The Incidence of Pleural
Defined Region*
Effusion
Epidemiologic
Bohemia
Study
in Central
Marel,
M.D.; Miroslava
Zristovd,
W Light,
M.D.
F. C. C. P
Miloslav
Richard
M.D.;
,
Bors
Pleural effusion
may complicate
various diseases.
To facilitate the differential
diagnosis
of pleural
effusion,
the
authors conducted
an epidemiologic
study of incidence
and
etiology
of different
types
of pleural
effusions
in a welldefined region in central Bohemia.
During a 1-year period,
the authors worked with the general practitioners
and other
physicians
from the local hospital
to identify patients with
pleural
effusion
either while the patient was alive or at
autopsy. During this period,
142 individuals
(93 living and
49 at autopsy) with pleural effusion were identified
among
a population
of 44,000
(incidence
0.32 percent).
The most
common
etiologies
of the effusions
were congestive
heart
T
he
differential
difficult
ists
in
diagnosis
both
of
for general
university
hospitals.
The
etiologies
ofpleural
effusions
declining
incidence
of tuberculosis
oral
Most
l,2
etiology
of
pleural
that
are
For
the
patients
This
our
with
is a mixed
search
precise
prior
of breath
in the
with
were
underwent
reviewed
the
failure (65, 46
parapneumonic
emboli
radiologists,
newly
ofthe
and
signs
In
were
Pneumological
chest
than
Clinic,
inhabitants.
vVe conducted
200
ml of pleural
cytologic
study,
We
included
The
following
were
for the
pulmonary
effusions
was
present.
and
in some
careful
macroscopic
along
with
particular
the medical
laboratory
patients
and
interest
was established
also
history.
on the
basis
recognized
designated
after
One
tern examinations.
The criteria for the classification
were as follows:
only after
the
examination
disease,
results
were
(M.Z.),
conducted
all of the
different
to the
criteria
of a
evaluated
pathologist
ofthe
on the
effusion
of postmortem
efflisions
microscopic
in pleural
based
findings,
who has a
types
postmor-
of effusions
Effusion
was
a transudate
with
according
clinical
were
congestive
patients
effusion
with
in whom
heart
clinical
the
of Light
failure.
Also
congestive
effusion
heart
resolved
et at’ in a
included
in this
failure
with
therapy
and
a
for the
All
diminution
pleural
Not
autopsy
a pleural
explanations
for the
or malignancy
effusion
were
such
excluded
as pulmonary
by careful
emboli,
pathologic
pneumonia,
examination.
Parapneumonic
Effusion
was
abscess,
an
effusion
associated
or bronchiectasis.
predominance
The
with
pleural
pneumonia,
fluid
of polymorphonuclear
was
pulmonary
an exudate
with
a
leukocytes.
Effusion
Malignant
established
fremitus,
radiographs.
Charles
fluid
In patients
with pleural
the etiologic diagnosis
was
findings.
This
diseases,
effusion.
all
etiologies
Other
An etiology for the pleural effusion
medical history,
physical
examination,
group
or
respiratory
tactile
to have
22 percent),
and
pulmonary
hemothorax
(6), intra-abdominal
processes
(4), uremia
(2), myxedema
(1), and
rheumatoid
pleuritis
(1). We conclude
that pleural
effusions
are relatively common
and if these figures are extrapolated
to the
United
States and Czechoslovakia
respectively,
one could
expect
at least 800,000
cases
in the United States and 48,000
in Czechoslovakia
annually.
Over 90 percent of the pleural
effusions
will be due tocongestive
heart failure, malignancy,
pneumonia,
or pulmonary
emboli.
(Chest
1993; 104:1486-89)
patient
1988,
company
effusion
addition,
said
percent).
