Pleural effusion: clinical features could help exclude malignant or granulomatous disease.

Clinical bottom line (level 4)

  1. Patients with pleural effusions who have none of the following were unlikely to have malignant or granulomatous disease (LR-0.050) :
    • weight loss > 4.5 kg on admission
    • fever > 38C on admission
    • positive tuberculin test
    • > 95% lymphocytes in pleural fluid
    • large effusion (more than half hemithorax)
  2. Patients with two or more of these findings were at risk of having malignant or granulomatous disease (LR+7.2) .
Leslie and Kinasewitz: Chest 1988; 94 (3): 603-608
Expires October 2003

The study

Setting: university hospital, USA

119 patients (aged mean 59 years, 84% male) pleural effusions who had closed needle pleural biopsy

Excluded if
  • chest X-ray or medical records not available



    • Independent ?blinded reference standard, applied in all patients from a consecutive inappropriate spectrum.
    Reference standard:
    • closed needle pleural biopsy. Malignant disease if:
      • malignant cells seen on biopsy or in pleural fluid
      • documented carcinoma within ipsilateral lung and no other cause for exudative effusion found
      Granulomatous disease if any of:
      • granulomas on biopsy
      • positive cultures for mycobacteria or fungi
    Diagnostic test: clinical features on admission
    • clinical prediction rule; not validated in an independent set of patients.

    The evidence

    pre-test probability of malignancy or granulomatous disease: 38%, (95% CI: 28% to 49%)

    diagnostic test malignancy or granulomatous disease no malignancy or granulomatous disease LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    weight loss > 4.5 kg 24 9 4.2
    (2.2 to 7.8)     		73% 0.35
    (0.21 to 0.60)     		19%
    fever > 38C 11 4 4.3
    (1.5 to 21)     		73% 0.73
    (0.57 to 0.93)     		32%
    positive tuberculin test 14 6 3.6
    (1.6 to 8.5)     		70% 0.66
    (0.49 to 0.89)     		30%
    > 95% lymphocytes in pleural fluid 14 6 3.6
    (1.6 to 8.5)     		70% 0.66
    (0.49 to 0.89)     		30%
    large effusion (> half hemithorax) 12 3 6.2
    (1.9 to 21)     		80% 0.69
    (0.53 to 89)     		31%
    any of the above criteria 33 22 2.3
    (1.7 to 3.2)     		60% 0.050
    (0.0072 to 0.35)     		3%
    any two of the above criteria 23 5 7.2
    (3.0 to 17)     		82% 0.36
    (0.22 to 0.59)     		19%
    total 34 53

    Comments

    1. Needs to be prospectively validated in an independent set of patients.

    Citation

    1. Leslie WK, and Kinasewitz GT: clinical characteristics of patients with nonspecific pleuritis. Chest 1988; 94 (3): 603-608
    Search Terms: reference from Pleural effusion chapter in 'Quick Consult Manual to Evidence-based Medicine': publd. Lippincott-Raven, 1997
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient pleural effusion
    Intervention or Exposure clinical features
    Outcome malignancy