08 arijitd medicine discussion

8/14/2019 08 ArijitD Medicine Discussion

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DISCUSSION

n the evaluation of a pleural effusion the first step is to differentiate the

transudates & exudates. It bears its implication in arriving at an etiological

diagnosis as the diagnostic and the therapeutic strategies for the transudates

and exudates are different. An exudative effusion requires extensive

sometimes invasive procedures for its etiological diagnosis, on the other hand

a transudative pleural effusion requires treatment directed only towards the

primary disease process. Histopathological examinations are confirmatory, but

it has its limitations ions as the specimen yield is very low, sometimes up to

30% [Escudero et al 1990] and being an invasive technique it has its

hazards.The laboratory parameters such as Lights criteria [Light et al1972],

pleural fluid protein value has variable results in the differential diagnosis as

reported by many workers.

i

Keeping all these factors in mind the present study was

undertaken to study the significance of serumeffusion albumin gradient in

differential diagnosis of pleural effusion and compare with the already

established Lights criteria.

The present study comprised of 40 cases of pleural effusion in

which the etiology was established by clinical examination, Radiological

investigations, pleural fluid cytology, special laboratory methods and

histopathological examination of pleural biopsy specimen in selected cases. In the

present series 75% were male and 25% cases were females belonged to age group

of 1383 years. Among 40 cases of transudates and exudates, 50% had right sided

pleural effusion, 30% had left sided and 20% had bilateral pleural effusions.

Differential Diagnosis of Transudates and Exudates:

Classically pleural effusion are divided into transudates and

exudates. In the present study of 40 cases of pleural effusion 65% were

established as exudates and 35% astransudates.


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Pleural Fluid Proteins in Differential Diagnosis of Pleural

Effusion:

In the present study of 40 cases of pleural 55% of exudates &

45% of transudates were differentiated by a pleural fluid protein value of 3

g/dl. The sensitivity and specificity of these parameters is 80% & 70%

respectively. Total misclassification of 25% occurred with this parameter ie

23.07% misclassified exudates and 28.52% of treansudates.

In a study, Carr & Power [1958] showed that a pleural fluid

protein value of 3 g/dl could differentiate 64% of exudates & 50% oftransudates with total misclassification of 21%.

In a study by K.B. Gupta et alshowed that pleural fluid protein

value of 3 g/dl misclassified 25% of exudates and 18.7% of transudate with

sensitivity and specificity of 83.3% and 75% with total misclassification of

20%.

Pleural Fluid to Serum Protein in Differential Diagnosis of

Pleural Effusion:

In the present study of 40 cases of pleural effusion pleural fluid

to serum protein ratio of.5 separated 57.5% as exudates & 42.5% as

transudates with sensitivity and specificity of 85% & 73.7% with total

misclassification rate of 20%. This parameter correctly classified 81% of

exudates and 85% of transudates. Misclassification rate for transudates

21.42% and for exudates is 1.9%.

Light et al[1972]; in their study reported that a pleural fluid to

serum protein ratio of >0.5 correctly classified 92% of transudates & 90% of

exudates.

Valdes et al[1991] also found in their study that this parameter

correctly classified 89% of transudates and 84% of exudates.

DISCUSSION 76


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Ram et al [1995] also reported that the pleural fluid protein to

serum protein ratio of 0.5 correctly classified 81.5% of transudates and all

exudates with a misclassification rate of 15%.

K.B. et alfound a sensitivity and specificity of 85% and 66.6%

with this parameter and are total misclassification of 18%.

From the above results by the above results by the other workers

it is found that results obtained in the present study are comparable. The

misclassification rate is higher in the present study.

Pleural Fluid Protein and Pleural Fluid to Serum Protein

Ratio in Differential Diagnosis of Pleural Effusion:


protein of 3 g/dl and p/s of.5 separated 55% as exudates and 45% as

transudates with true classification rate of 82% as exudates and 83.3% as

transudates. Total misclassification rate of 17.5% occurred.

Pleural Fluid LDH in Differential Diagnosis of Pleural

Effusion:


LDH of 200 U/L separated 60% as exudates and 40% as transudate. True

classification was 87% for exudates and 82% for transudates. Total

misclassification of 17.5% occurred. The sensitivity and specificity of this

parameter is 86% & 77%.

