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A Patient With Effusion Undergoing Pleural Biopsy

2018; Elsevier BV; Volume: 154; Issue: 2 Linguagem: Inglês

10.1016/j.chest.2018.02.041

1931-3543

Maged Hassan, Maaz Rana, Najib M. Rahman,

Amoebic Infections and Treatments

A 59-year-old woman presented with acute right-sided chest pain, dry cough, and dyspnea. Initial blood workup revealed leukocytosis with neutrophil predominance. Her D-dimer levels were elevated. A CT pulmonary angiography ruled out the presence of pulmonary embolism but revealed right-sided partially encysted pleural effusion associated with pleural thickening and bilateral multifocal lung consolidations (Fig 1). A sample of the pleural fluid was aspirated, and physically it was yellowish and slightly turbid. Biochemical analysis of the pleural aspirate showed it to be an exudate with a glucose level of 43.2 mg/dL and a lactate dehydrogenase level of 1,286 International Units/L. Bacterial culture and smear for acid-fast bacilli returned negative. Given the possibility of pleuropulmonary TB and the nonconclusive test results, an ultrasound-guided cutting-needle pleural biopsy was conducted. Ultrasound confirmed the presence of effusion and lung consolidation (Fig 2, star and arrowhead, respectively). In the routine preprocedural scan, Doppler examination of the intercostal space where the biopsy was planned did not detect any unhidden intercostal vessels. After the second needle biopsy, a plume of echogenicity was seen to arise from the site of pleural puncture (Video 1). Question: What does the video show and what are the next steps? Answer: At the center of the image in Video 1, echogenic shadows are seen propagating from a point at the deepest part of the pleura, which is very suggestive of bleeding from the parietal pleura. Doppler examination confirmed pleural bleeding. Finger external compression on the biopsy site was performed for 2 min, and subsequent ultrasound examination confirmed that the bleeding had stopped. A globular echogenic thrombus was noted at the bleeding site (Fig 3, hollow arrow). We think formed thrombus assumed such a conformation because of the presence of fine septations in the pleural fluid (Fig 3, solid arrow), which likely permitted tamponade of the bleeding site. To confirm this, a few milliliters of agitated saline were injected into the thrombus via a Tuohy needle. The echogenic air bubbles did not float into the adjacent fluid but rather remained confined inside the thrombus, confirming the presence of fine septations, likely contributing to limitation of blood spillage into the pleural cavity, therefore creating thrombus subsequently tamponading the site of bleeding (Video 2). Ultrasound-guided pleural biopsy is a sensitive test to diagnose pleural disease, particularly in TB where the pleura is diffusely affected.1Koegelenberg C.F. Irusen E.M. von Groote-Bidlingmaier F. Bruwer J.W. Batubara E.M. Diacon A.H. The utility of ultrasound-guided thoracentesis and pleural biopsy in undiagnosed pleural exudates.Thorax. 2015; 70: 995-997Crossref PubMed Scopus (41) Google Scholar In complex pleural spaces—a situation similar to the presented case—ultrasound-guided pleural biopsy is preferred to medical thoracoscopy, which is challenging in the presence of extensive adhesions and where the lung is expected to be tethered to the chest wall. It has been shown that ultrasound-guided cutting needle biopsy has good sensitivity in patients who were planned for thoracoscopic pleural biopsy but the lung failed to sufficiently collapse, therefore making thoracoscopy unsafe.2Hallifax R.J. Corcoran J.P. Ahmed A. et al.Physician-based ultrasound-guided biopsy for diagnosing pleural disease.Chest. 2014; 146: 1001-1006Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar In this case, the presence of effusion encystment was highly suggestive of failure of thoracoscopy. Ultrasound-guided cutting needle pleural biopsy is a generally safe technique with good yield. Besides pain and infection, intrapleural bleeding is among the commonly reported complications.3Psallidas I. Helm E.J. Maskell N.A. et al.Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention.Thorax. 2015; 70: 802-804Crossref PubMed Scopus (10) Google Scholar Proper antiseptic techniques, generous anesthesia, and careful preprocedural planning are necessary to avoid such complications in most of the situations. In particular, meticulous inspection of the targeted intercostal space for the intercostal artery using Doppler technique is of utmost importance.4Lee R.K. Griffith J.F. Ng A.W. Sitt J.C. Sonography of the chest wall: a pictorial essay.J Clin Ultrasound. 2015; 43: 525-537Crossref PubMed Scopus (8) Google Scholar Ultrasound aids in choosing the biopsy site when pleural involvement is focal. Where there is diffuse pleural involvement, biopsies are usually taken at the midaxillary or posterior axillary lines where the intercostal bundle coursing the space is typically hidden below the above rib. It has been shown, however, that the course of the intercostal artery is variable between individuals, particularly in older adults.5Helm E.J. Rahman N.M. Talakoub O. Fox D.L. Gleeson F.V. Course and variation of the intercostal artery by CT scan.Chest. 