• Tuberculosis and Respiratory Diseases
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• v.58 no.1
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• pp.5-10
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• 2005

Background : A pleural effusion is a common medical problem. Despite several diagnostic tests, 15-20% of pleural effusions go undiagnosed. The aim of this study was to evaluate the clinical characteristics and prognosis of a lymphocyte dominant exudative pleural effusion with a low adenosine deaminase (ADA), low carcinoembryonic antigen (CEA), negative cytology and negative acid fast bacilli (AFB) smear. Method : From Jan 2000 to Aug 2001, 43 patients with lymphocyte dominant exudative pleural effusions whose AFB smear and cytologic exam were negative, their pleural fluid ADA level was < 40 IU/L, and their CEA level was < 10 ng/mL were enrolled in this study. A retrospective analysis of the patients' medical records was carried out. Result : Among 31 of the 43 cases (72%), probable underlying diseases causing the pleural effusion were identified: 21cases of malignant diseases, 4 cases of liver cirrhosis, 2 cases of pulmonary tuberculosis, 1 case of end stage renal disease, 1 case of a chylothorax, 1 case of a post-CABG (coronary artery bypass graft) state, 1 case of a pulmonary embolism. No clinically suspected etiology was identified in the remaining 12 cases (28%). Of these 12 pleural effusions, 7 cases spontaneously resolved, 2 effusions resolved with antibiotics, and the other 2 cases were persistent. Conclusion : Lymphocyte dominant exudative pleural effusions with a low ADA, low CEA, negative cytological exam, and negative AFB smear, but without a definite cause might have a benign course and clinicians can observe them with attention.

• Tuberculosis and Respiratory Diseases
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• v.51 no.6
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• pp.559-569
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• 2001

Background : Pleural effusion is one of the most common clinical manifestations associated with a variety of pulmonary diseases such as malignancy, tuberculosis, and pneumonia. However, there are no useful laboratory tests to determine the specific cause of pleural effusion. Therefore, an attempt was made to analyze the various types of pleural effusion and search for useful laboratory tests for pleural effusion in order to differentiate between the diseases, especially between a malignant pleural effusion and a non-malignant pleural effusion. Methods : 93 patients with a pleural effusion, who visited the Severance hospital from January 1998 to August 1999, were enrolled in this study. Ultrasound-guided thoracentesis was done and a confirmational diagnosis was made by a gram stain, bacterial culture, Ziehl-Neelsen stain, a mycobacterial culture, a pleural biopsy and cytology. Results : The male to female ratio was 56 : 37 and the average age was $47.1{\pm}21.8$ years. There were 16 cases with a malignant effusion, 12 cases with a para-malignant effusion, 36 cases with tuberculosis, 22 cases with a para-pneumonic effusion, and 7 cases with transudate. The LDH2 fraction was significantly higher in the para-malignant effusion group compared to the para-pneumonic effusion group [$30.6{\pm}6.4%$ and $20.2{\pm}7.5%$, respectively (p<0.05)] and both the LDH1 and LDH2 fraction was significantly in the para-malignant effusion group compared to those with tuberculosis [$16.4{\pm}7.2%$ vs. $7.6{\pm}4.7%$, and $30.6{\pm}6.4%$ vs.$17.6{\pm}6.3%$, respectively (p<0.05)]. The pleural effusion/serum LDH4 fraction ratio was significantly lower in the malignant effusion group compared to those with tuberculosis [$1.5{\pm}0.8$ vs. $2.1{\pm}0.6$, respectively (p<0.05)]. The LDH4 fraction and the pleural effusion/serum LDH4 fraction ratio was significantly lower in the para-malignant effusion group compared to those with tuberculosis [$17.0{\pm}5.8%$ vs. $23.5{\pm}4.6%$ and $1.3{\pm}0.4$ vs. $2.1{\pm}0.6$, respectively (p<0.05)]. Conclusion : These results suggest that the LDH isoenzyme was the only useful biochemical test for a differential diagnosis of the various diseases. In particular, the most useful test was the pleural effusion/serum LDH4 fraction ratio to distinguish between a para-malignant effusion and a tuberculous effusion.

