatobiliary, or gastrointestinal tract can also fall into
of intracellular bacteria, as the presence of such organisms does not this category. Patients with a history of trauma are predisposed to
support a severe pancreatitis unless pancreatic abscessation or development of these types of effusions, but other causes should
bacterial translocation has occurred. Additionally, a greater than also be considered.
four-fold increase in peritoneal lipase activity than the serum upper
reference limit or more than twice the peripheral blood serum or Hemorrhagic Effusions
plasma lipase activity may be suggestive of pancreatitis if there is no Hemorrhagic effusions typically have a PCV .10%; however,
history of trauma.12 Further investigations of such diagnostic blood contamination of the effusion should be suspected if the
12
conclusions are needed. sample is not consistently red-tinged during sample collection.1
Feline Infectious Peritonitis. The wet form of feline infectious Inadvertent splenic aspiration, venipuncture, or acute severe
peritonitis (FIP) presents as an effusive disorder in which the fluid hemorrhage is suspected if the cytology is consistent with pe-
is often straw to gold in color and hazy.2 The total protein of the ripheral blood including platelets but lacking erythrophages or if
effusion is typically .3.5 g/dL and often .4.5 g/dL according to the blood clots readily. Hemorrhage is relatively common sec-
multiple references, such as in Hartmann et al. (2003), an effusion ondary to blunt trauma. When there is no history of trauma,
total protein .8.0 is 90% specific, 55% sensitive, and has a 0.78 coagulopathy or neoplasia is considered. Visceral torsion is a less
18
positive predictive value. The TNCC is usually low, but can range common cause of hemorrhagic effusion. Evaluation of a periph-
from 2,000–6,000 cells/mL (and rarely TNCCs can range from eral blood smear for platelet density or determination of a platelet
2,19
1,000–30,000 cells/mL). FIP can be difficult to definitively di- count for thrombocytopenia and determination of prothrombin
agnose. Effusion feline coronavirus (FCoV) antibodies (1:1,600), and activated partial thromboplastin times for evidence of a dis-
effusion gamma-globulin concentrations .1.0 g/dL, and effusion order of secondary hemostasis are indicated. Diagnostic imaging
albumin-globulin ratios #0.9 are all associated with FIP, but their may also be useful to identify intrathoracic or intra-abdominal
masses. Cytologic evaluation of hemorrhagic effusions is often of with idiopathic pericardial effusion.32 Troponin I levels have not
low diagnostic yield due to hemodilution (i.e., abnormal cells are been compared among patients with other causes of pericardial
diluted out by the large amount of peripheral blood present in the effusion, but this will likely be investigated in the future.32 The most
hemorrhagic effusions). For this reason, evaluation of the buffy common causes of pericardial effusion in cats include FIP, heart
coat or sediment preparations for an infectious or neoplastic disease, and lymphosarcoma.33,34
etiology is recommended. Hemorrhagic effusions typically do not
clot, do not have platelets, may appear hemolyzed (due to the Chylous Effusions
presence of free hemoglobin as some red blood cells may have Chylous effusions result from a loss of integrity of lymphatic
lysed or ruptured in the body cavity environment and as they are drainage from the gastrointestinal tract into the cranial vena cava.35
ingested and degraded by macrophages), usually have macro- Historically, chylous effusions were identified based on the milky
phages containing RBCs that have been erythrophagocytosed, and opaque appearance of effusions; however, it has been shown
and may have hemosiderophages if the hemorrhage is more that not all chylous effusions are opaque and not all effusions that
1
chronic. are white are chylous.10,35 Lecithin globulin complexes and cho-
In studies of noncoagulopathic spontaneous hemothorax and lesterol can also make effusions appear white.35 Chylous effusions
