MR MR 4/3/144/3/14

Dressler’s syndrome &

pleural effusions

Dressler’s syndrome Dressler’s syndrome • AKA postpericardiotomy syndrome (PPCS) • Fever and pleuropericardial disease days or

months after cardiac injury i.e. combination of pleuritis and pericarditis

• Pathogenesis: An immune response to damaged cardiac tissue immune complexes deposit onto the pleura, lungs, and pericardium, eliciting an inflammatory response

• Timeline: typically 1+ week after myocardial injury• Sx: chest pain, pericardial rub, fever, leukocytosis,

pulmonary infiltrates, pleural effusions• Tx: aspirin or other NSAIDs. Colchicine is

sometimes given for primary prevention after cardiac surgeryo Prednisone, HOWEVER, in patients s/p MI there is a greater incidence of

ventricular aneurysm formation and free wall rupture

What else you should know about pleural What else you should know about pleural

effusionseffusionsDiagnosis Comment

Common Causes

Heart failure Most common cause of transudative effusion; diuresis can cause borderline exudative chemical characteristics

Atelectasis Small effusion caused by negative transpleural pressure

Hepatic hydrothorax Most are right-sided; occurs in 6%-12% of patients with end-stage liver disease and clinical ascites; can occur in the absence of ascites

Hypoalbuminemia Small bilateral effusions with evidence of generalized anasarca, from decreased intravascular oncotic pressure

Constrictive pericarditis Usually bilateral with normal heart size; 95% have jugular venous distention

Trapped lung Unilateral as a result of remote pleural inflammation and resultant unexpandable lung; caused by negative transpleural pressure

Uncommon Causes

Cerebrospinal fluid leak into pleural space (duropleural fistula)

Caused by trauma or thoracic spinal surgery

Urinothorax Unilateral effusion caused by ipsilateral obstructive uropathy; the only low-pH transudate

Iatrogenic Caused by a central venous catheter misdirected into the pleural space

Superior vena cava obstruction From acute systemic venous hypertension or lymphatic congestion

Peritoneal dialysis Massive effusion; develops within 48 hours of initiating dialysis due to dialysate crossing into the chest because of congenital or acquired defects

• No thoracentesis if < 1 cm*• Gradients if transudative

• TP > 3.1 g/dL OR Alb > 1.2 g/dL*• Exudative if • Pleural TP : Serum TP > 0.5 OR Pleural LDH

> 2/3 ULN • > 10,000 WBC typically suggests infection• Uncomplicated parapneumonic: influx of

PMNs and fluid that resolves with treatment

• Complicated parapneumonic : bacterial invasion drain for faster recovery & less risk of complications

• Empyema: Pus drainage• Other causes• Pancreatitis, PE, Subphrenic abscess, TB,

rheumatoid, lupus pleuritis • Eosinophilia: meds, fungi, parasites,

eosinophilic pneumonia, Churg-Strauss, benign asbestos pleural effusions

* Not always

Pleural fluid quizPleural fluid quiz• Adenosine deaminase• Triglycerides• Magic cut-off for pleural triglyceride level• NT ProBNP• % of caner positive cells after first thoracentesis • % of caner positive cells after second

thoracentesis • % of caner positive cells after third thoracentesis • Magic cut-off for pleural glucose• Magic cut-off for pleural pH

*you don’t tend to see a low pH in uncomplicated effusions

Other things to Other things to considerconsider

• Erosion of a central venous catheter through venous structures into the pleural space pleural fluid accumulation and mediastinal widening (mediastinal hygroma)

• Disruption of the thoracic duct or its intrathoracic lymphatic tributaries chylothorax

• Infectious mediastinitis : usually bilateral effusions. Managed with debridement and irrigation