Melissa Wussow knew something was wrong when she started losing weight during her 29th week

of pregnancy. As it turns out Melissa's baby needed a risky surgery that came with a 30-percent chance of survival. "In a normal baby, there would be no black inside the chest," says Dr. Norman Davies, pointing out the danger on an ultra sound from last December when Wussow started having complications. That black spot was a half cup of fluid that shouldn't have been there, it was pushing baby Ava's heart and lungs into the left side of her chest and keeping them from developing normally. "When lungs are compressed, they don't develop as well as they should," adds Dr. Davies, who works at Mayo Clinic. On December 29, 2010 doctors told Melissa they'd have to induce labor when she was just 29 weeks into her pregnancy. "It was terrifying because at that point they weren't sure if she was even going to make it a day or two," recalls Wussow. "They were just saying what condition she would be like when she came and what to expect," she adds. But Dr. Davies decided to try a risky procedure that involved using a small shunt, a few inches long and inserting it into Ava's chest while she was still in her mother's womb in hopes of releasing the fluid. The surgery ended up working and Ava was born on February 20, 2011. Looking at her healthy baby today Melissa only has one thing on her mind, "she's a complete miracle, it's amazing." Ava's condition is called fetal pleural efusion, it only happens once in every 30,000 pregnancies and now doctors at Mayo Clinic have created a prototype that serves as a model to help young doctors learn how to perform in-utero fetal pleural effusion surgery. "As soon as the fluid got out, her lungs inflated again and developed perfectly normal." Pleural effusion

A pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. Causes Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal, excessive collection of this fluid. Two different types of effusions can develop:

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Symptoms

Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by increased pressure in, or low protein content in, the blood vessels. Congestive heart failure is the most common cause. Exudative effusions are caused by blocked blood vessels, inflammation, lung injury, and drug reactions.

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Chest pain, usually a sharp pain that is worse with cough or deep breaths Cough Fever Hiccups Rapid breathing Shortness of breath

Sometimes there are no symptoms. Exams and Tests During a physical examination, the doctor will listen to the sound of your breathing with a stethoscope and may tap on your chest to listen for dullness. The following tests may help to confirm a diagnosis:

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Treatment

Chest CT scan Chest x-ray Pleural fluid analysis (examining the fluid under a microscope to look for bacteria, amount of protein, and presence of cancer cells) Thoracentesis (a sample of fluid is removed with a needle inserted between the ribs) Thoracic CT Ultrasound of the chest

Treatment aims to:

Remove the fluid

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Prevent fluid from building up again Treating the cause of the fluid buildup

Therapeutic thoracentesis may be done if the fluid collection is large and causing chest pressure, shortness of breath, or other breathing problems, such as low oxygen levels. Removing the fluid allows the lung to expand, making breathing easier. Treating the cause of the effusion then becomes the goal. For example, pleural effusions caused by congestive heart failure are treated with diuretics (water pills) and other medications that treat heart failure. Pleural effusions caused by infection are treated with appropriate antibiotics. In people with cancer or infections, the effusion is often treated by using a chest tube for several days to drain the fluid. Sometimes, small tubes can be left in the pleural cavity for a long time to drain the fluid. In some cases, the following may be done:

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Chemotherapy Putting medication into the chest that prevents fluid from building up again after it is drained Radiation therapy Surgery

Outlook (Prognosis) The expected outcome depends upon the underlying disease. Possible Complications

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A lung that is surrounded by excess fluid for a long time may be damaged. Pleural fluid that becomes infected may turn into an abscess, called an empyema, which will need to be drained with a chest tube. Pneumothorax (air in the chest cavity) can be a complication of the thoracentesis procedure.

When to Contact a Medical Professional Call your health care provider if you have symptoms of pleural effusion. Call your provider or go to the emergency room if shortness of breath or difficulty breathing occurs immediately after thoracentesis.

ABSTRACT The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of -interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.

Fetal pleural effusion: In the fetus, excess fluid between the two membranes (the pleurae) that envelop the lungs. The pleural effusion may be unilateral (in one lung) or bilateral (in both lungs) and it may be an isolated finding in an otherwise normal fetus or be associated with generalized edema (hydrops). If untreated, fetal pleural effusion often causes severe, sometimes fatal, respiratory insufficiency in the neonatal period. Treatment is by the prenatal insertion of a thoracoamniotic shunt (to shunt the pleural effusion into the amniotic fluid). Survival after this procedure is over 90% in fetuses with isolated pleural effusion and about 50% in those with associated hydrops.

