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Body Fluid Analysis - Plerual Fluid

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Pleural fluid is the lubricating fluid that lies between the parietal pleura (chest wall) and the visceral pleura (lung surface). A pleural effusion occurs when excess fluid accumulates in this space — often due to infection, malignancy, or systemic illness

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Body Fluid Analysis - Pleural Fluid

  • Why is it done?
    • Diagnostic evaluation of pleural effusion (abnormal fluid accumulation in the pleural space between the lungs and chest wall)
    • Determine the underlying cause of fluid accumulation (exudate vs. transudate classification)
    • Identify infectious processes such as bacterial, tuberculosis, or fungal infections
    • Detect malignant cells indicating cancer involving the pleura
    • Evaluate for autoimmune or rheumatologic conditions
    • Assess for hemothorax (blood in pleural space) or chylothorax (lymphatic fluid)
    • Performed when patients present with dyspnea, chest pain, or imaging shows pleural effusion
  • Normal Range
    • Appearance: Clear, pale yellow, or colorless
    • Volume: Less than 15 mL total in pleural space (minimal physiologic fluid)
    • Cell Count - WBC: Less than 1,000 cells/μL (or 1.0 × 10⁹/L)
    • Cell Count - RBC: Less than 5,000 cells/μL (or 5.0 × 10⁹/L)
    • Protein: Less than 2.0 g/dL (20 g/L) or less than 50% of serum protein
    • Glucose: Greater than 60 mg/dL (60-100 mg/dL expected)
    • LDH (Lactate Dehydrogenase): Less than two-thirds of upper limit of serum LDH (typically <150-200 IU/L)
    • pH: 7.30-7.40 (similar to blood pH)
    • Cytology: Negative for malignant cells; no abnormal findings
    • Cultures: Negative for bacteria, acid-fast bacilli, and fungi
    • Interpretation Guide - Classification:
    • Transudate: Protein <2.5 g/dL, LDH <200 IU/L, pleural/serum protein ratio <0.5, indicates non-inflammatory process
    • Exudate: Protein >2.5 g/dL, LDH >200 IU/L, pleural/serum protein ratio >0.5, indicates inflammation or infection
  • Interpretation
    • Exudate Classification (indicates pathology):
    • High protein and LDH with normal glucose - suggests infection, malignancy, or inflammation
    • Low glucose (<30 mg/dL) - indicates rheumatoid arthritis, systemic lupus erythematosus, or esophageal rupture
    • Low pH (<7.20) - associated with infection, malignancy, rheumatologic disease, or esophageal rupture
    • Elevated WBC (>1,000 cells/μL) with lymphocyte predominance - suggests tuberculosis, fungal infection, or lymphoma
    • Elevated WBC (>1,000 cells/μL) with neutrophil predominance - indicates bacterial infection, acute pneumonia, or acute pulmonary embolism
    • Transudate Classification (indicates systemic process):
    • Low protein and LDH - suggests congestive heart failure (most common cause), hepatic cirrhosis, renal failure, or malnutrition
    • Appearance Abnormalities:
    • Cloudy/turbid appearance - indicates presence of WBCs, bacteria, or malignant cells
    • Bloody/hemorrhagic fluid (RBC >100,000 cells/μL) - suggests malignancy, trauma, or pulmonary embolism
    • Milky appearance - indicates chylothorax (lymphatic obstruction) or empyema
    • Greenish/purulent appearance - indicates empyema (pus in pleural space)
    • Positive Cytology:
    • Malignant cells detected - indicates pleural involvement by cancer (lung cancer most common, followed by breast, gastric, or lymphoma)
    • Positive Cultures:
    • Positive bacteria - indicates bacterial infection/empyema requiring antibiotics
    • Positive acid-fast bacilli (AFB) - indicates tuberculosis (usually 5-10% culture positive)
    • Positive fungi - indicates fungal infection such as Cryptococcus, Histoplasma, or Coccidioides
  • Associated Organs
    • Primary Organ System:
    • Respiratory system - pleural membranes surrounding the lungs
    • Lungs - primary site affected in pulmonary effusions
    • Conditions Associated with Transudate (Non-inflammatory):
    • Congestive heart failure (CHF) - most common cause of pleural effusion
    • Hepatic cirrhosis - decreased albumin and portal hypertension
    • Chronic kidney disease/nephrotic syndrome - protein loss and fluid retention
    • Pulmonary embolism - increased vascular permeability
    • Severe malnutrition - hypoproteinemia
    • Conditions Associated with Exudate (Inflammatory/Infectious):
    • Pneumonia and bacterial empyema - bacterial infection
    • Tuberculosis - mycobacterial infection
    • Fungal infections (Cryptococcus, Coccidioides, Histoplasma)