(31,
17 percent),
included
pleural
practitioners,
of percussion.
with
effusions
(24,
of Central
44,000
pathologists.
pleural
decreased
dullness
confirmed
patients
and
of pleural
study:
31,
effusion
with
and
diagnosed
December
of pleural
community.
tuberculosis
malignant
effusions
5.6
(8,
This
Bohemia.
in a district
all general
percent),
general
to document
of pleural
effusions
all patients
reports
effusion
University,
Czechoslovakia,
and the Pulmonary
Section,
Department
erans Affairs
Medical
Center,
Long Beach,
Calif.
Reprint
requests:
Dr. IJght
(151), VA Medical
Center,
Seventh
Street,
Ing
Beach,
CA 90803
1486
of
and
heart failure even though no thoracentesis
was done. In the autopsy
group, cardiomegaly
and venostasis
had to be present
and other
until
signs
agricultural
with
thoracentesis.
and
the
a sample
in the
M.D.;
death,
METHODS
at autopsy
and
for the
sounds,
living
with
the city ofBeroun
in
surgeons,
to the start
with
in central
with
effusion
around
specialists
criteria
deal
diseases
1, 1988
patients
industrial
patients
effective
based on the referral
It would be useful to
percentages
of pleural
AND
in collaboration
internists,
only
deal
population
January
pleural
a region
physicians,
*From
from
to identify
Bohemia,
that
more
of the present
study was
and identify
the etiologies
period
sought
the
to various
MATERIALS
we
the
selected
center.
of the
a defined
for
of
with
tasny,
Cardiac
population.
The purpose
the incidence
effusions
is
special-
distribution
and
effusion
due
effusion
and
is also changing
studies
patients
who have been
pattern
to that medical
have an overall
estimate
effusions
pleural
practitioners
in a Well-
were
if more
Prague,
of Vet5901
East
This
was
an effusion
Demonstration
This
type
associated
with
ofmalignancy
of effusion
hemithorax
and
or cardiotonic
Paraembolic
in the
usually
an intrathoracic
pleural
occupied
did not decrease
space
more
after
the
malignancy.
was
than
not required.
one
therapy
third
with
of the
antibiotics
agents.
Effusion
In this epidemiologic
pain,
tachycardia,
in the
venous
and
system
Incidence
study, patients
hemoptysis
and/or
of
positive
Pleural
were required
in combination
findings
EffUsiOn
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21677/ on 06/17/2017
on the
in Central
to have
with
lung
Bohemia
chest
a disorder
scan.
(Marel
et a!)
Table
Hemothorax
The
hematocrit
20 percent.
For the
of trauma
was
reasons
were
in the
for
pleural
fluid
hemothorax
required.
eg,
required
to be ascribed
For
bleeding,
was
the
to be more
to trauma,
nontraumatic
hemophilia
thoracic
Effusion
a history
hemothorax,
or
2-Diagnosesfor
than
Type
other
endometnosis,
of Effusion
Cardiac
49 Patients
the
Found
Was
n
%
21
42.8
Only
Basic
Ischemic
required.
Intro-abdominal
matory
an effusion
process
that
such
Myxedematous
This
15
30.6
Process
was
Pleural
Illness
heart
n
disease
19
Hypertension
Malignant
This
Whose
at Postmortem
accompanied
an intra-abdominal
as pericholecystitis
or hepatic
inflam-
abscess.
Effusion
was an effusion
and pericardial
that
occurred
in conjunction
with
myxedema
effusion.
2
Cancer
of the
rectum
3
Cancer
ofthe
gallbladder
3
Cancer
of the
lung
2
Cancer
of the
stomach
2
Cancer
of the
ovary
1
Cancer
of the
larynx
1
Cancer
of the
pancreas
1
Cancer
ofthe
kidney
1
Lymphoma
Rheumatoid
This
Effusion
was
arthritis
an effusion
lactate
Uremic
This
uremia
occurred
in a patient
that was characterized
and
a high
that
dehydrogenase
Effusion
was
exudative
an
by a low glucose
value,
and
negative
rheumatoid
level,
low PH,
bacterial
6
12.2
Parapneumonic
4
8.2
Pneumonia
4
Intra-abdominal
2
4. 1
Peritonitis
effusion
there
was
that
no other
occurred
in a patient
2
1
2. 1
Kidney
Uremia
fled who
existence
1-year
had the clinical
of which
was
graphs.
