RESULTS

AND
OBSERVATIONS

T he results of the study of the 40 cases of pleural effusions are presented

and the relevant observations are made.

The age incidence of the 40 cases of pleural effusion are shown

in Table–1

TABLE–1
AGE INCIDENCE OF 40 CASES OF PLEURAL EFFUSION

NUMBER
AGE GROUP PERCENTAGE
OF CASES
(IN YEARS) (%)
(N = 40)
13–23 1 2.5
24–33 12 30.0
34–43 6 15.0
44–53 5 12.5
54–63 8 20.0
64–73 5 12.5
74–83 3 7.5
Total 40 100.0

The age ranges from 13–83 years in the study the commonest
age group affected in the present study was found to be third decade.

The sex incidence in the 40 cases of pleural effusion are shown

in the Table–2

TABLE–2
SEX INCIDENCE OF 40 CASES OF PLEURAL EFFUSION

NUMBER
PERCENTAGE
SEX OF CASES
(%)
(N = 40)
Male 30 75.0
Female 10 25.0
  RES ULTS AN D OBS ERVATI ONS  62

In the present study 75% cases were male and 25% were
females.

Pleural effusion affects either one or both sides. From the

present study the distribution of affection are shown in the Table–3.

TABLE–3
SHOWING THE DISTRIBUTION OF 40 CASES OF PLEURAL
EFFUSION AFFECTING ONE OR BOTH SIDES OF CHEST

SIDES OF NUMBER
PERCENTAGE
PLEURAL OF CASES
(%)
EFFUSION (N = 40 )
Right 20 50.0
Left 12 30.0
Bilateral 8 20.0

Right sided pleural effusion was found in 50% of cases as

compared to 30% on left sides. Bilateral effusion was found in 20% of cases.

The patients of the present study were presented with various

symptoms which are shown in the following table.

TABLE–4
SHOWING PRESENTING SYMPTOMS OF
THE 40 CASES OF PLEURAL EFFUSION

NUMBER
PERCENTAGE
SYMPTOMS OF CASES
(%)
(N = 40 )
Breathlessness 35 87.5
Chest pain 21 52.5
Dry cough 26 65.0
Cough with expectoration 12 30.0
Fever 24 60.0
Night Sweat ]2 30.0
Hemoptysis 5 12.5
Others 18 45.0
  RES ULTS AN D OBS ERVATI ONS  63

The commonest symptom of presentation was breathlessness

(87.5%). Dry cough and fever were present in 65% and 60% of cases
respectively.

The erythrocyte sedimentation rates (ESR) were examined in all

40 cases of pleural effusion and the findings are shown in the following table.

TABLE– 5
SHOWING ESR OF 40 CASES OF PLEURAL EFFUSION

NUMBER
ESR PERCENTAGE
OF CASES
(mmAEFH) (%)
(N = 40 )

0–10 1 2.5

11–20 3 7.5

21–30 6 15.0

31–40 7 17.5

41–50 4 10.0

51–60 6 15.0

61– 70 2 5.0

71–80 1 2.5

81–90 1 2.5

90–100 4 10.0

> 100 5 12.5

In the present study 90% of patients had an ESR above 20 mm

AEFH.

Sputum was examined for cytology in all the 40 cases of pleural

effusion irrespective of parenchymal lesions present or absent and the results
are shown in the following table.
  RES ULTS AN D OBS ERVATI ONS  64

TABLE–6
SHOWING THE RESULTS OF CYTOLOGICAL EXAMINATION OF SPUTUM

NUMBER
PERCENTAGE
SPUTUM EXAMINATION OF CASES
(%)
(N = 40 )
Positive Gram stain for Pyogenic bacteris 2 5.0

Positive Ziehl–Neelsen Stain for AFB 5 12.5

Positive pap smear for malignant cells 4 10.0

Negative for pyogenic organism, AFB or malignant cells 29 72.5

In the present study only 27.5% of 40 cases of pleural effusion

had positive cytological examination of sputum for pyogenic organism, AFB
and malignant cells. All other patients had a negative cytology.

