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cardiac PE and hepatic hydrothorax&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Chylothorax and cholesterol effusions</span><p id="par0010" class="elsevierStylePara elsevierViewall">Both chylothorax and cholesterol PEs &#40;also known as chyliform PEs or pseudochylothorax&#41; are characterized by their richness in lipids&#58; chylomicrons&#47;triglycerides in the first case and cholesterol in the second&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The chylothorax involves a chyle leak due to disruption or blockage of the thoracic duct or its branches&#46; The causes of chylothorax can be classified into four categories<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a>&#58; &#40;1&#41; surgeries &#40;40&#37;&#41;&#44; such as the repair of heart disease and congenital diaphragmatic hernias&#44; esophagectomy and lung resections with mediastinal lymphadenectomy&#59; &#40;2&#41; tumors &#40;30&#37;&#41;&#44; mainly lymphomas&#59; &#40;3&#41; miscellaneous processes&#44; such as cirrhosis &#40;transdiaphragmatic passage of chylous ascites&#41;&#44; superior vena cava syndrome and acquired lymphatic disorders &#40;e&#46;g&#46;&#44; lymphangioleiomyomatosis&#44; yellow nail syndrome &#91;YNS&#93;&#41;&#59; and &#40;4&#41; idiopathic chylothorax &#40;10&#37;&#41;&#44; although &#8220;trivial&#8221; trauma should be ruled out &#40;cough&#44; hiccups&#44; intense sneezing&#41; before considering this condition&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cholesterol PEs&#44; which are much more uncommon than chylothorax&#44; are not related to any lymphocytic anomaly but rather with long-standing pleural collections &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>years in 90&#37; of patients&#41;&#46; In 80&#37; of cases&#44; these PEs are associated with pleural thickening or calcification<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> in which the cholesterol is generated by lysis of erythrocytes and leukocytes&#46; The two most common etiologies of cholesterol PE are tuberculosis &#40;which should be differentiated from tuberculous empyema&#44; described later in this article&#41; and rheumatoid arthritis&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with voluminous chylothorax usually have dyspnea but not fever &#40;except in the context of B symptoms of a lymphoma&#41; or chest pain&#44; due to the noninflammatory nature of chyle&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> Depending on the location of the thoracic duct lesion&#44; chylothoraces are unilaterally left or right&#44; although 20&#37; of cases are bilateral&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Chylothorax should be suspected with any patient with pleural fluid &#40;PF&#41; of milky appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; or with persistent or recurring PE of uncertain cause&#44; particularly if there are predisposing factors &#40;e&#46;g&#46;&#44; cardiothoracic surgery&#44; lymphoma&#44; cirrhosis and lymphangioleiomyomatosis&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to consider that both chylothorax and cholesterol PE have the classic milky appearance in only 40&#8211;50&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;7</span></a> PF analysis of a chylothorax shows an exudate &#40;85&#37;&#59; the transudate should lead to a suspicion of cirrhosis&#41;&#44; predominantly lymphocytic &#40;80&#37;&#41; and with triglyceride concentrations &#62;110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;85&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> The finding of intermediate triglyceride values &#40;50&#8211;110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; 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the use of lymphography by magnetic resonance imaging or transnodal lymphangiography with lipiodol is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There are three classes of therapeutic strategies for chylothorax&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#8211;12</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment of the underlying disease&#58; chemotherapy for lymphomas&#44; percutaneous intrahepatic portosystemic shunt for cirrhosis and sirolimus for lymphangioleiomyomatosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Conservative treatment&#58; therapeutic thoracentesis or pleural drainage for symptomatic relief&#44; a period of total parenteral nutrition or low-fat diet supplemented with medium-chain triglycerides&#44; and octreotide to reduce the intestinal production of chyle&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Interventionist&#44; surgical or palliative therapies if the conservative measures applied for 2 weeks fail&#44; if severe malnutrition occurs or if the daily loss of chyle exceeds 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>L for 5&#8211;7<span class="elsevierStyleHsp" style=""></span>days&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#8211;12</span></a> For high-output chylothorax &#40;&#62;1<span class="elsevierStyleHsp" style=""></span>L&#47;day&#41;&#44; we can attempt catheterization of the thoracic duct &#40;after intranodal lymphangiography or percutaneous access to Pecquet&#39;s cistern with the use of computed tomography &#91;CT&#93;&#41; and its selective embolization through the insertion of microcoils or liquid glue &#40;cyanoacrylate&#41;&#46; Conventional lymphangiography <span class="elsevierStyleItalic">per se</span> can reduce or solve chylous leaks in some patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> The other option for chylothorax with significant output is video-assisted thoracoscopic surgery with the intent to repair the disruption of the thoracic duct or its ligation&#44; generally followed by talc pleurodesis&#46; For persistent low-output chylothorax&#44; pleurodesis or the placement of a tunneled pleural catheter may be attempted&#46; Finally&#44; prophylactic ligation of the thoracic duct during esophagectomy is considered an effective measure for reducing the incidence of postoperative chylothorax&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment of cholesterol PEs includes the treatment of the underlying disease&#44; therapeutic thoracentesis for temporary symptomatic