The
effusion
average
was
45 women
The
66.7
with
and
five
1.
for
malignancy
each
cent
than
Table
was
Type
of Effusion
Cardiac
the
in this
emboli
ofsix
average
72.7
identi-
with
age
of these.
nearly
disease
Pneumonia
cancer
leading
cause
the 93 Patients
Was Discovered
During
n
%
Basic
44
47.3
Ischemic
heart
Cor pulmonale
district
lung
11
Cancer
of the colon
1
Cancer
of the
breast
1
Cancer
ofthe
gallbladder
1
Cardiac
pleural
Cancer
ofthe
kidney
1
and
1
5
1
Paraembolic
2
2. 1
Thromboembolic
Intra-abdominal
2
2. 1
Pericholecystitis
2
Myxedematous
1
1. 1
Myxedema
1
Rheumatoid
1
1. 1
Rheumatoid
Uremia
1
1. 1
Kidney
Total
93
failure
disease
arthritis
autopsy
An
was
altered
autopsy
found
518
219
was
individuals
of them
had
the
was
in each
results
in two
a
to a malignant
died
autopsies.
in the
Beroun
At the
time
of
years.
ofthe
thorax
died.
effusion
13
1
Cancer
aneurysm
effusion
in
in 25 patients.
with clinically
2
41
17.2
to the
in 45 patients,
bilateral
had not had an effusion
diagnosed
prior
to death,
were
found
to have more
than
200 ml of fluid
in their pleural
cavity.
Twentytwo of these
individuals
were
male
with a mean age of
66 years while 27 were female
with
a mean
age of 74
16
Ruptured
side
and
performed
28 patients
an
effusion
and
autopsy,
11
Trauma
was
study,
13 and
The
right
patients,
pleural
pleural
effusion.
During
1988,
Malignant
6.5
on the
35
changed
Pneumonia
6
each
parapneumonic
21 .5
Hemothorax
rheu-
and
20
primary
in
at autopsy.
Parapneumonic
Unknown
were
of paraembolic
effusion
while
in the other
n
disease
while
uremia
patients;
in one the diagnosis
was changed
to parapneumonic,
Pleural
disease
in
effusions,
and
one
He-
Illness
two
in origin.
processes
was
14fe
heart
Valvular
50
performed
effusion
Whose
were
side
Thoracentesis
the year ofthe
demonstrated
for more
effusions.
ofpleural
1
one.
effusions
left
for
myxedema,
for
in
20 per-
accounted
pleural
the
patients.
During
of the
for approximately
Lung
The
on
the
shown
for
heart
failure
category
were traumatic
and
intra-abdominal
responsible
disease,
responsible
years.
are
each
matoid
effusion,
the
chest
radio-
men
accounted
malignant
1 -Diagnosesfor
Effusion
48
ischemic
majority
the fifth
were
93 patients
accounted
of the effusions.
half of all the
mothorax
these
and
the
the
was
failure
of effusions
responsible
of
effusion
Cardiac
percent
93 patients
while
years
for
were
signs of pleural
supported
by
age
the
diagnoses
Table
period,
6
with
explanation.
RESULTS
the
disease
49
Pulmonary
During
Thromboembolic
process
cultures.
Total
Pleural
for which
with
1
Paraembolic
2
1
1
49
patients,
The diagnoses
were
found
only
failure
effusions
who
for the 49 patients
whose
effusions
at autopsy
are tabulated
in Table 2.
was the
followed
most common
by malignancy,
cause
of these
parembolic,
parapneumonic
effusions.