TABLE–7
SHOWING THE RESULTS OF THE SKIAGRAM
OF CHEST OF PARENCHYMAL LESIONS ONLY

NUMBER
RESULTS OF THE PERCENTAGE
OF CASES
SKIAGRAM OF CHEST (%)
(N = 40 )
Tuberculosis 8 20.0
Malignancy 3 7.5
Pneumonic consolidation 2 5.0
No lung parenchymal changes 27 67.5

In the present study 8 patients had tubercular lesions present in

chest X–ray and 3 had evidence of malignancy. Pneumonic consolidations
were seen in two patients. In 67.5% of the cases (27) had no associated lung
parenchymal changes.

The pleural fluids from the 40 cases of pleural effusions on

gross examination appeared as follows.

TABLE–8
  RES ULTS AN D OBS ERVATI ONS  65

SHOWING THE PLEURAL FLUID APPEARANCES

OF THE 40 CASES OF PLEURAL EFFUSION

NUMBER
PLEURAL FLUID PERCENTAGE
OF CASES
APPEARANCE (%)
(N = 40 )
Pale Yellow 30 75.0
Hemorrhagic 7 17.5
Turbid 3 7.5

The pleural fluid appeared pale yellow coloured in 75% of cases

and hemorrhagic in 17.5% of cases. In other 7.5% cases the pleural fluid was
turbid.

The pleural fluid was examined for cytology in all 40 cases of

pleural effusion and the results obtained are shown in table 10.

TABLE– 9
SHOWING THE RESULTS OF CYTOLOGICAL EXAMINATION
OF PLEURAL FLUID OF 40 CASES OF PLEURAL EFFUSION

NUMBER
PERCENTAGE
Cells OF CASES
(%)
(N = 40 )
Lymphocytes:
 Few 29 72.5
 Plenty 7 17.5
Pus Cells:
 Few 12 30.0
 Plenty 2 5.0
RBC's:
 Few 6 15.0
 Plenty 7 17.5

In majority of cases (72.5%) the pleural fluid contained few

lymphocytes. Plenty of RBC's and pus cells were present in 17.5% and 5%
cases respectively.
  RES ULTS AN D OBS ERVATI ONS  66

The pleural fluid was examined for AFB, malignant cells and
culture for pyogenic organism and result are shown in the following table.

TABLE–11
RESULTS OF POSITIVE PLEURAL FLUID EXAMINATION FOR AFB,
MALIGNANT CELLS AND CULTURE FOR PYOGENIC ORGANISMS

NUMBER
PERCENTAGE
Pleural fluid for OF CASES
(%)
(N = 40 )
Acid fast bacilli 4 10.0
Malignant cells 3 7.5
Culture for pyrogenic organism 2 5.0

The etiologic diagnosis could be made in 22.5% of cases. Acid

fast bacilli and malignant cells were demonstrated in 10% & 7.5% each and
pyogenic organism was isolated in 5% of cases. In 31 cases (77.5%) all the
smear studies were negative for AFB, malignant cells and culture for poygenic
organism.

Pleural biopsy was done in 11 cases of pleural effusion in the

present study and the results are shown in the Table–12.

TABLE– 12
RESULTS OF THE PLEURAL BIOPSY IN
SELECTED CASES OF PLEURAL EFFUSION

PLEURAL BIOPSY NUMBER PERCENTAGE

RESULTS OF CASES (%)
Tuberculosis 8 20.0
Adenocarcinoma 2 5.0
Non Hodgkin's lymphoma 1 2.5
TOTAL 11 27.5

Pleural Biopsy was done in 11 cases & on comparing with the

etiological diagnosis of 40 cases of pleural effusion, 20% of biopsy came out
to be tuberculosis & 7.5% were malignancies.
  RES ULTS AN D OBS ERVATI ONS  67

TABLE– 13
THE CAUSES OF THE 40 CAUSES OF PLEURAL EFFUSION

NUMBER
PERCENTAGE
CAUSES OF CASES
(%)
(N = 40 )
Transudates:
 Heart failure 6 15.0
 Cirrhosis 4 10.0
 Nephrotic syndrome 3 7.5

 Pericardial effusion 1 2.5

Exudates :
 Tuberculosis 15 37.5
 Neoplasm 8 20.0
 Parapneumonic effusion 2 5.0

 Rheumatoid Arthritis 1 2.5

Among the transudates 15% cases are caused by congestive

heart failure and 37.5% of exudates are caused by tuberculosis.