• Tuberculosis and Respiratory Diseases
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• v.40 no.5
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• pp.468-473
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• 1993

Background: Recent advance in video technology, endoscopic equipments, and surgical techniques have expanded the use of thoracoscopy from diagnosis of the pleural diseases to treatment of the various intrathoracic diseases. Video Assisted Thoracoscopic Surgery(VATS) is a pretty new and fascinating thoracic surgical modality, and so we present our early VATS resuls. Methods: Using Video Thoracoscopic techniques in 30 patients for 10 months from July 1992 to April 1993, we had performed a variety of procedures. These incuded (1) bleb resections in 18 patients (19 cases), (2) mediastinal tumor excision in 4, (3) lung biopsies for parenchymal pulmonary disease in 3, (4) pleural biopasies in 3, (5) pleural tumor excision in 1, (6) and pleuropericardial window in 1. Results: There were no mortality associated with the procedures. We had minor 8 complications; prolonged air leak in 3 patients, prolonged serous drainage in 2, recurrence of pneumothorax in 1, Honer's syndrome in 1, and hoarseness in 1 patient. None of the 30 patients had reverted to the conventional full thoracotomies. Mean postoperative hospital stay of non-complicated pneumothoraces was about 5 days, which was a little shorter than conventional thoracotomy group. Conclusion: Though we had somewhat higher postoperative complication rate due to lack of experiences in the begining, we were able to convince that VATS had benifical value for patients; lesser postoperative pain, shorter hospitalization, quicker recovery time, and cosmetically superior scar. The role of VATS can be expanded to the diagnosis and treatment of various thoracic diseases, even to the cardiovascular diseases, with satisfactory outcome and less postoperative morbidity.

• Tuberculosis and Respiratory Diseases
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• v.57 no.2
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• pp.132-137
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• 2004

Background : The measurement of adenosine deaminase(ADA) level in pleural fluid is useful in the diagnosis of tuberculous(TB) pleural effusion. However, ADA is also elevated in other diseases such as malignancy, bacterial infections, empyema, and collagen vascular disease, ADA alone has limited value. The object of this study is to determine diagnostic usefulness of the combined use of ADA value with lymphocyte/neutrophil ratio(L/N ratio) rather than the use of ADA alone. Method : We evaluated 198 patients(age=$55.9{\pm}12.9$, M/F=2.7:1) with pleural effusion who had admitted in Gyeong-sang National University Hospital from Jan. 1999 to Dec. 2001. retrospectively. Patients were divided into four diagnostic groups: TB pleural effusion(n=91), parapneumonic effusion(n=65), malignant effusion(n=21), and transudative effusion(n=13). The ADA level, differential cell count, biochemistry, cytology, and microbiology of each diagnostic groups were evaluated. The sensitivity, specificity, negative predictive value(npv), positive predictive value(ppv) and efficiency were calculated at each ADA values and combined ADA value with various L/N ratios. Results : The ADA level in TB pleural effusion was significantly higher than that of parapneumonic effusion, malignant pleural effusion, and transudative effusion(p<0.05). Sensitivity, specificity, ppv, npv and efficiency at $ADA{\geqq}50$ IU/L in the diagnosis of TB pleural effusion were 89.0%, 82.2%, 81.0%, 89.8% and 85.5% respectively. When $ADA{\geqq}50$ IU/L was combined with lymphocyte/neutrophil $ratio{\geqq}0.75$, sensitivity, specificity, ppv, npv, and efficiency were 83.5%, 96.3%, 95.0%, 87.9% and 90.5% respectively. Specificity, ppv and efficiency were increased with combination of ADA value and L/N ratio. Conclusion : Combination of ADA value and L/N ratio in pleural effusion is more useful than ADA value alone in the diagnosis of TB pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.52 no.6
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• pp.608-615
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• 2002