hemoabdomen in dogs, the most common etiology is neoplasia have an effusion triglyceride concentration greater than concur-
(i.e., hemangiosarcoma, malignant mesothelioma, metastatic carci- rent serum triglyceride concentration and an effusion cholesterol
20,21
noma, rib osteosarcoma, pulmonary carcinoma, and lymphoma). less than the effusion triglyceride level.10,36 An effusion tri-
In one study of cats with nontraumatic hemoabdomens, 7 of 16 glyceride concentration .100 mg/dL is also consistent with
had neoplasia as the underlying cause (31% hepatic neoplasia chylous effusion.37
[i.e., hemangiosarcoma, hepatic carcinoma, and mast cell tumor] Primary cardiac disease, lung lobe torsion, trauma, and mass
and 13% had “other” types of neoplasias [i.e., intestinal mast cell effect (compression of lymphatic drainage) are among the most
tumor and splenic lymphosarcoma]). The overall prognosis was common causes of chylous effusions, but chylous effusions are also
22
poor with only 2 of the 16 cats surviving. Most canine peri- commonly idiopathic. Chylous abdominal effusions often carry
cardial effusions are hemorrhagic with a port wine appearance a poor prognosis because of the gravity of the underlying etiologies
and a predominance of macrophages, neutrophils, and reactive in most cases (i.e., lymphangiectasia or neoplasia compromising
mesothelial cells. Because the prognosis varies greatly according lymphatic drainage either through infiltrative or compressive
to the etiology (idiopathic versus neoplastic) of the effusion, a [mass effect] obstruction of lymphatic drainage). Treatment of
study by Sisson et al. (1984) evaluated the value and accuracy of idiopathic chylothorax has become much more successful in the
23
pericardial effusion cytology in dogs. The cytologic specimens of past 20 yr as more aggressive surgical management has been in-
recurrent effusions differed from initial effusion cytology in the stituted. If heart disease is not found and the patient does not have
same animal and some cytologic diagnoses were incorrect a history of trauma and is not responding to medical management,
(i.e., 13% false-positive diagnoses on original cytology [4 of 31 then thoracic duct ligation, pericardectomy, and cisterna chyli
patients without neoplasia had cytology suggestive of neoplasia]; ablation are often pursued to allow more efficient lymphatic
74% false-negative on original cytology in patients [only 5 of 19 drainage.
patients with neoplasia had cytology consistent with neoplasia,
and only 1 patient had the correct type of neoplasia identified Bartonella spp.-Associated Effusion
cytologically]). Thus, cytologic findings for pericardial effusions Bartonella spp. organisms affect vascular integrity and are there-
should be considered in light of other clinical findings.23 When fore categorized within the class of effusions that occur secondary
the effusion is not grossly hemorrhagic, cytology becomes more to vessel or viscus disruption.38 Bartonella spp. directly invade and
valuable as septic pericarditis, cardiac lymphosarcoma, cholesterol- infect the vascular endothelium leading to increased permeability
based pericardial effusion, and chylous pericardial effusions have all and fluid accumulation.38 These bacteria can lead to effusions
24–27
been reported in dogs. morphologically classified as both pure and modified transudates
Other studies have evaluated biochemical and cytometric and may possess immune-modulating effects that prevent the
values in canine pericardial effusions with inconclusive and variable production of inflammatory exudative effusions.38 When other
results.23,28–31 Serum cardiac troponin I concentration appears to be causes of effusion have been excluded then fluid culture and PCR
higher in dogs with pericardial effusion secondary to hemangio- for Bartonella spp. may be worthwhile if there is clinical suspicion
sarcoma compared with cardiac troponin I concentrations in dogs of Bartonellosis.
JAAHA.ORG 7
Effusion Caused by Ruptured Viscus infectious), obstruction of a bile duct, or surgery (i.e., iatrogenic).