relief and&#44; in recurrent cases&#44; pleurodesis or decortication&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;5&#44;7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Nonexpansible lung</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nonexpansible lung &#40;NEL&#41; is a mechanical complication resulting from a restriction of the visceral pleura of an inflammatory or malignant nature or resulting from extrapleural diseases &#40;endobronchial obstruction&#44; chronic atelectasis&#44; advanced pulmonary fibrosis&#41;&#44; which hinders the normal apposition between the two pleural membranes&#59; in other words&#44; the complete expansion of the lung until it touches the chest wall&#46; The resulting excess negative pleural pressure leads to the onset of a PE&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Two forms of NEL have been classically differentiated but actually represent the spectrum of one disease&#58; lung entrapment and trapped lung&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In the first case&#44; there is active inflammation or tumor invasion of the visceral pleura&#44; which determines the formation of a pleural exudate&#46; The underlying process can be resolved and with it the PE or a pleural fibrous layer can remain as irreversible sequela that permanently limits lung expansion&#46; In the second case &#40;trapped lung&#41;&#44; the imbalance of hydrostatic forces in the pleural space causes the generation of PE with biochemical characteristics of borderline transudate or exudate due to the protein criterion &#40;lactate dehydrogenase tends to be normal because it is not in an inflammatory phase&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> If therapeutic thoracentesis is performed&#44; the PE will reproduce in a few days until it reaches the same volume it had previously&#46; Thus&#44; a PF analysis in a NEL will show an exudate or transudate depending on when &#40;active inflammation or resolution phase&#41; the thoracentesis is performed&#46; Common causes of NEL are complicated parapneumonic PE and empyema&#44; postaortocoronary bypass surgery PE&#44; postcardiac injury syndrome&#44; pleural tuberculosis&#44; hemothorax&#44; thoracic radiation&#44; uremia and rheumatoid PE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with trapped lung are often asymptomatic but can have dyspnea&#46; Generally&#44; there is a history of a previous predisposing episode of pleural inflammation&#46; The PE tends to be small or moderate&#44; unilateral and consistent over time&#46; Therapeutic thoracentesis produces a pneumothorax or hydropneumothorax <span class="elsevierStyleItalic">ex vacuo</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and usually substernal chest pain during or after the procedure&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A CT scan with air contrast showing a thickened visceral pleura suggests an NEL&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Pleural manometry can support the diagnosis if a significant reduction in pleural pressure is observed as the PE is drained &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; although it is not for widespread use&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The treatment for lung entrapment involves treating the underlying disease that produces the condition &#40;e&#46;g&#46;&#44; antibiotics and early drainage in a complicated parapneumonic PE&#44; immediate evacuation of a hemothorax and endoscopic resection of an endobronchial tumor&#41;&#46; In the context of a malignant PE&#44; the presence of an NEL contraindicates pleurodesis&#44; while favoring the indication for a tunneled catheter if the patient is symptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Asymptomatic patients with small PEs due to a trapped lung do not require specific treatment&#44; just observation&#46; For symptomatic patients&#44; the therapeutic alternatives are decortication or insertion of a tunneled pleural catheter&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Rheumatoid pleural effusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">CT identifies PE in 10&#37; of patients with rheumatoid arthritis&#44; although only 4&#37; have a symptomatic pleurisy at some point in the disease progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;20</span></a> Rheumatoid pleurisy is more common in men &#40;75&#8211;80&#37;&#41; with long-standing rheumatic disease &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>years&#41;&#44; subcutaneous nodules &#40;50&#8211;80&#37;&#41; and positive rheumatoid factor &#40;95&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;20</span></a> Only rarely does the PE precede &#40;5&#37;&#41; or occur simultaneously with joint symptoms &#40;10&#37;&#41; in a patient with no previous diagnosis of rheumatic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> Most patients with rheumatoid PE are asymptomatic&#44; but others develop fever&#44; chest pain or dyspnea proportional to the size of the PE and to the underlying lung involvement&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The PE is usually small or moderate&#44; unilateral in 75&#37; of cases&#44; and can be loculated&#46; In a third of cases&#44; the PE is associated with parenchymal lung lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#8211;21</span></a> Although the PE resolves in 4<span class="elsevierStyleHsp" style=""></span>months in two-thirds of patients&#44; the PE can persist &#40;even for years&#41; or relapse in 20&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> PF is an exudate characterized&#44; particularly in its chronic forms&#44; by a pH<span class="elsevierStyleHsp" style=""></span>&#60;7&#46;20&#44; glucose concentrations &#60;60<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;80&#37;&#41; and high titers of rheumatoid factor&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Occasionally&#44; false high concentrations of pleural adenosine deaminase can be found&#46; The cytological study of the PF shows the presence of elongated macrophages &#40;tadpole-shaped cells&#41; on a base of amorphous granular material in 60&#37; of cases&#44; a finding considered specific&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Pleural biopsy has little value&#44; because