Background : ADA is an enzyme found in most cells, and is involved in purine metabolism, but its chief role concerns the proliferation and differentiation of lymphocytes, especially T-lymphocytes. For that reason ADA has been looked on as a marker of cell-mediate immunity, which is the key mechanism of the tuberculous pleural effusion. Thus, the pleural fluid ADA activity is increased in the tuberculous pleural effusion. Age associated immune decline is characterized by decreases in both B and T-lymphocyte function and the former may be largely a result of the latter. Therefore, the pleural fluid ADA activity would be lower in old rather than in young, patients with tuberculous pleural effusion. We studied the relationship between age, and pleural fluid ADA activity, in patients with tuberculous pleural effusion. Materials and Methods : In the 46 patients with tuberculous pleural effusion enroll in this study, the pleural fluid ADA activities were measured by means of an automated kinetic method. Results : The mean age of the patients was $53.0{\pm}22.0$ years, with a male to female ratio of 30:16. The patients were divided into two groups, young patients, regarded as < 65 and old regarded as ${\geq}65$ years with 28 and 18 patients, respectively. The pleural fluid ADA activity in both groups show significant differences : $99.4{\pm}22.6$ IU/L(young patients) Vs. $75.8{\pm}30.9$ IU/L(old patients)(p<0.05), but a negative correlation with age (r=-0.311, p<0.05). Conclusion : Although pleural fluid ADA activity was not adequately increased, tuberculous pleural effusion, in older patients, would have to be considered clinically suspicious tuberculous pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.55 no.4
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• pp.353-360
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• 2003

Background : Although most patients with tuberculous pleurisy respond well to anti-tuberculous drugs, some are known to progress into severe pleural thickening which needs decortication despite adequate anti-tuberculous treatment. Therefore, the purpose of this study was to identify factors associated with the development of severe pleural thickening in patients who finally underwent pleural decortication in tuberculous pleurisy. Patients and Methods : From retrospective medical records review, 121 patients initially diagnosed as tuberculous pleurisy without initial pleural fluid loculation were enrolled between January 1998 and December 2002. They were separated into two groups: 85 patients in group 1 who improved by anti-tuberculous drugs only, and 36 patients in group 2 who had progressed into pleural adhesion and finally underwent pleural decortication despite adequate (more than 6 months) anti-tuberculous treatment. Results : Males were more common in group 2 (M/F=31/5) than in group 1 (M/F=53/32) (p=0.010). Group 2 patients tended to have lower pleural fluid glucose level ($58{\pm}4$ mg/dL) than group 1 ($89{\pm}3$ mg/dL) (p=0.001) and higher pleural fluid adenosine deaminase level ($86{\pm}5$ IU/L) than group 1 ($76{\pm}3$ IU/L), (p=0.038). There were no significant differences in age, symptom duration, pleural fluid amount, or pleural fluid LDH level between groups 1 and 2. Conclusions : There was a relative risk of tuberculous pleurisy progression into severe pleural thickening which needed decortication in the case of male patients, low pleural fluid glucose or high adenosine deaminase level. But further, large-scale, prospective studies should be investigated.

• Tuberculosis and Respiratory Diseases
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• v.45 no.2
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• pp.397-403
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• 1998

Background: Little information is available concerning the value of bronchoscopy in patients with a lymphocytic exudative pleural effusion in which percutaneous pleural biopsy have been regarded as cornerstone in investigating the etiology. Recently, a few reports suggest that bronchoscopy may be more effective diagnostic method in patients with unexplained pleural effusion accompanied by hemoptysis or other roentgenographic abnormalities, such as mass, infiltrate, atelectasis. Method: Mter initial examinations of sputum and pleural fluid through thoracentesis in 112 patients(male 75 cases, female 37 cases, mean age 53.2 years) who were admitted for evaluation of the cause of pleural effusion, we performed bronchoscopy and closed pleural biology in most patients with undiagnosed lymphocytic exudate and compared the diagnostic yield of both invasive methods according to hemoptysis or other roentgenographic abnormalities, and investigated the sole diagnostic contribution of bronchoscopy. Results: Tuberculosis(57 cases, 51%) was the most common cause of pleural effusion. Percutaneous pleural biopsy showed more diagnostic yield than bronchoscopy regardless of presence or absence of other clinical or radiologic abnormalities. In 25 cases with unknown etiology after pleural biopsy, additional diagnostic yield by bronchoscopy was 36 % (4/11) in patients with associated features and only 7 % (1/14) with lone effusion, and, as the sole mean for diagnsosis in all patients with pleural effusion, was only 4.5%(5/12). Conclusion : In a region of high prevalence of tuberculosis as a cause of pleural effusion, percutaneous pleural biospy is more effective method when invasive method is required for confirmative diagnosis of unexplained lymphocytic exudative pleural effusion, and bronchoscopy is unlikely to aid in the diagnosis of lone pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.61 no.5
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• pp.456-462
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• 2006