The
effusions
were
right-sided
in 8, left-sided
in 9, and bilateral
in 32.
Overall,
a total of 142 patients
had a pleural
effusion
in this one
Bohemia
provides
that has a total population
of 44,000.
This
an incidence
of 0.32
percent
or 320 per
100,000.
When
the diagnoses
postmortem
were combined,
still
were identified
who
district
from central
accounted
for nearly
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21677/ on 06/17/2017
made
during
life and
congestive
heart failure
50 percent
I
104
ofall
I 5 I NOVEMBER,
the
effusions
1993
1487
Table
the 142 Patients
3-Diagnosesfor
Diagnosed
Were
When
Either
Whose
Living
Diagnosis
Conditions
We believe
that the data reported
in this article
are
more representative
of the causes
of pleural
effusions
in the general
population
than are those
cited
in the
Postmortem
or
n
%
Cardiac
65
45.8
Malignant
31
21.8
Parapneumonic
24
17.0
8
5.6
several
6
4.2
4
2.8
a tentative
Although
paragraph
Paraembolic
Hemothorax
Intra-abdominal
process
Uremia
2
1.4
Myxedema
1
0.7
Rheumatoid
1
Total
0.7
142
100.0
before
in a well-defined
reached
instance,
suggests
3). The
second
was malignancy
was pneumonia
leading
cause
(21 .8 percent).
(17.0 percent)
of pleural
The third leading
cause
followed
by pulmonary
emboli
(5.6 percent).
These
four
for slightly
more than 90 percent
diagnoses
of all the
the
present
study
demonstrates
that when
population
is surveyed,
pleural
common.
If the figures
obtained
are extrapolated
to the population
States,
cases
failure
effusions.
Malignancy,
emboli
are
the
an entire
the
effusion
is relatively
in the present
study
ofthe
entire
United
pneumonia,
next
three
and
fact
most
there
leading
causes
The
estimate
is surprisingly
effusions
that
studied.
Mayo
For
Clinic
example,
to
Storey
of
the
patients
lymphoma.
patients
obtained
patients
was
and
effusion
of the
30 percent
from
for
popuat
coworkers3
reported
and
passes
no cases
will
not be ascer-
of tuberculosis
in the
established
the
patients
had
of the
patients
Laennec
congestive
had
with
pleural
percentage
due
effusion
to the
incidence
of tuberculosis
100/100,000
present
incidence
100,000.
When
of
the
at that
inhabitants
tuberculosis
figures
would
tuberculous
in the previous
that the patients
were
ofa district
hospital.
fact
department
the
had
of cases
in
of
are
has
time
while
fallen
examined,
the
to
one
18/
would
of tuberculous
pleuritis
per
area.
With
a population
of
of 18/100,000,
only 8 cases
be
anticipated.
Since
only
1 in
30 cases
of tuberculosis
is tuberculous
pleurisy,8
at
most only 1 case would be expected.
Third, there were very few cases ofbreast
carcinoma
lymphoma
It is possible
or breast
of physicians
in
survey.
However,
that
carcinoma
and
Prague
in general,
some
were
pleural
breast
carcinoma
and lymphoma
tively rare in Czechoslovakia.
Fourth,
the fourth
leading
cause
was
pulmonary
with
pleural
embolism.
effusion,
In
very
patients
were
under
missed
effusions
appear
few
series
cases
care
by this
due to
to be
of pleural
most
with
the
rela-
effusion
of patients
are
due
to
pulmonary
embolism.
However,
when
one considers
the total number
ofcases
ofpulmonary
embolism
and
realizes
that approximately
one third will have a pleural
in 25 patients
effusion,
one would
expect
pulmonary
embolism
to be
the fourth
leading
cause
of effusion.7
This suggests
that in the clinical
situation,
the diagnosis
of pulmonary
embolism
as a cause
of pleural
effusion
is frequently
diagnosis
was
series
of 743
being
missed.