TABLE– 14
PLEURAL FLUID PROTEIN CONCENTRATION
OF THE 40 CASES OF PLEURAL EFFUSION

PROTEIN
NUMBER
CONCENTRATION IN PERCENTAGE
OF CASES
PLEURAL FLUID (%)
(N = 40 )
(g/dl)
1.0—2.0 3 7.5
2.1—3.0 15 37.5
3.1—4.0 0 0.0
4.1—5.0 22 55.0

In 55% of cases pleural fluid protein concentrations were above

3 g/dl & in 45% the protein concentration was 3 or below 3 g/dl.

The graphical representation of the above table is shown in

Fig. 1.
  RES ULTS AN D OBS ERVATI ONS  68

TABLE– 15
SHOWING THE DISTRIBUTION OF PLEURAL FLUID
TO SERUM PROTEIN RATIO

PLEURAL FLUID NUMBER

PERCENTAGE
TO SERUM OF CASES
(%)
PROTEIN RATIO (N = 40 )
0.01—0.25 0 0.0

0.26—0.50 17 42.5

0.51—0.75 17 42.5

0.76—1.00 6 15.0

In 57.5% of cases pleural fluid protein to serum protein was

above .5 & in 42.5% cases it was 0.5 or below 0.5

The graphical representation of the above table is shown in

Fig. 2.

TABLE–16
SHOWING THE DISTRIBUTION OF PLEURAL FLUID LDH

PLEURAL NUMBER
PERCENTAGE
FLUID LDH OF CASES
(%)
(U/L) (N = 40 )
0—200 16 40.0

201—400 3 7.5

401—600 16 40.0

601—800 5 12.5

In 60% of cases Pleural Fluid LDH is greater than 200 U/L & in
40% cases it is equal or less than 200 U/L.

The graphical representation of the above table is shown in

Fig. 3.

TABLE– 17
  RES ULTS AN D OBS ERVATI ONS  69

SHOWING THE DISTRIBUTION OF PLEURAL FLUID LDH TO SERUM LDH

NUMBER
PLEURAL FLUID PERCENTAGE
OF CASES
LDH/SERUM LDH (%)
(N = 40 )
0.00—0.30 2 5.0
0.31—0.60 11 17.5
0.61—0.90 10 25.0
0.91—1.20 6 15.0
1.21—1.50 11 27.5

In 67.5% of cases Pleural fluid LDH to serum LDH is above 0.6

& in 32.5% it is equal or less than 0.6

The graphical representation of the above table is shown in

Fig. 4.

TABLE– 18
SHOWING DISTRIBUTION OF SEAG [SERUM–EFFUSION ALBUMIN
GRADIENT] IN 40 CASES OF PLEURAL EFFUSION

NUMBER
PERCENTAGE
SEAG OF CASES
(%)
(N = 40 )
0.30—0.60 3 7.5
0.61—0.90 4 10
0.91—1.20 19 47.5
1.21—1.50 10 25
1.51—1.80 3 7.5
1.81—2.10 0 0
2.11—2.40 1 2.5

In 35% of cases Serum–Effusion Albumin gradient is above 1.2

g/dl & in 65% of cases it is equal or less than 1.2 g/dl.

The graphical representation of the above table is shown in

Fig. 5.

TABLE– 19
  RES ULTS AN D OBS ERVATI ONS  70

SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL

FLUID PROTEIN OF 3 gms/dl IN COMPARISON TO THE
ESTABLISHED DIAGNOSIS OF TRANSUDATES & EXUDATES

NUMBER OF
CASES NUMBER NUMBER OF
TYPES OF ETIOLOGICALLY
DIFFERENTIATED OF CASES CASES
PLEURAL DIAGNOSED
BY PLEURAL TRULY FALSELY
FLUID (N = 40)
FLUID PROTEIN CLASSIFIED CLASSIFIED
OF 3 g/dl
Exudate 26 22 16 6
Transudate 14 18 14 4

The Pleural fluid Protein of 3g/dl separated 22 cases (55%) as

exudates & 18 (45%) as transudate. When etiology was reviewed 6 of the
exudates & 4 of the transudates were falsely classified. A total
misclassification of 25% occurred.

The graphical representation of the above table is shown in

Fig. 6.

