• Tuberculosis and Respiratory Diseases
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• v.76 no.1
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• pp.42-45
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• 2014

An immunoglobulin G4 (IgG4)-related disease is a recently emerging entity, and a few cases of IgG4-related disease in lung and pleura have been reported. Herein, we report the case of a 74-year-old man with IgG4-related disease of lung and pleura, clinically suspicious of malignant mesothelioma. Chest computed tomography showed diffuse nodular pleural thickening, and microscopic finding disclosed diffuse thickening of visceral pleura with infiltrations of many lymphoplasma cells with increased number of IgG4-positive plasma cells and a few multinucleated giant cells. It is important for pathologists and clinicians to recognize this rare entity and its histologic finding, because it can be confused with malignant tumors on the radiologic examination although it can be treated with steroid therapy.

• Tuberculosis and Respiratory Diseases
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• v.54 no.5
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• pp.563-569
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• 2003

Background : Pleural effusions with high amylase levels are reported frequently in patients with pancreatic diseases, a rupture of the esophagus and a malignancy. However, there is no data available on the clinical features of an amylase-rich pleural effusion in Korea. This report describes the causes of the high amylase levels in a pleural effusion and analyzes its association with malignancy. Methods : The records of patients with an amylase-rich pleural effusion who were assessed at the Gyeongsang National University Hospital from January 1998 to August 2002 were examined retrospectively, and the distribution of amylase levels in those patients, the causative diseases, and the histological type in the case of a malignancy were analyzed. Among the 532 patients whose pleural effusion was evident on a chest X-ray, there were 36 cases with an amylase-rich pleural effusion. The amylase levels were determined by an enzyme method (Hitach 747 autoanalyzer). Results : Of the 36 patients with an amylase-rich pleural effusion, there were 18 patients(50%) associated with a malignancy, 8 patients(22%) with a parapneumonic effusion, 7 patients(19%) with pancreatic disease, and 3 patients with other causes. The amylase level in a pleural effusion due to pancreatic disease was much higher than that due to other causes(p<0.01). Among the malignant pleural effusions with high amylase levels, the origin of the malignancy was a primary lung cancer in 13 cases and metastatic lung cancer in 5 cases. The histological types of malignant causes were adenocarcinoma in 10 cases(56%), squamous cell carcinoma in 2 cases(11%) and unknown type of carcinoma in 6 cases. The amylase level in the adenocarcinoma cases was much higher than that in the other cell type carcinomas(p<0.01). There was no significant association between the amylase level and the glucose level among the malignant cases with amylase-rich pleural effusion(p=0.21). Conclusion : The most frequent cause of an amylase-rich pleural effusion was a malignancy. Primary lung cancer and adenocarcinoma were the most common malignancies and histological types associated with a malignant pleural effusion with high amylase levels. The amylase level in a pleural effusion secondary to pancreatic disease was much higher than from any other causes.

• Tuberculosis and Respiratory Diseases
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• v.45 no.2
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• pp.388-396
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• 1998

Background: Etiologic diagnosis of pleural effusion is usually made by clinical characteristics, pleural fluid analysis and pleural biopsy. But, despite careful diagnostic study, the cause of pleural effusion cannot be found in about 20 percent of patients, especially in loculated pleural effusions. Tuberculous pleurisy is one of the most common cause of pleural effusion in Korea. But, pleural fluid culture for Mycobacterium tuberculosis are positive in only 20 to 30 percent of patients and typical pleural biopsy finding in less than 50 percent of patients with this disease. In recent studies, adenosine deaminse(ADA) and its isoenzymes were proposed to be a useful diagnostic tool for differential diagnosis of pleural effusion. We investigated the pattern of ADA and its iscenzyme activities in various cause of pleural effusions to evaluate the diagnostic value of measuring ADA and its isoenzymes. Method: We measured total ADA and its isoenzyme activities in pleural fluid and serum from 54 patients with pleural effusion(25 tuberculous pleural effusion, 10 parapneumonic effusion, 14 malignant pleural effusion, 5 transudative pleural effusion), including 5 loculated tuberculous pleural effusions and 6 loculated parapneumonic effusions. Total ADA activity was measured by the spectrophotometric method and ADA2 isoenzyme activity was measured with same method using EHNA, potent inhibitor of ADA1 isoenzyme activity. Result: Total ADA activity of tuberculous pleural effusion was higher than malignant pleural effusion(p<0.01), but no significant difference was found between tuberculous pleural effusion and parapneumonic effusion(tuberculous pleural effusion: $148.9{\pm}89.9IU/L$, parapneumonic effusion: $129.0{\pm}119.4IU/L$, malignant pleural effusion: $48.7 {\pm}39.7IU/L$). Percentage of ADA2 activity to total ADA activity(ADA2%) of pleural effusion of tuberculous pleurisy was higher than parapneumonic effusion(p<0.05). but no significant difference was found between tuberculous pleural effusion and malignant pleural effusion(tuberculous pleural effusion: $57.2{\pm}10.7%$, parapneumonic effusion: $35.9{\pm}17.8%$, malignant pleural effusion: $60.7{\pm}4.1%$). In loculated pleural effusion, ADA2% of tuberculous pleural effusion was higher than parapneumonic effusion(tuberculous pleural effusion: $53.3{\pm}3.9%$, parapneumonic effusion: $27.8{\pm}7.9%$). Conclusion: Measurement of ADA isoenzyme activity is useful for differentiating tuberculous pleural effusion from parapneumonic effusion, especially in loculated pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.76 no.1
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• pp.15-22
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• 2014