Fetal pleural effusion refers to a nonspeci c accumulation of uid in the pleural space. In newborn infants,pleural effusion is de ned as chylothorax when the uid contains more than 1.1 mmol/L tryglicerides (with oral fat intake), and has a lymphocyte proportion exceeding 80% (Buttiker et al., 1999). Since the fetus is not fed in utero and the mean percentage of lymphocytes in the blood of normal fetuses is normally >80% (Poblete et al., 2001), these parameters cannot be used prenatally,hence it is more pertinent to de ne any accumulation of uid in the fetal thorax as hydrothorax. Fetal pleural effusion is a rare condition, whose incidence (reported more than 15 years ago) of 1/10 000 1/15 000 pregnancies is still generally accepted (Longaker et al, 1989). At prenatal ultrasonography, it appears as a unilateral or bilateral anechoic space in the thorax, surrounding the lungs. The clinical course varies from spontaneous resolution to a progressive increase and the development of hydrops and polyhydramnios, with a high risk of preterm delivery and in utero death (Aubard et al., 1998). If severe and long-standing, it has the effect of a space occupying lesion, impeding normal lung development, with the risk of pulmonary hypoplasia and neonatal death (Castillo et al., 1987). The optimal approach to prenatal management is stilla matter of debate (Knox et al, 2006), given that the natural course of the disease can vary, but there is general consensus that pleural effusion is a serious condition with a high rate of perinatal morbidity and mortality, making it advisable in selected cases to offer prenatal therapy (Weber and Philipson, 1992)

The current update in Pleural Effusions reviews the past year s most in uential articles relevant to pulmonologists. They present possible new diagnostic approaches for pleural effusions secondary to heart failure (HF), infections or malignancies by the application of certain biomarkers and imaging techniques. A summary of changes that clinicians can implement on the basis of this research is provided in the Table 1.Detection of pleural effusions by physical examinationThe bedside determination of the presence of pleural effusions may identify patients who require diagnostic imaging. A metaanalysis addressed the diagnostic accuracy of the physical examination for pleural effusion using chest radiograph or computed tomography (CT) scan as the reference standard (1). To achieve this objective, the authors identi ed 310 potential studies, of which only 5, totaling 934 patients, met the inclusion criteria. Of the 8 physical examination maneuvers evaluated in the included studies, the presence of dullness to conventional percussion (summary positive likelihood ratio-LR-8.7) and asymmetric chest expansion (positive LR 8.1) argued convincingly for the diagnosis of pleural effusion. In contrast, the absence of reduce tactile vocal fremitus reduced the probability of pleural effusion (negative LR 0.21). These signs should guide clinical teaching and performance of the clinical examination for detecting pleural effusion. Pleural effusions secondary to diseases of the heartThe diagnosis of pleural effusions resulting from HF is usually made clinically and supported by pleural uid is examined. However, the pleural nding a transudate, according to Light s criteria, when

uid from approximately 20%of patients with HF may ful ll Light s criteria for an exudate. Mislabeled transudates

are particularly likely in patients receiving diuretics or in those whose pleural uid red blood cell count is greater than 10,000/mm3 Traditionally, it has .been proposed that an albumin gradient (serum albuminpleural uid albumin) >1.2 g/dL or a protein gradient > 3.1 g/dL be used to identify these misclassi ed transudates. In the last few years, it has become apparent that the measurement of natriuretic peptides, either NT-proBNP or BNP, help to diagnose HF. One study has recently evaluated whether the pleural uid levels of BNP or NT-proBNP can be used to make the diagnosis of HF. And, if these natriuretic peptides allow better categorization of cardiac effusions misclassi ed by Light s criteria than do the albumin or protein gradients (2). NT-proBNP > 1300 pg/mL performed better than BNP > 115 pg/mL for discriminating 90 cardiac effusions from 91 non-cardiac effusions (AUC 0.96 vs 0.90, respectively). In addition, NT-proBNP correctly classi ed 90% of mislabeled cardiac effusions, as compared with BNP (70%) or the protein (50%) or albumin (75%) gradients. Therefore, NT-proBNP should be measured whenever a suspected cardiac effusion meets the exudative criteria.