Uroabdomen and bile peritonitis cause effusion secondary to Bile peritonitis can also occur spontaneously in rare instances and
rupture of the urinary and hepatobiliary tracts, respectively. Rupture lead to bicavitary effusion of the abdomen and thorax.8 Con-
of the gastrointestinal and genital tract are also included in this current bacterial infection from contaminated bile increases the
category; however, rupture of organs in these latter two systems severity of inflammation and worsens the prognosis. Bile impairs
usually releases bacteria and foreign material into the body cavities local host defense mechanisms against bacterial contamination
causing a dramatic inflammatory response that results in the fluid through a decrease in phagocytic activity.8
being categorized as a septic exudate. Viscus rupture usually occurs Bile peritonitis should be suspected when green, orange, or
secondary to trauma but it can also occur secondary to a pene- yellow-tinged abdominal fluid is obtained from a patient with
trating foreign body or wound, obstruction, or necrosis or neo- a known or suspected history of gallbladder disease, pancreatitis,
plastic erosion of the viscus wall. trauma, or cholelithiasis. In some instances, the fluid associated
with bile peritonitis may be red due to the strong inflammatory
Uroabdomen response inducing the chemotaxis of inflammatory cells and
When urine leaks from any part of the urinary tract into the ab- increased vascular permeability leading to the leakage of red
dominal cavity, the resulting condition is called uroperitoneum or blood cells into the effusion. Cytology of bile peritonitis effusions
uroabdomen. Prior to the development of an inflammatory re- often reveals golden, green or black-brown pigment within mac-
sponse to free urine in the abdominal cavity, acute uroperitoneum rophages or free in the background. Sometimes it can be difficult to
can be morphologically classified as a pure transudate. Creatinine distinguish bile pigment from the pigment of red blood cell
and urea are both concentrated in the urine compared with the degradation products such as hemosiderin (green-blue granules)
peripheral blood. Urea is smaller than creatinine and is therefore or hematoidin (rhomboid gold crystals); therefore, evaluation of
more readily absorbed across the mesothelial lining of the abdomen. bilirubin concentrations in the effusion is useful. An abdominal
The concentration of urea within uroperitoneal effusion begins fluid bilirubin concentration that is more than two times con-
to readily equilibrate with the blood urea concentration whereas current serum bilirubin concentration confirms a diagnosis of bile
creatinine is too large to cross the mesothelium and therefore peritonitis.8,39 Cytologic evaluation for sepsis should also be per-
achieves higher concentrations in the effusion compared with formed since concurrent infection greatly affects prognosis.8 Some
the serum. In one study of dogs with uroperitoneum, dogs with at cases of bile peritonitis have basophilic mucinous material in
least two of the three following criteria were considered to have clumps and lakes (white bile) on cytology rather than bilirubin
uroperitoneum: (1) abdominal fluid creatinine at least four times crystals.39 If abdominocentesis does not yield a sample of effusion
greater than normal peripheral blood creatinine; (2) an abdominal but bile peritonitis is high on the differential list, then diagnostic
fluid potassium-peripheral blood potassium ratio .1.4; and/or (3) peritoneal lavage is recommended. If the bilirubin concentration
an abdominal fluid creatinine-peripheral blood creatinine ratio of the lavage is greater than that of blood, then bile peritonitis
.2.0.9 These guidelines were 100% specific and 100% sensitive should be strongly suspected.8
for uroperitoneum.9 A retrospective study by Aumann et al. (1998)
found that cats with uroabdomen had a mean abdominal fluid Effusions that Result from Exfoliation of Cells into
creatinine-peripheral blood creatinine ratio of 2:1 with a range a Body Cavity
that was actually between 1.1:1 and 4.1:1. Mean abdominal fluid Exfoliation of neoplastic and/or reactive mesothelial cells into
potassium-peripheral blood potassium was 1.9:1 with a range of a body cavity can lead to the accumulation of highly cellular ef-
1.2:1–2.4:1.39 To date, specific guidelines have not been developed fusions. Carcinomas, mesotheliomas, and discrete (round) cell
for the diagnosis of feline uroabdomen based on these ratios (be- neoplasms (e.g., lymphoma, mast cell tumors, malignant histio-
cause a control group was lacking in this study), but these values cytosis) exfoliate cells into effusions more readily than sarcomas.1
can be used to increase the degree of clinical suspicion or eliminate When exposed to foreign irritants or chronic effusions, the cells of
39
uroperitoneum as a potential cause for an effusion in some cases. the mesothelium are activated to proliferate and exfoliate into the
fluid as reactive mesothelial cells.1 Cytologic differentiation of re-
Bile Peritonitis active mesothelial cells and neoplastic epithelial or mesothelial cells
Bile peritonitis is defined as an inflammatory response to free bile can be difficult.