Background: Apoptosis plays a role in the development of pleural effusion. Caspase-cleaved cytokeratin 18, a marker for epithelial cell apoptosis, was evaluated in pleural effusion. Methods: A total of 79 patients with pleural effusion were enrolled. The underlying causes were lung cancer (n=24), parapneumonic effusion (n=15), tuberculous effusion (n=28), and transudates (n=12). The levels of M30, an epitope of caspase-cleaved cytokeratin 18, were measured in blood and pleural fluids using enzyme-linked immunosorbent assay along with routine cellular and biochemical parameters. The expression of M30 was evaluated in the pleural tissues using immunohistochemistry for M30. Results: The M30 levels in pleural fluid were significantly higher in patients with tuberculosis ($2,632.1{\pm}1,467.3U/mL$) than in patients with lung cancer ($956.5{\pm}618.5U/mL$), parapneumonic effusion ($689.9{\pm}413.6U/mL$), and transudates ($273.6{\pm}144.5U/mL$; all p<0.01). The serum levels were not significantly different among the disease groups. Based on receiver operating characteristics analysis, the area under the curve of M30 for differentiating tuberculous pleural effusion from all other effusions was 0.93. In the immunohistochemical analysis of M30, all pathologic types of cancer cells showed moderate to high expression, and the epithelioid cells in granulomas showed high expression in tuberculous pleural tissues. Conclusion: Caspase-cleaved cytokeratin 18 was most prominently observed in tuberculous pleural effusion and showed utility as a clinical marker. The main source of M30 was found to be the epithelioid cells of granulomas in tuberculous pleural tissues.

• Tuberculosis and Respiratory Diseases
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• v.62 no.6
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• pp.499-505
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• 2007

Background: Triggering receptor expressed on myeloid cells 1 protein (TREM-1) is a cell surface molecule expressed on neutrophils and monocytes, and it plays an important role in myeloid cell-activated inflammatory response. The aim of this study was to investigate the diagnostic efficiency of soluble (s) TREM-1 in the patients who had pleural effusion from various causes. Methods: Forty-five patients with exudative pleural effusion were included in this study. The level of sTREM-1 was measured in both the serum and pleural fluids by immunoblot assay with using human-sTREM-1 antibody. Results: The pleural fluid sTREM-1 was significantly different in the three groups of exudative pleural effusion (p=0.011). Particularly, the patients with parapneumonic effusion were found to have significantly higher pleural fluid levels of sTREM-1 than patients with tuberculous (p<0.05) and malignant effusion, respectively (p<0.05). However, the serum sTREM-1 did not show a significant difference in the three groups. In order to evaluate the diagnostic utility of pleural fluid sTREM-1, the receiver operating characteristic (ROC) curve was constructed and the area under the curve (AUC) was 0.818 (p=0.001). Using a cutoff value of 103.5 pg/mL for the pleural fluid sTREM-1, the sensitivity and specificity were 73% and 81%, respectively, for differentiating parapneumonic effusion from tuberculous or malignant effusions. Conclusion: Pleural fluid sTREM-1 can be an additional marker for making the differential diagnosis of pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.57 no.1
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• pp.32-36
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• 2004

Background : The purpose of this study was to evaluate the usefulness of the pleural fluid carcinoembryonic antigen (CEA) and cytokeratin fragment 19 (CYFRA 21-1) tumor markers as complementary tools for the diagnosis of malignant pleural effusions. Patients and Methods : The levels of pleural and serum CEA and CYFRA 21-1 were prospectively assayed in 222 patients with pleural effusions (150 benign effusions, 57 bronchogenic carcinomas and 15 metastatic carcinomas). Results : The levels of pleural fluid CEA and CYFRA 21-1 in the malignant effusions were significantly higher than those in the benign effusions. With a specificity of 95%, the cut off values for the CEA and CYFRA 21-1 in pleural effusions were 5 and 89 ng/ml, respectively. The diagnostic sensitivities of the pleural fluid CEA and CYFRA 21-1 in malignant effusions were 72 and 54%, respectively, whereas using a combination of the two, the sensitivity increased to 87% (p<0.05). Conclusions : These findings suggest that a combination of the pleural fluid CEA and CYFRA 21-1 in pleural effusions can be useful in the diagnosis of malignant pleural effusions.