it shows fibrosis and nonspecific inflammation&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The diagnosis of rheumatoid pleurisy first requires ruling out other potential causes of PE in a patient with rheumatoid arthritis&#58; bacterial or mycobacterial infections&#44; drug-induced pleurisy &#40;e&#46;g&#46;&#44; methotrexate&#44; lupus induced by biologic agents&#41;&#44; pseudochylothorax&#44; secondary amyloidosis and trapped lung&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Treatment for rheumatoid PE consists of the therapeutic optimization of the underlying disease&#46; Nonsteroidal anti-inflammatory drugs or corticosteroids are usually prescribed if infection has been ruled out&#46; If the PE is voluminous&#44; the patient could benefit from a therapeutic thoracentesis&#44; and the intrapleural injection of corticosteroids could be attempted&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Tuberculous empyema</span><p id="par0105" class="elsevierStylePara elsevierViewall">Tuberculous empyema is a particular form of NEL and is a rare variant of pleural tuberculosis&#44; due to the withdrawal of therapeutic artificial pneumothorax&#44; which constituted the typical predisposing factor&#46; This condition is a chronic and active mycobacterial infection &#40;lasting for years&#41; of the pleural space characterized by the presence of an loculated empyematous collection&#44; limited by a fibrocalcified pleura along with costal thickening&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> The PF is purulent and neutrophilic and has low pH and glucose concentrations and mostly contains tubercle bacilli&#44; which is demonstrated in direct smears for bacilli and in the cultures&#46; There can be co-infection with conventional aerobic and anaerobic bacteria&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> The presence of a hydropneumothorax in the imaging tests should lead to the suspicion of a bronchopleural fistula&#46; Patients with tuberculous empyema are usually oligosymptomatic&#44; manifesting nonspecific symptoms or consulting for empyema <span class="elsevierStyleItalic">necessitatis</span> &#40;drainage and rupture of the collection toward the subcutaneous tissue and chest wall skin&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The therapeutic approach for tuberculous empyema follows the same principles as those for bacterial empyema&#59; i&#46;e&#46;&#44; drainage and antimicrobials&#46; Antituberculosis agents might not reach therapeutic levels in the pleural space due to the marked thickening of the pleura&#44; which makes extending their duration advisable&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> Decortication&#44; open drainage or pleural window might be necessary if a trapped lung is present&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Tuberculous empyema should not be confused with classical tuberculosis PE&#44; in which neutrophils can predominate in 10&#37; of cases &#40;a situation that also increases the likelihood of obtaining positives cultures&#41; or low pH and pleural glucose readings can be detected in 25&#37; of cases&#44; conditions in which the PF appearance is not purulent&#44; and thickening and pleural calcification are not detected&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Benign asbestos pleural effusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Benign asbestos PE &#40;BAPE&#41; is one of the numerous pleuropulmonary manifestations that result from exposure to asbestos &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; A recent Japanese series reported the main clinical characteristics of 110 patients with BAPE&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> All the patients were men&#44; the PE was mostly unilateral &#40;75&#37;&#41;&#44; and 40&#37; of the cases were casually discovered in an asymptomatic patient&#46; All patients had a recorded history of prior occupational exposure to asbestos &#40;except in one case in which the exposure was environmental&#41; and a median age of 48<span class="elsevierStyleHsp" style=""></span>years &#40;interquartile range&#44; 17&#8211;76<span class="elsevierStyleHsp" style=""></span>years&#41; before the BAPE diagnosis&#46; The PE corresponded to exudates&#44; generally with a predominance of lymphocytes&#46; Most of the patients had other radiological manifestations related to asbestos exposure&#58; pleural plaques &#40;90&#37;&#41;&#44; round atelectasis &#40;37&#37;&#41;&#44; diffuse pleural thickening &#40;27&#37;&#41; and asbestosis &#40;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> The BAPE diagnosis in a patient with a pleural exudate and a history of asbestos exposure always requires ruling out other etiologies such as mesothelioma&#44; lung cancer and tuberculosis&#46; A follow-up every 1&#8211;3<span class="elsevierStyleHsp" style=""></span>years with chest radiography and pulmonary function tests is recommended for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Yellow nail syndrome</span><p id="par0120" class="elsevierStylePara elsevierViewall">YNS is a rare acquired disorder that almost always occurs in adults older than 50<span class="elsevierStyleHsp" style=""></span>years&#46; Fewer than 400<span class="elsevierStyleHsp" style=""></span>cases of YNS have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> The diagnosis is clinical and is based on the presence of 2 of the following three characteristics&#44; which can appear sequentially or simultaneously<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#58; &#40;1&#41; xanthonychia or yellow nails &#40;&#62;90&#37;&#41;&#59; &#40;2&#41; lymphedema of the lower limbs &#40;70&#37;&#41;&#59; and &#40;3&#41; chronic pulmonary manifestations &#40;60&#37;&#41; such as cough&#44; bronchiectasis and PE&#46; The complete triad is only present in approximately 40&#37; of cases&#59; a third of patients also experience acute or chronic rhinosinusitis&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The etiology of YNS is unknown&#44; although morphofunctional abnormalities of the lymphatic vessels&#44; microvasculopathy with protein leakage and exposure to titanium dioxide have been implicated&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">PE is observed in approximately 40&#37; of patients