2013; 143: 634-639Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Many of the patients who require therapeutic pleural interventions are among this age group, which makes routine ultrasound inspection of the intercostal space before needle puncture a valuable practice.6Carney M. Ravin C.E. Intercostal artery laceration during thoracocentesis: increased risk in elderly patients.Chest. 1979; 75: 520-522Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Real-time ultrasound guidance during needle insertion and biopsy acquisition is very useful both for safe execution of the procedure and accurate sampling. Studies have shown that chest physicians performing thoracic ultrasound are competent in delineating aberrant and vulnerable arteries when ultrasound examination is conducted before invasive pleural procedures (Fig 4A).7Salamonsen M. Dobeli K. McGrath D. et al.Physician-performed ultrasound can accurately screen for a vulnerable intercostal artery prior to chest drainage procedures.Respirol Carlton Vic. 2013; 18: 942-947Crossref PubMed Scopus (38) Google Scholar In the event of suspected bleeding, Doppler examination can easily prove or rule out such a complication. A unidirectional Doppler flow is seen to arise from a distinct point in the pleura (Fig 4B) (Discussion Video). In the presented case, the bleeding was inconsequential, in part because of the avoidance of large vessels. The injured vessel was probably a small branch. Postbiopsy pleural bleeding is seen fairly commonly and can potentially lead to life-threatening hemorrhage because the pleural space can accommodate > 4 L of fluid without effective tamponading, which theoretically can lead to exsanguination.8Corcoran J.P. Psallidas I. Ross C.L. Hallifax R.J. Rahman N.M. Always worth another look? Thoracic ultrasonography before, during, and after pleural intervention.Ann Am Thorac Soc. 2016; 13: 118-121Crossref PubMed Scopus (11) Google Scholar Fortunately, this occurs very rarely. Direct compression on the bleeding site is sometimes sufficient for control of bleeding, and septated pleural spaces are probably less likely to result in large volume bleeds. More brisk bleeding occasionally is seen, and ultrasound can help pickup such bleeding and expedite management. Such bleeding requires either coiling of the bleeding intercostal artery by interventional radiology9Chemelli A.P. Thauerer M. Wiedermann F. Strasak A. Klocker J. Chemelli-Steingruber I.E. Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries.J Vasc Surg. 2009; 49: 1505-1513Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar or formal surgical repair via thoracotomy. 1.In experienced hands, ultrasound-guided cutting needle biopsy is a sensitive test to diagnose pleural diseases.2.Ultrasound examination is indispensible for safe execution of invasive pleural procedures.3.Routine Doppler examination of the targeted intercostal space improves the safety of pleural procedures and guards against inadvertent intercostal artery laceration.4.Pleural bleeding can potentially be fatal. Timely identification by ultrasound is essential for proper and prompt management. Financial/nonfinancial disclosures: None declared. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the videos, see the online article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1NzZiODJjNzg4YmZhY2IxZjY5NjNhMjA0MDBmMmUzMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjMzNTQzNTU3fQ.SL16N5SNC-1z8I1aZZ3tJ0ccnxn4SKXLHHMYjFX1nMVjwbqjLzJosF9XNNlRFNBw2yIpa8qvIOvSAgwzlGxLEnqzZqwb3FH8J3pjNnzviP7-ZzY5-2wJRo6xqcznLq5T7w0Z6jaaXFK2JRYixrWlNcx3N6u6alygC_dYG2q1Z3S6y3t1aEeYWVQZpcrEqmuU_LAPg6WLjI2_W-Lz9BP7PDtup1qEkUqjWQZhAHDv_bOMiAtGqYcIWuPwbF6SJWUnOQOpfQ7hB_skv1ZZTRqhfmQxk1EtpKH8nLB5TK3eNt8P1TiEgLPqHRdiYjbAUDJnObh9V0yXdI1nOujuKq1C7w Download .mp4 (2.51 MB) Help with .mp4 files Video 1Pleural bleeding is seen at the center of the image as echogenic shadows propagate from a point at the deepest part of the pleura.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5MTNkYTk1ZDk5NTQwZDNhNjBkY2Q2NGE5ODAwZmYyZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjMzNTQzNTU3fQ.Iw6gHAi6FPct_8Igrag6KRkactCeqhLBUok-nCWP5gjq9k2-W1TojFH0783v5q9lcsQ9GEI5RyIaFTYTxaeqx24YHjvDr5THI7Z35lyVNW2is3G_CAuOwuR9pu2XVz9N_d9uE7gnxZc3YIgJaq5fkbuJQKp8D5TIWvuSUmpS9Kkg3CftAvCzQghRIdqYxjZQvUaTFljtAorMW81PPOhtGlxPGGTuv7TkOW-Yo_f9FBM-Ib9boN7_IGFrYEDp80rM62n1ZQXu7RGYwOSeASzK2-B-IFM8WiQw-X4VcSWDLQrdQYR5kpOIH9g67FlTa1Pa5wI2dQSESf0C-Qc3mh7Kfw Download .mp4 (4.93 MB) Help with .mp4 files Video 2Tuohy needle is seen as a hyperechoic line traversing the chest wall and ending inside the formed thrombus. Few air bubbles are seen to come out of the needle tip with little movement beyond the tip, denoting probable incarceration with fibrous septation.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMjMxMzVmYzY2ODZmYTJhMDM5ZDBkMDY3ZTNlNmQyNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjMzNTQzNTU3fQ.arN4VBnlw9ulKYfXhTFKKBKwJip4hKsnAmZErBBIFzec8w_mAMSUUCux5V7sApy_V2oXUL-ok4cNKxpPXkontk7ISx4E3_YVpq3A8ZNRLTKU01sVf7MrouF8cTmfSoD5m63oX0ZTHiLPqQskqzkWChqIGEw5JZ-DhliMaiO5rVBvtYx4zHF-dU2ro3EME4-eT3QA2GJsoYucIGtACxOv_MoHD1BVW5YmGVjT9qaZWzBel4-CST9S9pSsxZJRbIpdN7GHZSab16kXNbh2JvaKqmzPdA9MpuCeyxyYtKtfBW3NHkFllKyHMRuK6Rze0lsPHieljr3Ub5m6IUlBG1u2rw Download .mp4 (4.67 MB) Help with .mp4 files Discussion Video