TABLE– 20
SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL
FLUID PROTEIN TO SERUM PROTEIN OF .5 IN COMPARISON TO THE
ESTABLISHED. DIAGNOSIS OF TRANSUDATES & EXUDATES

NUMBER OF
NUMBER NUMBER OF
TYPES OF ETIOLOGICALLY CASES
OF CASES CASES
PLEURAL DIAGNOSED. DIFFERENTIATED
TRULY FALSELY
FLUID (N = 40) BY P/S PROTEIN
CLASSIFIED CLASSIFIED
OF 0.5
Exudate 26 23 18 5
Transudate 14 17 14 3

The pleural fluid to serum protein ratio of .5 separated 23 cases

(57.5%) as exudates & 17 (42.5%) as transudates. When etiology was
reviewed 5 of the exudates & 3 transudates were falsely classified. Total
misclassification of 20% occurred.

The graphical representation of the above Table–20 is shown in

  RES ULTS AN D OBS ERVATI ONS  71

Fig. 7.

TABLE– 21
SHOWING EXUDATES & TRANSUDATES SEPARATED BY PLEURAL
FLUID PROTEIN OF 3g/dl & PLEURAL FLUID TO SERUM PROTEIN
RATIO OF .5 IN COMPARISON TO THE ESTABLISHED.
DIAGNOSIS OF EXUDATES & TRANSUDATES
NUMBER OF
NUMBER OF NUMBER OF
TYPES OF ETIOLOGICAL CASES
CASES CASES
PLEURAL DIAGNOSIS DIFFERENTIATED
TRULY FALSELY
FLUID (N = 40) BY P.F. PROTEIN
CLASSIFIED CLASSIFIED
3g/dl & P/S OF 0.5
Exudate 26 22 18 4
Transudate 14 18 15 3

Pleural fluid protein of 3g/dl & p/s of .5 separated 22(55%)

cases as exudates & 18(45%) as transudates. When the etiology was reviewed
4 of the exudates & 3 of the transudates were falsely classified. Total
misclassification rate of 17.55% occurred.

The graphical representation of the above table is shown in

Fig. 8.

TABLE– 22
SHOWING EXUDATES & TRANSUDATES SEPARATED BY
PLEURAL FLUID LACTATE DEHYDROGENASE (LDH) OF 200 U/L
NUMBER OF
CASES NUMBER OF NUMBER OF
TYPES OF AETIOLOGICAL
DIFFERENTIATED CASES CASES
PLEURAL DIAGNOSIS
BY PLEURAL TRULY FALSELY
FLUID (N = 40)
FLUID LDH OF CLASSIFIED CLASSIFIED
200 U/L
Exudate 26 24 20 4
Transudate 14 16 13 3

Pleural fluid LDH of 200 U/L separated 24 (60%) as exudates &

16 (40%) as transudates. When etiology was reviewed 4 of exudates & 3 of
transudates were falsely classified. Total misclassification of 17.5% occurred.

The graphical representation of the above Table–22 is shown in

  RES ULTS AN D OBS ERVATI ONS  72

Fig. 9.

TABLE– 23
SHOWING EXUDATES AND TRANSUDATES SEPARATED BY PLEURAL
FLUID LDH TO SERUM LDH OF O.6 IN COMPARISON TO THE ESTABLISHED
DIAGNOSIS OF EXUDATES & TRANSUDATES

NUMBER OF NUMBER NUMBER OF

TYPES OF AETIOLOGICAL
CASES OF CASES CASES
PLEURAL DIAGNOSIS
DIFFERENTIATED TRULY FALSELY
FLUID (N = 40)
BY P/S LDH OF 0.6 CLASSIFIED CLASSIFIED
Exudates 26 27 24 3
Transudates 14 13 11 2

Pleural fluid LDH to Serum LDH of .6 separated 27 (67.5%) as

exudates & 13 (32.5%) as transudates. When the etiology was reviewed 3 of
the Exudates & 2 transudates were falsely classified. Total misclassification
of 12.5% occurred.

The graphical representation of the above table is shown in

Fig. 10.