with YNS&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> A systematic review assessed the clinical characteristics of 150 patients with PE secondary to YNS&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> The mean age was 60<span class="elsevierStyleHsp" style=""></span>years&#44; with no predominance by sex&#46; All patients had lymphedema&#59; however&#44; xanthonychia was not detected in 14&#37; of the patients&#46; The PEs were bilateral in two-thirds of the patients&#44; had a serous appearance in 75&#37; and a milky appearance in 20&#37;&#46; The PEs corresponded to exudates with lymphocytic predominance in 95&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> The pleural biopsies showed nonspecific data or chronic pleurisy&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Treatment for YNS is supportive&#46; In the specific case of PE&#44; the general recommendations described above for this condition are followed if the patient has a chylothorax&#46; For the other persistent and symptomatic PEs&#44; we can opt for inserting a tunneled pleural catheter&#44; a pleurodesis or&#44; in highly selected cases&#44; pleurectomy&#47;decortication&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The author declares that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres875317"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Chylothorax and cholesterol effusions"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Nonexpansible lung"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Rheumatoid pleural effusion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Tuberculous empyema"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Benign asbestos pleural effusion"
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        9 => array:2 [
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          "titulo" => "Yellow nail syndrome"
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            0 => "Chylothorax"
            1 => "Cholesterol effusion"
            2 => "Trapped lung"
            3 => "Rheumatoid pleural effusion"
            4 => "Tuberculous empyema"
            5 => "Benign asbestos pleural effusion"
            6 => "Yellow nail syndrome"
            7 => "Tunneled pleural catheter"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:8 [
            0 => "Quilot&#243;rax"
            1 => "Derrame de colesterol"
            2 => "Pulm&#243;n atrapado"
            3 => "Derrame pleural reumatoide"
            4 => "Empiema tuberculoso"
            5 => "Derrame pleural asbest&#243;sico benigno"
            6 => "S&#237;ndrome de las u&#241;as amarillas"
            7 => "Cat&#233;ter pleural tunelizado"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In this narrative review we describe the main aetiologies&#44; clinical characteristics and treatment for patients with benign pleural effusion that characteristically persists over time&#58; chylothorax and cholesterol effusions&#44; nonexpansible lung&#44; rheumatoid pleural effusion&#44; tuberculous empyema&#44; benign asbestos pleural effusion and yellow nail syndrome&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En esta revisi&#243;n narrativa se describen las principales etiolog&#237;as&#44; caracter&#237;sticas cl&#237;nicas y tratamiento de los derrames pleurales de naturaleza benigna que&#44; caracter&#237;sticamente&#44; pueden persistir en el tiempo&#58; quilot&#243;rax y derrames de colesterol&#44; pulm&#243;n no expansible&#44; derrame pleural reumatoide&#44; empiema tuberculoso&#44; derrame pleural asbest&#243;sico benigno y s&#237;ndrome de las u&#241;as amarillas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Porcel JM&#46; Derrames pleurales benignos persistentes&#46; Rev Clin Esp&#46; 2017&#59;217&#58;336&#8211;341&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Typical milky appearance of a chylothorax&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nonexpansible lung of malignant nature&#46; A right pleural effusion can be seen &#40;A&#41;&#44; with the onset of an <span class="elsevierStyleItalic">ex vacuo</span> pneumothorax after the therapeutic thoracentesis &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Digital pleural manometry system during a thoracentesis&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Small benign left asbestos pleural effusion&#44; associated with calcified pleural plaques &#40;arrowheads&#41;&#44; visible in the posteroanterior radiological projections &#40;A&#41; and lateral &#40;B&#41;&#46;</p>"
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                      "titulo" => "Comparing approaches to the management of malignant pleural effusions"
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Review
Persistent benign pleural effusion
Derrames pleurales benignos persistentes
J.M. Porcela,b
a Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain
b Instituto de Investigación Biomédica de Lleida Fundación Dr. Pifarré, IRBLLEIDA, Lleida, Spain
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            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommended algorithm for the risk stratification of patients with pulmonary thromboembolism&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#42; Authors&#8217; suggestions&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; BNP&#44; brain natriuretic peptide&#59; V&#47;P scintigraphy&#44; ventilation&#47;perfusion scintigraphy&#59; NT-proBNP&#44; amino-terminal fragment of BNP&#59; PESI&#44; Pulmonary Embolism Severity Index&#59; PESIs&#44; simplified PESI scale&#59; RIETE&#44; Computerized Registry of Patients with Venous Thromboembolism&#59; CT&#44; computed tomography&#59; CTA&#44; computer tomography angiography&#59; PTE&#44; pulmonary thromboembolism&#59; DVT&#44; deep vein thrombosis&#59; RV&#44; right ventricle&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from Konstantinides et al&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">8</span></a> and modified by the authors&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nonexpansible lung of malignant nature&#46; A right pleural effusion can be seen &#40;A&#41;&#44; with the onset of an <span class="elsevierStyleItalic">ex vacuo</span> pneumothorax after the therapeutic thoracentesis &#40;B&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pleural effusion &#40;PE&#41; is one of the most common processes facing medical specialists&#44; particularly pulmonologists&#44; internists and thoracic surgeons&#46; Typically&#44; malignant PE is persistent over time and&#44; when it causes dyspnea&#44; requires specific palliative procedures such as therapeutic thoracentesis&#44; pleurodesis and the insertion of tunneled pleural catheters &#40;PleurX<span class="elsevierStyleSup">&#174;</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> However&#44; there are various benign diseases that produce chronic PE&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> which are often difficult to treat and diagnose due to their rarity&#46; These diseases are the focus of this review&#46; We will not consider benign PEs that generally resolve in a few days or weeks but are occasionally persistent or recurrent due to a lack of response to conventional therapy &#40;e&#46;g&#46;&#44; cardiac PE and hepatic hydrothorax&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Chylothorax and cholesterol effusions</span><p id="par0010" class="elsevierStylePara elsevierViewall">Both chylothorax and cholesterol PEs &#40;also known as chyliform PEs or pseudochylothorax&#41; are characterized by their richness in lipids&#58; chylomicrons&#47;triglycerides in the first case and cholesterol in the second&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The chylothorax involves a chyle leak due to disruption or blockage of the thoracic duct or its branches&#46; The causes of chylothorax can be classified into four categories<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a>&#58; &#40;1&#41; surgeries &#40;40&#37;&#41;&#44; such as the repair of heart disease and congenital diaphragmatic hernias&#44; esophagectomy and lung resections with mediastinal lymphadenectomy&#59; &#40;2&#41; tumors &#40;30&#37;&#41;&#44; mainly lymphomas&#59; &#40;3&#41; miscellaneous processes&#44; such as cirrhosis &#40;transdiaphragmatic passage of chylous ascites&#41;&#44; superior vena cava syndrome and acquired lymphatic disorders &#40;e&#46;g&#46;&#44; lymphangioleiomyomatosis&#44; yellow nail syndrome &#91;YNS&#93;&#41;&#59; and &#40;4&#41; idiopathic chylothorax &#40;10&#37;&#41;&#44; although &#8220;trivial&#8221; trauma should be ruled out &#40;cough&#44; hiccups&#44; intense sneezing&#41; before considering this condition&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cholesterol PEs&#44; which are much more uncommon than chylothorax&#44; are not related to any lymphocytic anomaly but rather with long-standing pleural collections &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>years in 90&#37; of patients&#41;&#46; In 80&#37; of cases&#44; these PEs are associated with pleural thickening or calcification<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> in which the cholesterol is generated by lysis of erythrocytes and leukocytes&#46; The two most common etiologies of cholesterol PE are tuberculosis &#40;which should be differentiated from tuberculous empyema&#44; described later in this article&#41; and rheumatoid arthritis&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with voluminous chylothorax usually have dyspnea but not fever &#40;except in the context of B symptoms of a lymphoma&#41; or chest pain&#44; due to the noninflammatory nature of chyle&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> Depending on the location of the thoracic duct lesion&#44; chylothoraces are unilaterally left or right&#44; although 20&#37; of cases are bilateral&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Chylothorax should be suspected with any patient with pleural fluid &#40;PF&#41; of milky appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; or with persistent or recurring PE of uncertain cause&#44; particularly if there are predisposing factors &#40;e&#46;g&#46;&#44; cardiothoracic surgery&#44; lymphoma&#44; cirrhosis and lymphangioleiomyomatosis&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It is important to consider that both chylothorax and cholesterol PE have the classic milky appearance in only 40&#8211;50&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;7</span></a> PF analysis of a chylothorax shows an exudate &#40;85&#37;&#59; the transudate should lead to a suspicion of cirrhosis&#41;&#44; predominantly lymphocytic &#40;80&#37;&#41; and with triglyceride concentrations &#62;110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;85&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> The finding of intermediate triglyceride values &#40;50&#8211;110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; requires the demonstration of the presence of chylomicrons in the PF&#44; which would be a definitive test of chylothorax&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Cholesterol PE are exudates&#44; often of lymphocyte predominance &#40;60&#37;&#41;&#44; with a ratio of cholesterol to triglycerides in the PF<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1 &#40;97&#37;&#41;&#44; cholesterol crystals visible under a polarized light microscope &#40;90&#37;&#41;&#44; pleural cholesterol concentrations &#62;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;75&#37;&#41; and the absence of chylomicrons&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To locate the anatomical site of the lymphocytic leak in patients with chylothorax for whom surgical repair or ligation of the thoracic duct is planned&#44; the use of lymphography by magnetic resonance imaging or transnodal lymphangiography with lipiodol is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There are three classes of therapeutic strategies for chylothorax&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#8211;12</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment of the underlying disease&#58; chemotherapy for lymphomas&#44; percutaneous intrahepatic portosystemic shunt for cirrhosis and sirolimus for lymphangioleiomyomatosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Conservative treatment&#58; therapeutic thoracentesis or pleural drainage for symptomatic relief&#44; a period of total parenteral nutrition or low-fat diet supplemented with medium-chain triglycerides&#44; and octreotide to reduce the intestinal production of