    • Malignancy (lung cancer, breast cancer, lymphoma, mesothelioma)
    • Autoimmune disorders (systemic lupus erythematosus, rheumatoid arthritis)
    • Pulmonary infarction - secondary to thromboembolism
    • Pancreatitis - inflammation extending to pleural space
    • Esophageal rupture - digestive contents leaking into pleural space
    • Special Pleural Fluid Findings:
    • Hemothorax - blood in pleural space (RBC >5,000-100,000 cells/μL) from trauma or malignancy
    • Chylothorax - lymphatic fluid (triglycerides >110 mg/dL) from lymphatic obstruction or trauma
    • Empyema - pus with positive bacterial cultures requiring drainage
    • Potential Complications:
    • Untreated pleural infection leading to sepsis and respiratory compromise
    • Progressive dyspnea and hypoxemia from large effusions compressing lung tissue
    • Fibrothorax and lung restriction if effusion is chronic and untreated
  • Follow-up Tests
    • If Transudate (Non-inflammatory) Suspected:
    • Serum albumin and total protein to evaluate nutritional status
    • BNP (B-type Natriuretic Peptide) to confirm heart failure etiology
    • Echocardiography to evaluate cardiac function
    • Liver function tests and coagulation profile if cirrhosis suspected
    • Renal function tests (BUN, creatinine) if kidney disease suspected
    • If Exudate (Inflammatory/Infectious) Suspected:
    • Repeat pleural fluid cultures if first sample not diagnostic
    • ADA (Adenosine Deaminase) testing - if tuberculosis suspected (sensitivity 90-100%)
    • PCR (Polymerase Chain Reaction) testing for tuberculosis, fungal, or viral pathogens
    • Pleural biopsy if tuberculosis highly suspected but cultures negative
    • Blood cultures if bacterial infection suspected
    • Sputum culture if concurrent pneumonia present
    • If Malignancy Suspected:
    • Repeat thoracentesis with cytology if first sample non-diagnostic (sensitivity improves with repeat sampling)
    • Flow cytometry for lymphoma detection
    • Immunohistochemistry to characterize malignant cells
    • CT scan of chest to evaluate underlying malignancy
    • Pleural biopsy or imaging-guided biopsy if malignancy suspected
    • If Autoimmune/Rheumatologic Disease Suspected:
    • Pleural fluid ANA (Antinuclear Antibody) test
    • Pleural fluid rheumatoid factor
    • Pleural fluid complement (C3, C4) levels
    • Serum ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein)
    • Special Testing Based on Findings:
    • Triglyceride and cholesterol levels if chylothorax suspected
    • Hematocrit comparison (pleural vs. serum) if hemothorax suspected
    • Pleural amylase if esophageal rupture or pancreatitis suspected
    • Imaging Follow-up:
    • Chest X-ray or CT to monitor effusion size and response to treatment
    • Ultrasound-guided thoracentesis if repeat sampling needed
    • Monitoring Frequency:
    • Acute bacterial infection: Re-evaluate within 24-48 hours of treatment initiation
    • Tuberculosis: Assess response after 2-4 weeks of therapy
    • Malignancy: Follow-up imaging and staging studies based on cancer type
    • Heart failure: Re-evaluate effusion after optimizing diuretic therapy
  • Fasting Required?
    • Fasting Requirement: No - Fasting is NOT required for pleural fluid analysis
    • Patient Preparation:
    • No special fasting required - patient can eat and drink normally
    • Patient should be seated in upright position for 30 minutes prior to procedure if possible to allow fluid to collect at dependent areas
    • Remove any restrictive clothing from the chest area
    • Empty bladder and bowel before procedure for comfort
    • Pre-procedure Instructions:
    • Anticoagulant medications (warfarin, heparin, DOACs) - may need to be held per physician discretion; discuss with ordering provider
    • Antiplatelet agents (aspirin, clopidogrel) - typically continued but notify provider if on high-dose therapy
    • Inform provider of all current medications, especially immunosuppressants
    • Recent antibiotic use should be noted as it may affect culture results
    • What to Bring:
    • Insurance card and photo identification
    • List of current medications and allergies
    • Any recent imaging (chest X-ray, CT scan) if available
    • Post-procedure Instructions:
    • Remain under observation for 1-2 hours after procedure to monitor for complications
    • Chest X-ray performed post-procedure to rule out pneumothorax
    • May resume normal diet and activities once cleared by healthcare provider
    • Report any chest pain, increased dyspnea, fever, or dizziness to healthcare provider immediately

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