One should
Hospital,
the results
of the present
Certainly
in some countries
incidence
of tuberculosis,
effusion
had
than
15 percent
of the
In the
same
series
of
the present
series
a likely
for every
patient.
In another
with
6 percent
1488
malignancy
no diagnosis
in
responsible
on the
life
who
for nearly
50 percent
of
and that nearly
one third
In contrast,
less
had
heart
failure.
patients,
while
while
with
during
patients
of 133 patients
in a series
that malignancy
accounted
patients
with pleural
effusion
a patient
effusion
expect
at most one case
year in our catchment
44,000 and an incidence
more
close
occurred
were missed
and less than one halfofthe
died had an autopsy.
The distribution
of the diagnoses
pleural
effusion
is obviously
dependent
the
patient.
in each
diagnosis
was made
a pleural
effusion
can
before
they reach
a
once
high
approximately
or lymphoma.
lation
were
is probably
United
some
are
First,
processes
necessary
to reach a
is a substantial
likelihood
that
in a tuberculosis
In addition,
was
of pleural
for
patients
seen
the figures
provided
by the current
study. The estimates
provided
by this research
represent
a minimum
at least
However,
of his pleural
of tuberculosis
since
a tentative
with
diagnosed
patients
the screening
center,
there
There
have been
few previous
studies
on the mcidence
ofpleural
effusions
in a general
population.
One
author7
estimated
that there
were
approximately
1,000,000
cases
of pleural
effusion
per
year
in the
This
that
conditions
etiology
study
pulmonary
effusion.
The above
four diagnoses
account
than 90 percent
of all pleural
effusions.
States.
for every
definitive
the
were
who
there
diagnosis
was attained
the diagnosis
was not
center.
pleurisy.
could expect
approximately
800,000
effusion
in a year. Congestive
heart
for nearly
50 percent
of all pleural
then one
of pleural
accounts
those
Nevertheless,
present
series.
In one series from central
Bohemia
the period
between
1956 and 1960,
36.5 percent
DISCUSSION
The
center.
all the patients
only
surprising.
tamed.
Second,
accounted
effusions.
than
somewhat
their
through
referral
effusion
include
rather
that
that
referral
(Table
they
region
a referral
findings
have
because
heart
tuberculosis.
only
failure
be
Incidence
somewhat
of Pteural
careful
in extrapolating
study
to other
countries.
in which
there
is a high
the most common
type of
EffUSiOn
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21677/ on 06/17/2017
ifl
Central Bohemia (Mare! et a!)
pleural
effusion
parasitic
diseases
may account
for
is tuberculosis.
In
other
such as paragonimiasis
a significant
percentage
countries
or filariasis
of pleural
effusions.
However,
we believe
that the relative
mcidences
reported
in the present
article
are fairly
representative
for industrialized
countries
in Europe
is a common
problem
in a well-defined
region
in central
Bohemia.
Congestive
heart failure
accounts
for nearly
50 percent
of all effusions
and this
pulmonary
along
emboli
with
malignancy,
account
for
with
pneumonia,
90 percent
ofall
and
pleural
effusions.
the period
and
Cas
beta,
Lek
of 1961-1970.
Stud
microglobulin
Ces
1988;
treated
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effusions
Cechoslov
in
1974;
34:36-40
3 Storey
DD,
dilemma.
Ann
Dines
JAMA
RW,
the
Intern
DT
MI,
diagnostic
Med
Chretien
Yearbook
1972;
Medical
M.
Stat Zdravo
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Coles
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Luchsinger
separation
Nak,
PC,
Philadelphia:
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extrapulmonary
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Ball
of transudates
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152-64
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1 Marel M, Kryltifkov#{225}, Svarcov#{225}H. Importance
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4 Light
or North
America.
In conclusion,
pleural
effusion
with an incidence
of 320/100,000
diagnosis
carcmnoembryonic
A,
to the patient.
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