chyle&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Interventionist&#44; surgical or palliative therapies if the conservative measures applied for 2 weeks fail&#44; if severe malnutrition occurs or if the daily loss of chyle exceeds 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>L for 5&#8211;7<span class="elsevierStyleHsp" style=""></span>days&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#8211;12</span></a> For high-output chylothorax &#40;&#62;1<span class="elsevierStyleHsp" style=""></span>L&#47;day&#41;&#44; we can attempt catheterization of the thoracic duct &#40;after intranodal lymphangiography or percutaneous access to Pecquet&#39;s cistern with the use of computed tomography &#91;CT&#93;&#41; and its selective embolization through the insertion of microcoils or liquid glue &#40;cyanoacrylate&#41;&#46; Conventional lymphangiography <span class="elsevierStyleItalic">per se</span> can reduce or solve chylous leaks in some patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> The other option for chylothorax with significant output is video-assisted thoracoscopic surgery with the intent to repair the disruption of the thoracic duct or its ligation&#44; generally followed by talc pleurodesis&#46; For persistent low-output chylothorax&#44; pleurodesis or the placement of a tunneled pleural catheter may be attempted&#46; Finally&#44; prophylactic ligation of the thoracic duct during esophagectomy is considered an effective measure for reducing the incidence of postoperative chylothorax&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment of cholesterol PEs includes the treatment of the underlying disease&#44; therapeutic thoracentesis for temporary symptomatic relief and&#44; in recurrent cases&#44; pleurodesis or decortication&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;5&#44;7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Nonexpansible lung</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nonexpansible lung &#40;NEL&#41; is a mechanical complication resulting from a restriction of the visceral pleura of an inflammatory or malignant nature or resulting from extrapleural diseases &#40;endobronchial obstruction&#44; chronic atelectasis&#44; advanced pulmonary fibrosis&#41;&#44; which hinders the normal apposition between the two pleural membranes&#59; in other words&#44; the complete expansion of the lung until it touches the chest wall&#46; The resulting excess negative pleural pressure leads to the onset of a PE&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Two forms of NEL have been classically differentiated but actually represent the spectrum of one disease&#58; lung entrapment and trapped lung&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In the first case&#44; there is active inflammation or tumor invasion of the visceral pleura&#44; which determines the formation of a pleural exudate&#46; The underlying process can be resolved and with it the PE or a pleural fibrous layer can remain as irreversible sequela that permanently limits lung expansion&#46; In the second case &#40;trapped lung&#41;&#44; the imbalance of hydrostatic forces in the pleural space causes the generation of PE with biochemical characteristics of borderline transudate or exudate due to the protein criterion &#40;lactate dehydrogenase tends to be normal because it is not in an inflammatory phase&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> If therapeutic thoracentesis is performed&#44; the PE will reproduce in a few days until it reaches the same volume it had previously&#46; Thus&#44; a PF analysis in a NEL will show an exudate or transudate depending on when &#40;active inflammation or resolution phase&#41; the thoracentesis is performed&#46; Common causes of NEL are complicated parapneumonic PE and empyema&#44; postaortocoronary bypass surgery PE&#44; postcardiac injury syndrome&#44; pleural tuberculosis&#44; hemothorax&#44; thoracic radiation&#44; uremia and rheumatoid PE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with trapped lung are often asymptomatic but can have dyspnea&#46; Generally&#44; there is a history of a previous predisposing episode of pleural inflammation&#46; The PE tends to be small or moderate&#44; unilateral and consistent over time&#46; Therapeutic thoracentesis produces a pneumothorax or hydropneumothorax <span class="elsevierStyleItalic">ex vacuo</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and usually substernal chest pain during or after the procedure&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A CT scan with air contrast showing a thickened visceral pleura suggests an NEL&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Pleural manometry can support the diagnosis if a significant reduction in pleural pressure is observed as the PE is drained &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; although it is not for widespread use&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The treatment for lung entrapment involves treating the underlying disease that produces the condition &#40;e&#46;g&#46;&#44; antibiotics and early drainage in a complicated parapneumonic PE&#44; immediate evacuation of a hemothorax and endoscopic resection of an endobronchial tumor&#41;&#46; In the context of a malignant PE&#44; the presence of an NEL contraindicates pleurodesis&#44; while favoring the indication for a tunneled catheter if the patient is symptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Asymptomatic patients with small PEs due to a trapped lung do not require specific treatment&#44; just observation&#46; For symptomatic patients&#44; the therapeutic alternatives are decortication or insertion of a tunneled pleural catheter&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Rheumatoid pleural effusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">CT identifies PE in 10&#37; of patients with rheumatoid arthritis&#44; although only 4&#37; have a symptomatic pleurisy at some point in the disease progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;20</span></a> Rheumatoid pleurisy is more common in men &#40;75&#8211;80&#37;&#41; with long-standing rheumatic disease &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>years&#41;&#44; subcutaneous nodules &#40;50&#8211;80&#37;&#41; and positive rheumatoid factor &#40;95&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;20</span></a> Only rarely does the PE precede &#40;5&#37;&#41; or occur simultaneously with joint symptoms &#40;10&#37;&#41; in a patient with no previous diagnosis of rheumatic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> Most patients with rheumatoid PE are asymptomatic&#44; but others develop fever&#44; chest pain or dyspnea proportional to the size of the PE and to the underlying lung involvement&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The PE is usually small or moderate&#44; unilateral in 75&#37; of cases&#44; and can be loculated&#46; In a third of cases&#44; the PE is associated with parenchymal lung lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#8211;21</span></a> Although the PE resolves in 4<span class="elsevierStyleHsp" style=""></span>months in two-thirds of patients&#44; the PE can persist &#40;even for years&#41; or relapse in 20&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> PF is an exudate characterized&#44; particularly in its chronic forms&#44; by a pH<span class="elsevierStyleHsp" style=""></span>&#60;7&#46;20&#44; glucose concentrations &#60;60<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;80&#37;&#41; and high titers of rheumatoid factor&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Occasionally&#44; false high concentrations of pleural adenosine deaminase can be found&#46; The cytological study of the PF shows the presence of elongated macrophages &#40;tadpole-shaped cells&#41; on a base of amorphous granular material in 60&#37; of cases&#44; a finding considered specific&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Pleural biopsy has little value&#44; because it shows fibrosis and nonspecific inflammation&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The diagnosis of rheumatoid pleurisy first requires ruling out other potential causes of PE in a patient with rheumatoid arthritis&#58; bacterial or mycobacterial infections&#44; drug-induced pleurisy &#40;e&#46;g&#46;&#44; methotrexate&#44; lupus induced by biologic agents&#41;&#44; pseudochylothorax&#44; secondary amyloidosis and trapped lung&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Treatment for rheumatoid PE consists of the therapeutic optimization of the underlying disease&#46; Nonsteroidal anti-inflammatory drugs or corticosteroids are usually prescribed if infection has been ruled out&#46; If the PE is voluminous&#44; the patient could benefit from a therapeutic thoracentesis&#44; and the intrapleural injection of corticosteroids could be attempted&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Tuberculous empyema</span><p id="par0105" class="elsevierStylePara elsevierViewall">Tuberculous empyema is a particular form of NEL and is a rare variant of pleural tuberculosis&#44; due to the withdrawal of therapeutic artificial pneumothorax&#44; which constituted the typical predisposing factor&#46; This condition is a chronic and active mycobacterial infection &#40;lasting for years&#41; of the pleural space characterized by the presence of an loculated empyematous collection&#44; limited by a fibrocalcified pleura along with costal thickening&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> The PF is purulent and neutrophilic and has low pH and glucose concentrations and mostly contains tubercle bacilli&#44; which is demonstrated in direct smears for bacilli and in the cultures&#46; There can be co-infection with conventional aerobic and anaerobic bacteria&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> The presence of a hydropneumothorax in the imaging tests should lead to the suspicion of a bronchopleural fistula&#46; Patients with tuberculous empyema are usually oligosymptomatic&#44; manifesting nonspecific symptoms or consulting for empyema <span class="elsevierStyleItalic">necessitatis</span> &#40;drainage and rupture of the collection toward the subcutaneous tissue and chest wall skin&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The therapeutic approach for tuberculous empyema follows the same principles as those for bacterial empyema&#59; i&#46;e&#46;&#44; drainage and antimicrobials&#46; Antituberculosis agents might not reach therapeutic levels in the pleural space due to the marked thickening of the pleura&#44; which makes extending their duration advisable&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> Decortication&#44; open drainage or pleural window might be necessary if a trapped lung is present&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Tuberculous empyema should not be confused with classical tuberculosis PE&#44; in which neutrophils can predominate in 10&#37; of cases &#40;a situation that also increases the likelihood of obtaining positives cultures&#41; or low pH and pleural glucose readings can be detected in 25&#37; of cases&#44; conditions in which the PF appearance is not purulent&#44; and thickening and pleural calcification are not detected&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Benign asbestos pleural effusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Benign asbestos PE &#40;BAPE&#41; is one of the numerous pleuropulmonary manifestations that result from exposure to asbestos &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; A recent Japanese series reported the main clinical characteristics of 110 patients with BAPE&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> All the patients were men&#44; the PE was mostly unilateral &#40;75&#37;&#41;&#44; and 40&#37; of the cases were casually discovered in an asymptomatic patient&#46; All patients had a recorded history of prior occupational exposure to asbestos &#40;except in one case in which the exposure was environmental&#41; and a median age of 48<span class="elsevierStyleHsp" style=""></span>years &#40;interquartile range&#44; 17&#8211;76<span class="elsevierStyleHsp" style=""></span>years&#41; before the BAPE diagnosis&#46; The PE corresponded to exudates&#44; generally with a predominance of lymphocytes&#46; Most of the patients had other radiological manifestations related to asbestos exposure&#58; pleural plaques &#40;90&#37;&#41;&#44; round atelectasis &#40;37&#37;&#41;&#44; diffuse pleural thickening &#40;27&#37;&#41; and asbestosis &#40;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> The