K.B. Gupta et al found a sensitivity and specificity of 80% &

75% with this parameter with total misclassification of 21.6% occurred.

From the above results by other workers it is found that results

found in the present study are comparable. The misclassification rate in the

present study is 17.5% ie low compared to the above study.

DISCUSSION 77


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Pleural Fluid LDH to Serum LDH of 0.6 in Differential

Diagnosis of Pleural Effusion:


LDH to serum LDh of.6 separated 67.5% as exudates and 32.5% as

transudates with true classification of 88.8% as exudates & 84.6% as

transudates. The sensitivity & specificity of this parameter is 92% & 73.3%

with total misclassification of 12.5%.

Light et al found a total misclassification of 10% with this

parameter.

K.B. Gupta et al found a total misclassification of 15.4% with

this parameter.

From the results found by other workers they are quite similar

but the misclassification rate in the present study is 12.5%.

Pleural Fluid LDH of 200 U/L & P/S LDH of.6 in Differential



LDH of 200U/L & P/S LDH of.6 separated 70% as exudates & 30% as

transudates with true classification of 93% for exudates & 88% for

transudates with total misclassification of 10%. The sensitivity & specificity

of this parameter is 90.4% & 82.6%.

SerumEffusion Albumin Gradient of 1.2g/dl in Differential


In the present study of 40 cases of pleural effusion serum

effusion albumin gradient of 1.2g/dl separated 65% as exudates & 35% as

transudates with true classification rate of 96.15% for exudates & 94% for

treansudates with total misclassification of only 5%. The sensitivity and

specificity of this parameter is 96.1% & 93%.

DISCUSSION 78


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Roth et alin a series of 59 patients used serum effusion albumin

gradient of 1.2g/dl & classified all the transudates correctly & only 2 exudates

were miss classified with total misclassification rate of 3.3%. The sensitivity

& the specificity of the parameter used was 90% & 92%.

E Razi et al attained a sensitivity & specificity of 91.5% &

92.86% respectively.

K.B. Gupta et alattained a sensitivity & specificity of 97.9% &

100% with total misclassification rate of 2%.

M.C. Dhar et alobtained a sensitivity & specificity of 100% &

94% with this parameter.

From the results obtained by the above workers, they are quite

similar to the present study. Misclassification rate obtained in the present

study is 5%.

Comparative Analysis of the Parameters Used In the Study of 40

Cases of Pleural Effusion:

PARAMETER

EXUDATE

CLASSIFIED

CORRECTLY

[%]

TRANSUDATES

CLASSIFIED

CORRECTLY

[%]

MIS

CLASSIFICATION

RATE

[%]

PF Protein [3gm/dl]

P/S Protein [0.5]

PF Protein + P/S Protein

PF LDH [2001U/L]

P/S LDH [0.6]

PF LDH + P/S LDH

SEAG of 1.2 gm/dl

72.70

78.26

81.80

83.30

88.80

92.80

96.15

77.70

82.35

83.30

81.25

84.60

83.30

93.60

25.00

20.00

17.50

17.50

12.50

10.00

5.00

The parameters of protein, LDH & SerumEffusion Albumin

gradient were studied in the 40 cases of pleural effusion & compared with the

established diagnosis of pleural effusion in the present study. The study

DISCUSSION 79


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revealed that even though the parameter of pleural fluid protein of 3 gm/dl,

pleural fluid to serum protein ratio of.5, pleural fluid LDH level of 200 U/L &

pleural fluid LDH to Serum LDH ratio of.6 are useful in differentiating the

exudates & transudates. The greater differential value is found with the SEAG

value of 1.2 gm/dl which correctly classified 96.15% of exudates & 93.6% of

transudates with a total misclassification of only 5% & with a sensitivity &

specificity of 96.1% & 93%.

Therefore the present study shows that SerumEffusion Albumin

gradient of 1.2 gm/dl is a useful parameter in differential diagnosis of pleural

effusion which can be tried as a first step in the evaluation of cases of pleural

effusion.

The graphical representation of the misclassification rate of

various parameters showed in the above table is given in Fig13.

usu

DISCUSSION 80

08 arijitd medicine discussion

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