TABLE– 24
SHOWING EXUDATES & TRANSUDATES SEPARATED BY
PLEURAL FLUID LDH OF 200 U/L & PLEURAL FLUID LDH
TO SERUM LDH OF 0.6 IN COMPARISON TO THE
ESTABLISHED DIAGNOSIS OF EXUDATE & TRANSUDATE

NUMBER OF CASES
NUMBER NUMBER OF
TYPE OF ETIOLOGICAL DIFFERENTIATED BY
OF CASES CASES
PLEURAL DIAGNOSIS PLEURAL FLUID LDH
TRULY FALSELY
FLUID ( N = 40 ) OF 200 U/L &
CLASSIFIED CLASSIFIED
P/S LDH OF 0.6
Exudate 26 28 26 2
Transudate 14 12 10 2

Pleural fluid LDH of 200 U/L & pleural fluid LDH to serum
LDH of .6 seperated 28 ( 70% ) cases as exudates & 12 ( 30% ) as transudates
  RES ULTS AN D OBS ERVATI ONS  73

when etiology was reviewed 2 of the exudates & 2 of the transudates were
falsely classified. Total misclassification of 10% occurred.

The graphical representation of the above table is shown in

Fig. 11.

TABLE– 25
SHOWING NUMBER OF CASES SEPARATED BY SERUM–EFFUSION
ALBUMIN GRADIENT OF 1.2 g/dl IN COMPARISON TO THE ESTABLISHED
DIAGNOSIS OF EXUDATES & TRANSUDATES

NUMBER OF CASES NUMBER NUMBER OF

TYPE OF AETIOLOGICAL
DIFFERENTIATED OF CASES CASES
PLEURAL DIAGNOSIS
BY SEAG TRULY FALSELY
FLUID
OF 1.2 G/DL CLASSIFIED CLASSIFIED
Exudate 26 26 25 1
Transudate 14 14 13 1

Serum–Effusion Albumin gradient of 1.2 g/dl separated 26

(65%) cases as exudates & 14 (35%) as transudates when etiology was
reviewed only 1 exudate & 1 transudate was falsely classified. Total
misclassification of 5% occurred.

The graphical representation of the above table is shown in

Fig. 12.
  RES ULTS AN D OBS ERVATI ONS  74

TABLE– 26
MEAN (M) VALUES, RANGES (R), STANDARD DEVIATIONS (SD),
OF PARAMETERS STUDIED IN 40 CASES OF PLEURAL EFFUSIONS

Non–
Transudates Exudates Tubercular Neoplasm Others “p”
Parameter Character Tubercular
(N = 14) (N = 26) (N = 15) (N = 8) (N = 1) value
(N = 2)

Pleural M 2.534 4.344 3.33 3.78 3.69

Fluid <.01
R 1.92–3 4.18–4.69 1.92–4.69 2.73–4.63 2.41–4.52 4.22
Protein (S*)
of 3g/dl SD 0.344 0.143 0.946 1.34 0.898
M 0.45 0.699 0.545 0.56 0.64
P/S
<.01
Protein R 0.39–.5 0.5–.8 0.39–.8 0.44–.68 0.45–.8 0.69
(S*)
of 0.5
SD 0.03 0.074 0.14 0.17 0.14

Pleural M 101.25 483.92 333.4 348 402.38

Fluid LDH <.01
R 399–680 73–131 83–73 123–573 73–680 412
of 200 (S*)
U/L SD 19.15 109.38 214.49 318.2 216.5
M 0.39 1.01 0.87 0.66 0.83
P/S LDH
<.001
of R 0.11–2.6 0.61–1.27 0.31–1.27 0.4–.92 0.37–1.25 1.24
(H.S.**)
0.6
SD 0.11 0.25 0.36 0.38 0.35
M 1.45 0.999 1.13 0.82 1.08
SEAG
<.001
of R 1.21–2.24 0.51–1.2 0.59–2.24 0.51–1.12 0.63–1.7 1.01
(H.S.**)
1.2g/dl
SD 0.29 0.23 0.39 0.43 0.31

(* S : Significant; ** H.S. : Highly Significant)

The differences in the means of the transudates & exudates were

significant (p < 0.01) for the parameters–pleural fluid protein, pleural fluid
protein to serum protein ratio & pleural fluid LDH. The differences of the
means of pleural fluid to serum LDH & serum–effusion albumin gradient were
highly significant (p < 0.001) indicating the usefulness in the differential
diagnosis of pleural effusion.

usu