6
in the peritoneal cavity. Bile leakage into the abdominal cavity Lymphosarcoma is among the most common malignancies
can occur secondary to trauma, cholangitis (inflammatory or in companion animals that can lead to an exfoliative effusion
characterized by a monomorphic population of immature or between an idiopathic chylous effusion, small cell lymphoma, and
atypical lymphoid cells (Figure 2).40 The immature or atypical other disease processes with similar cytologic findings.42
lymphoid cells are usually larger than neutrophils, have a mod- Irritation of the mesothelium by a foreign substance, cyto-
erate amount of clear to blue cytoplasm, variably shaped nuclei kines, or accumulating fluid causes mesothelial proliferation, ac-
with prominent and often bizarre, angular nucleoli, and finely tivation, and exfoliation. Reactive mesothelial cells can exhibit
stippled nuclear chromatin.2,13 Clinical pathologists can often atypical cytologic features including multinucleation, anisocytosis,
diagnose lymphosarcoma based on cellular morphology when it is and anisokaryois. As such, reactive mesothelial cells are often
the underlying cause of an effusion, but additional diagnostic tests confused with neoplastic cells.1 Reactive mesothelial cells usually
are now available for effusions whose definitive diagnosis is more appear dark blue and often have an indistinct brush border ap-
elusive, such as PCR for analysis of antigen receptor rearrange- pearance to their cell membrane. Mesothelioma, an uncommon
ments (PARR) and flow cytometry. primary neoplasm of the mesothelium, can cause exfoliative
The PARR test relies on the fact that a malignant population effusions. Cytologic differentiation between reactive mesothelial
originates from a single cell with specific DNA, so the malignant cells and mesothelioma is very difficult.1 Incisional biopsy of
population is a population of clones with identical DNA. Sam- proliferative mesothelium for histopathology is frequently re-
ples that are submitted for PARR undergo PCR amplification of quired for differentiation.
certain regions of their immunoglobulin and T-cell receptor
genes to detect clonal lymphocyte populations.41 Clonal pop- Other Approaches for Evaluating Neoplastic
ulations are associated with T and B cell lymphoid malignancies Effusions
and are also documented in cases of ehrlichiosis.41 The PARR During the past decade, additional diagnostic tests have evaluated
test only requires that 0.1% to 10% of the DNA to be derived the use of growth factors and enzymes as indicators of neoplastic
from neoplastic cells and has successfully been performed on disease. So far these tests have failed to yield any clinically useful
effusions.42 assays.43–45
Flow cytometry can also be used to analyze effusion samples
to determine if cell size, molecular complexity, and antigenic Conclusion
composition are consistent with either benign or malignant The traditional morphologic evaluation of effusions according
lymphocyte populations. Flow cytometry requires only 0.1 mL to their TNCC and total protein can be useful and practical, but
of an anticoagulated effusion sample and can help distinguish does not classify effusions according to their inciting cause. The
classification of effusions according to their underlying etiology is
clinically useful and allows the clinician to proceed with more
directed diagnostic tests. Studies published in the recent past have
identified more definitive diagnostic tests for disorders including
portal hypertension, uroperitoneum, bile peritonitis, Bartonella
spp., and lymphoid neoplasia. Challenges in the diagnosis of
effusions remain, but hopefully with collaborative research efforts
and future evidence-based studies, the clinician’s ability to di-
agnose and effectively treat effusive disorders (or disorders of
effusion) will improve.
The authors would like to thank Dr. Pamela Mouser for her assis-
tance in formatting images for this manuscript.
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