• Tuberculosis and Respiratory Diseases
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• v.71 no.5
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• pp.355-358
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• 2011

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a useful, safe diagnostic modality for evaluating mediastinal and hilar lymphadenopathy. We report a 51-year-old male who presented with a left renal mass and multiple pleural masses without lung parenchymal lesions. The pleural masses were thought to be metastatic tumors or malignant mesothelioma. The patient underwent two percutaneous needle biopsies of the pleural mass, but the specimens were insufficient for a histopathological diagnosis. Because one pleural mass was adjacent to the right main bronchus, we decided to perform EBUS-TBNA for the pleural mass. As a result, sufficient core tissue was obtained with no complications, and the histopathological findings were consistent with metastatic papillary renal cell carcinoma. To our knowledge, this is the first case of using EBUS-TBNA for a pleural mass.

• Tuberculosis and Respiratory Diseases
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• v.81 no.2
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• pp.106-115
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• 2018

Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (${\leq}14F$) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions (for which an immediate pleurodesis is planned). Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains. Chest tube insertion should be guided by imaging, either bedside ultrasonography or, less commonly, computed tomography. The so-called trocar technique must be avoided. Instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used. All chest tubes are connected to a drainage system device: flutter valve, underwater seal, electronic systems or, for indwelling pleural catheters (IPC), vacuum bottles. The classic, three-bottle drainage system requires either (external) wall suction or gravity ("water seal") drainage (the former not being routinely recommended unless the latter is not effective). The optimal timing for tube removal is still a matter of controversy; however, the use of digital drainage systems facilitates informed and prudent decision-making in that area. A drain-clamping test before tube withdrawal is generally not advocated. Pain, drain blockage and accidental dislodgment are common complications of small-bore drains; the most dreaded complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema. IPC represent a first-line palliative therapy of malignant pleural effusions in many centers. The optimal frequency of drainage, for IPC, has not been formally agreed upon or otherwise officially established.

• Tuberculosis and Respiratory Diseases
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• v.40 no.5
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• pp.584-594
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• 1993

Background: Among the respiratory diseases, there are a lot of cases of pleural effusion. The most common cause is tuberculosis. But the other cause such as lung malignancy is in an increasing tendency because of the development of diagnostic procedure, the decrease of the prevalence of the tuberculosis and the increase of the longevity. We need to know the accurate diagnosis as soon as possible for the correct therapy. Method: A clinical observation was made on 315 cases of pleural effusion seen at Pusan Adventist Hospital, from Jan, 1989 to Dec, 1992. For diagnostic procedure, thoracentesis, lymph node biopsy, bronchoscopy and percutaneous biopsy of the parietal pleura with Cope needle were performed. The following are parameters used in seperating the exudate from the transudate: pleural protein 3.0 g/dl, pleural protein/serum protein ratio 0.5, pleural LDH 200 IU, pleural LDH/serum LDH ratio 0.6, pleural cholesterol 60 mg/dl and pleural cholesterol/serum cholesterol ratio 0.3. Each parameters were compared, and misclassified rate and diagnostic efficiency were calculated. Results: The most common cause of exudate pleurisy was tuberculosis (82.3%) and malignancy was next (12.2%). The chief complaints of pleural effusion were noted as dyspnea (58.7%), chest pain (54.9%), coughing (50.2%) and fever (36.2%). Location of pleural effusion was noted as right side (51.4%), left side (41.3%) and both sides (7.3%). Amount of pleural effusion of the chest X-ray was minimum (46.8%), moderate (40.5%) and maximum (12.7%). Misclassified rates for each parameters in seperating the exudates from the transudates were as follows; protein: 5.2%, pleural protein/serum protein:7.6%, LDH: 13.9%, pleural LDH/serum LDH: 6.9%, cholesterol: 8.0%, pleural cholesterol/serum cholesterol: 5.6%. On the pleural biopsy, the tuberculosis granuloma was 60.8%, malignancy was 13.6%, infection was 2.3% and nonspecific inflammatory reaction was 23.3%. Conclusion: on the basis of the above results, the most common cause of exudative pleurisy was tuberculosis. We think that the plerual cholesterol/serum cholesterol ratio is the most useful supportive parameter in separating the exudates from the transudates. For accurate diagnosis, the pleural biopsy is the first procedure and repeated pleural biopsy of nonspedcific inflammatory reaction is required.

• Tuberculosis and Respiratory Diseases
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• v.76 no.1
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• pp.38-41
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• 2014

Immunoglobulin G4 (IgG4)-related disease is a newly recognized condition characterized by fibroinflammatory lesions with dense lymphoplasmacytic infiltration, storiform-type fibrosis and obliterative phlebitis. The pathogenesis is not fully understood but multiple immune-mediated mechanisms are believed to contribute. This rare disease can involve various organs and pleural involvement is even rarer. We report a case of IgG4-related disease involving pleura. A 66-year-old man presented with cough and sputum production for a week. Chest radiography revealed consolidation and a pleural mass at right hemithorax. Treatment with antibiotics resolved the consolidation and respiratory symptoms disappeared, but the pleural mass was unchanged. Video-assisted thoracoscopic surgery was performed. Histopathology revealed dense lymphoplasmacytic infiltration and storiform fibrosis with numerous IgG4-bearing plasma cells. The serum IgG4 level was also elevated. Further examination ruled out the involvement of any other organ. The patient was discharged without further treatment and there is no evidence of recurrence to date.