Background: Differential diagnosis is very important in patients with pleural effusions. A few studies on the etiologies of massive pleural effusions have been reported, but these were conducted in different decades and locations. In the present study, the etiologic spectrum of massive pleural effusions in Korea, were evaluated through an investigation at one university hospital. Methods: Retrospective chart reviews were performed in patients having undergone thoracentesis between July 2002 and July 2005. Pleural effusions were deemed to be massive if they occurred in two thirds or more of one hemithorax. The etiologies of massive pleural effusions, pleural fluid findings, serum laboratory findings, and sputum and pleural fluid cytologies were compared. Results: Of 298 pleural effusions cases, 41 (13.8%) had massive pleural effusions. The most frequent causes of massive pleural effusions were malignancy (19; 46.3%) followed by tuberculosis (15; 36.6%), parapneumonic effusion (4; 9.8%) and transudate (3; 7.3%). Compared with massive benign effusions, patients with massive malignant pleural effusions were more likely to have lower adenosine deaminase (ADA) activity, a higher amylase level and higher RBC count in their pleural fluids. Also, compared with non-tuberculosis effusions, patients with massive tuberculous pleural effusions were more likely to have lower RBC and neutrophil counts, but a higher lymphocyte count, adenosine deaminase (ADA) activity and protein level. Conclusion: The most common etiologies of massive pleural effusions in Korea are malignancy and tuberculosis. A high ADA content favors a tuberculous condition, while bloody effusions with a relatively lower ADA content. favors malignancy. The proportion of tuberculosis in massive pleural effusions was higher than in previous reports.

• Journal of Chest Surgery
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• v.43 no.4
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• pp.399-403
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• 2010

Background: Video-Assisted Thoracic Surgery can be performed with the lung collapsed. During the procedure, pleural adhesion may result in lung injury, bleeding, and thoracotomy conversion. Identifying the presence of pleural adhesion before surgery can make it easy to plan trocar introduction and perform the procedure. Material and Method: Between June 2009 and November 2009, we performed ultrasound in 24 patients to detect pleural adhesion before surgery and compared the results with the operative findings. We primarily examined the lateral chest, where the trocar would be inserted, and, occasionally, the anterior or posterior chest. Result: Patient diseases were: 6 hyperhidroses, 8 interstitial lung diseases, 5 lung cancers, 2 mediastinal tumors, 1 peripheral pulmonary embolism, 1 metastatic lung cancer, and 1 sarcoidosis. Of the 22 patients who did not have pleural adhesions on ultrasound, four revealed mild adhesions not related to the trocar insertion sites. However, ultrasound showed pleural adhesions in two patients, consistent with the operative findings. There was no air leak or thoracotomy conversion related with trocar insertion. Conclusion: Ultrasound requires only a few minutes to detect the presence of the pleural adhesion and was very useful in identifying the pleural adhesion before VATS.

• Tuberculosis and Respiratory Diseases
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• v.75 no.6
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• pp.244-249
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• 2013

Background: Conventional biomarkers cannot always establish the cause of pleural effusions; thus, alternative tests permitting rapid and accurate diagnosis are required. The primary aim of this study is to assess the ability of pentraxin-3 (PTX3) in order to diagnose the cause of pleural effusion and compare its efficacy to that of other previously identified biomarkers. Methods: We studied 118 patients with pleural effusion, classified as transudates and exudates including malignant, tuberculous, and parapneumonic effusions (MPE, TPE, and PPE). The levels of PTX3, C-reactive protein (CRP), procalcitonin (PCT) and lactate in the pleural fluid were assessed. Results: The levels of pleural fluid PTX3 were significantly higher in patients with PPE than in those with MPE or TPE. PTX3 yielded the most favorable discriminating ability to predict PPE from MPE or TPE by providing the following: area under the curve, 0.74 (95% confidence interval, 0.63-0.84), sensitivity, 62.07%; and specificity, 81.08% with a cut-off point of 25.00 ng/mL. Conclusion: Our data suggests that PTX3 may allow improved differentiation of PPE from MPE or TPE compared to the previously identified biomarkers CRP and PCT.