BAPE diagnosis in a patient with a pleural exudate and a history of asbestos exposure always requires ruling out other etiologies such as mesothelioma&#44; lung cancer and tuberculosis&#46; A follow-up every 1&#8211;3<span class="elsevierStyleHsp" style=""></span>years with chest radiography and pulmonary function tests is recommended for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Yellow nail syndrome</span><p id="par0120" class="elsevierStylePara elsevierViewall">YNS is a rare acquired disorder that almost always occurs in adults older than 50<span class="elsevierStyleHsp" style=""></span>years&#46; Fewer than 400<span class="elsevierStyleHsp" style=""></span>cases of YNS have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> The diagnosis is clinical and is based on the presence of 2 of the following three characteristics&#44; which can appear sequentially or simultaneously<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#58; &#40;1&#41; xanthonychia or yellow nails &#40;&#62;90&#37;&#41;&#59; &#40;2&#41; lymphedema of the lower limbs &#40;70&#37;&#41;&#59; and &#40;3&#41; chronic pulmonary manifestations &#40;60&#37;&#41; such as cough&#44; bronchiectasis and PE&#46; The complete triad is only present in approximately 40&#37; of cases&#59; a third of patients also experience acute or chronic rhinosinusitis&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The etiology of YNS is unknown&#44; although morphofunctional abnormalities of the lymphatic vessels&#44; microvasculopathy with protein leakage and exposure to titanium dioxide have been implicated&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">PE is observed in approximately 40&#37; of patients with YNS&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> A systematic review assessed the clinical characteristics of 150 patients with PE secondary to YNS&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> The mean age was 60<span class="elsevierStyleHsp" style=""></span>years&#44; with no predominance by sex&#46; All patients had lymphedema&#59; however&#44; xanthonychia was not detected in 14&#37; of the patients&#46; The PEs were bilateral in two-thirds of the patients&#44; had a serous appearance in 75&#37; and a milky appearance in 20&#37;&#46; The PEs corresponded to exudates with lymphocytic predominance in 95&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> The pleural biopsies showed nonspecific data or chronic pleurisy&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Treatment for YNS is supportive&#46; In the specific case of PE&#44; the general recommendations described above for this condition are followed if the patient has a chylothorax&#46; For the other persistent and symptomatic PEs&#44; we can opt for inserting a tunneled pleural catheter&#44; a pleurodesis or&#44; in highly selected cases&#44; pleurectomy&#47;decortication&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The author declares that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres875317"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Chylothorax and cholesterol effusions"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Nonexpansible lung"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Rheumatoid pleural effusion"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Tuberculous empyema"
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          "titulo" => "Benign asbestos pleural effusion"
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          "titulo" => "Yellow nail syndrome"
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            0 => "Chylothorax"
            1 => "Cholesterol effusion"
            2 => "Trapped lung"
            3 => "Rheumatoid pleural effusion"
            4 => "Tuberculous empyema"
            5 => "Benign asbestos pleural effusion"
            6 => "Yellow nail syndrome"
            7 => "Tunneled pleural catheter"
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            0 => "Quilot&#243;rax"
            1 => "Derrame de colesterol"
            2 => "Pulm&#243;n atrapado"
            3 => "Derrame pleural reumatoide"
            4 => "Empiema tuberculoso"
            5 => "Derrame pleural asbest&#243;sico benigno"
            6 => "S&#237;ndrome de las u&#241;as amarillas"
            7 => "Cat&#233;ter pleural tunelizado"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In this narrative review we describe the main aetiologies&#44; clinical characteristics and treatment for patients with benign pleural effusion that characteristically persists over time&#58; chylothorax and cholesterol effusions&#44; nonexpansible lung&#44; rheumatoid pleural effusion&#44; tuberculous empyema&#44; benign asbestos pleural effusion and yellow nail syndrome&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En esta revisi&#243;n narrativa se describen las principales etiolog&#237;as&#44; caracter&#237;sticas cl&#237;nicas y tratamiento de los derrames pleurales de naturaleza benigna que&#44; caracter&#237;sticamente&#44; pueden persistir en el tiempo&#58; quilot&#243;rax y derrames de colesterol&#44; pulm&#243;n no expansible&#44; derrame pleural reumatoide&#44; empiema tuberculoso&#44; derrame pleural asbest&#243;sico benigno y s&#237;ndrome de las u&#241;as amarillas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Porcel JM&#46; Derrames pleurales benignos persistentes&#46; Rev Clin Esp&#46; 2017&#59;217&#58;336&#8211;341&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Typical milky appearance of a chylothorax&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nonexpansible lung of malignant nature&#46; A right pleural effusion can be seen &#40;A&#41;&#44; with the onset of an <span class="elsevierStyleItalic">ex vacuo</span> pneumothorax after the therapeutic thoracentesis &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Digital pleural manometry system during a thoracentesis&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Small benign left asbestos pleural effusion&#44; associated with calcified pleural plaques &#40;arrowheads&#41;&#44; visible in the posteroanterior radiological projections &#40;A&#41; and lateral &#40;B&#41;&#46;</p>"
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Original language: English
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