Introduction
Pleural effusion is defined as accumulation of fluid in the pleural space. The condition can have various causes and may be a life-threatening (
1). The type of the effusion is classified into transudate and exudate based on the amount of protein, lactate dehydrogenase (LDH), and some other factors in the fluid. Increased vascular permeability of the lungs can cause an exudative effusion. A complete evaluation for the possible cause in exudative effusion is essential. The main causes of an exudative fluid are infections (parapneumonic, tuberculosis pleurisy, fungal, and viral infections), malignancies, autoimmune inflammatory diseases, pulmonary embolism, pancreatitis, and some drugs (
2). However, the main cause of exudative pleural effusion and empyema in children is bacterial infection (
3,
4), mostly caused by
Streptococcus pneumonia (5, 6). Malignancy is a rare cause of pleural effusion in children. Lymphoma is the most common malignancy associated with pleural effusion. About 5% of patients with Hodgkin's or non-Hodgkin's lymphoma will develop a pleural effusion. In addition, T-cell lymphoblastic leukemia can also cause a malignant pleural effusion. Common symptoms of pleural effusion are dyspnea, cough, and chest pain that are more severe in effusions with greater volumes. Respiratory distress is an important symptom that needs urgent management (
2). Here, we present a 2.5-years-old boy with acute fever, one-sided pleural effusion, and poor response to the insertion of chest tube.
CASE PRESENTATION
A 2.5-year-old boy was admitted to the pediatric infectious ward in Taleghani Hospital of Gorgan, northeast of Iran, with a history of fever starting from a week ago. He was the third child, with a normal development, and no history of previous admission. There was no history of suspected contact and recent travel. He had no history for allergic reactions or hyperreactive airway disease. In physical examination, he had multiple bilateral, enlarged lymph nodes less than 0.5 cm in diameter in his neck. Right shift of heart and mediastinum, alveolar opacity in the left side, and fading of diaphragmatic border was reported in an upright chest X-ray and a possibility of left side pleural effusion was raised. SARS-CoV-2 test (RT-PCR) of nasopharyngeal swab was negative. In pleural sonography, massive accumulation of fluid was reported in the left pleural space with floating particles, and heart and mediastinum had been shifted to the right. Intravenous (IV) ceftriaxone and vancomycin as well as IV fluid treatment was started. The temperature w:as char:ted and fever was controlled with acetaminophen. A left sided chest tube was inserted by a pediatric surgeon on the third day of admission, and the aspirated fluid sample was sent to laboratory for tuberculosis and other possible bacterial infections, which were reported as negative.
Characteristics of an exudate effusion were confirmed. Analysis of the pleural fluid is shown in (
table 1).
Table 1. Analysis of the pleural fluid the patient
Variable |
Amount |
Normal range |
Glucose (mg/dl) |
20 |
The same as that of plasma |
Protein (g/dl) |
3.8 |
1.5 |
WBC
(cells/mm3) |
2300 |
PMN:35% |
<1700 consisting of 75% macrophage ,23% lymph and 2% mesothelial |
Lymphocyte:65% |
RBC
(cells/mm) |
180000 |
0 |
LDH (U/l) |
1910 |
<200 |
WBC: White blood cell, RBC: Red blood cell, LDH: Lactate dehydrogenase, PMN: polymorphonuclear leukocytes
(
Table 2) shows the blood biochemical parameters that were normal during the hospitalization.
Table 2. The analysis of blood biochemical parameters
Parameter |
Day 1 |
Day 3 |
Day 5 |
Day 8 |
Day 12 |
Normal range |
WBC (mm) |
20000 |
33600 |
22300 |
36700 |
38900 |
4000-10000 |
Neutrophil |
15600 |
20832 |
11819 |
14680 |
15560 |
60% |
Lymphocyte |
4400 |
11088 |
8920 |
22020 |
21395 |
40% |
Hemoglobin (g/dl) |
10.3 |
10 |
9.9 |
9.9 |
10 |
12-14 |
Hematocrit (%) |
32 |
30.5 |
29.7 |
29.7 |
31.4 |
26-32 |
Platelet (per µl) |
596000 |
356000 |
384000 |
245000 |
222000 |
150000-450000 |
ESR (mm/hour) |
45 |
52 |
42 |
20 |
18 |
<20 |
CRP |
|
Negative |
|
Negative |
|
Negative |
LDH (U/L) |
|
|
2040 |
1582 |
|
500-700 |
ESR: Erythrocyte sedimentation rate, CRP: C-reactive protein, LDH: Lactate dehydrogenase
After the insertion of chest tube, fever and the amount of pleural fluid reduced and resolved completely after a few days. Three days later, fever relapsed and the amount of the pleural fluid increased. The second RT-PCR test was negative for SARS-CoV-2. Second chest tube was inserted and pleural tissue samples were sent for histopathologic analysis. Analysis of the pleural fluid was in favor of empyema and suspected for superimposed infections. Fibrinolytic was prescribed at three consecutive doses through chest tube and fever ended.
A spiral CT-scan without contrast was done after the insertion of the chest tube, and a bilateral mosaic attenuation, left sided pleural effusion about 100 cc, and subcutaneous emphysema in the left hemithorax and cervical region were detected (
Figure 1).