Persistent benign pleural effusion

Porcel, J.M.

doi:10.1016/j.rceng.2017.05.002

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Abbreviations: BNP, brain natriuretic peptide; V/P scintigraphy, ventilation/perfusion scintigraphy; NT-proBNP, amino-terminal fragment of BNP; PESI, Pulmonary Embolism Severity Index; PESIs, simplified PESI scale; RIETE, Computerized Registry of Patients with Venous Thromboembolism; CT, computed tomography; CTA, computer tomography angiography; PTE, pulmonary thromboembolism; DVT, deep vein thrombosis; RV, right ventricle. Source: Adapted from Konstantinides et al.<a class="elsevierStyleCrossRef" href="#bib0425">8</a> and modified by the authors." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Maestre Peiró, A. Gonzálvez Gasch, M. Monreal Bosch" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Maestre Peiró" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Gonzálvez Gasch" ] 2 => array:2 [ "nombre" => "M." 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Porcel" "autores" => array:1 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Porcel" "email" => array:1 [ 0 => "jporcelp@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Lleida Fundación Dr. Pifarré, IRBLLEIDA, Lleida, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Derrames pleurales benignos persistentes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1174 "Ancho" => 2500 "Tamanyo" => 223784 ] ] "descripcion" => array:1 [ "en" => "Nonexpansible lung of malignant nature. A right pleural effusion can be seen (A), with the onset of an ex vacuo pneumothorax after the therapeutic thoracentesis (B)." ] ] ] "textoCompleto" => "Pleural effusion (PE) is one of the most common processes facing medical specialists, particularly pulmonologists, internists and thoracic surgeons. Typically, malignant PE is persistent over time and, when it causes dyspnea, requires specific palliative procedures such as therapeutic thoracentesis, pleurodesis and the insertion of tunneled pleural catheters (PleurX®).<a class="elsevierStyleCrossRef" href="#bib0155">1</a> However, there are various benign diseases that produce chronic PE,<a class="elsevierStyleCrossRef" href="#bib0160">2</a> which are often difficult to treat and diagnose due to their rarity. These diseases are the focus of this review. 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 (e.g., cardiac PE and hepatic hydrothorax).Chylothorax and cholesterol effusionsBoth chylothorax and cholesterol PEs (also known as chyliform PEs or pseudochylothorax) are characterized by their richness in lipids: chylomicrons/triglycerides in the first case and cholesterol in the second.<a class="elsevierStyleCrossRef" href="#bib0165">3</a> The chylothorax involves a chyle leak due to disruption or blockage of the thoracic duct or its branches. The causes of chylothorax can be classified into four categories<a class="elsevierStyleCrossRefs" href="#bib0170">4,5</a>: (1) surgeries (40%), such as the repair of heart disease and congenital diaphragmatic hernias, esophagectomy and lung resections with mediastinal lymphadenectomy; (2) tumors (30%), mainly lymphomas; (3) miscellaneous processes, such as cirrhosis (transdiaphragmatic passage of chylous ascites), superior vena cava syndrome and acquired lymphatic disorders (e.g., lymphangioleiomyomatosis, yellow nail syndrome [YNS]); and (4) idiopathic chylothorax (10%), although “trivial” trauma should be ruled out (cough, hiccups, intense sneezing) before considering this condition.Cholesterol PEs, which are much more uncommon than chylothorax, are not related to any lymphocytic anomaly but rather with long-standing pleural collections (>5years in 90% of patients). In 80% of cases, these PEs are associated with pleural thickening or calcification<a class="elsevierStyleCrossRef" href="#bib0180">6</a> in which the cholesterol is generated by lysis of erythrocytes and leukocytes. The two most common etiologies of cholesterol PE are tuberculosis (which should be differentiated from tuberculous empyema, described later in this article) and rheumatoid arthritis.<a class="elsevierStyleCrossRefs" href="#bib0165">3,4</a>Patients with voluminous chylothorax usually have dyspnea but not fever (except in the context of B symptoms of a lymphoma) or chest pain, due to the noninflammatory nature of chyle.<a class="elsevierStyleCrossRef" href="#bib0185">7</a> Depending on the location of the thoracic duct lesion, chylothoraces are unilaterally left or right, although 20% of cases are bilateral.<a class="elsevierStyleCrossRef" href="#bib0175">5</a> Chylothorax should be suspected with any patient with pleural fluid (PF) of milky appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) or with persistent or recurring PE of uncertain cause, particularly if there are predisposing factors (e.g., cardiothoracic surgery, lymphoma, cirrhosis and lymphangioleiomyomatosis).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>It is important to consider that both chylothorax and cholesterol PE have the classic milky appearance in only 40–50% of cases.<a class="elsevierStyleCrossRefs" href="#bib0165">3,7</a> PF analysis of a chylothorax shows an exudate (85%; the transudate should lead to a suspicion of cirrhosis), predominantly lymphocytic (80%) and with triglyceride concentrations >110mg/dL (85%).<a class="elsevierStyleCrossRef" href="#bib0190">8</a> The finding of intermediate triglyceride values (50–110mg/dL) requires the demonstration of the presence of chylomicrons in the PF, which would be a definitive test of chylothorax.<a class="elsevierStyleCrossRef" href="#bib0175">5</a> Cholesterol PE are exudates, often of lymphocyte predominance (60%), with a ratio of cholesterol to triglycerides in the PF>1 (97%), cholesterol crystals visible under a polarized light microscope (90%), pleural cholesterol concentrations >200mg/dL (75%) and the absence of chylomicrons.<a class="elsevierStyleCrossRef" href="#bib0195">9</a>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, the use of lymphography by magnetic resonance imaging or transnodal lymphangiography with lipiodol is recommended.<a class="elsevierStyleCrossRef" href="#bib0200">10</a>There are three classes of therapeutic strategies for chylothorax.<a class="elsevierStyleCrossRefs" href="#bib0200">10–12</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Treatment of the underlying disease: chemotherapy for lymphomas, percutaneous intrahepatic portosystemic shunt for cirrhosis and sirolimus for lymphangioleiomyomatosis.</li><li class="elsevierStyleListItem" id="lsti0010">2.Conservative treatment: therapeutic thoracentesis or pleural drainage for symptomatic relief, a period of total parenteral nutrition or low-fat diet supplemented with medium-chain triglycerides, and octreotide to reduce the intestinal production of chyle.<a class="elsevierStyleCrossRef" href="#bib0215">13</a></li><li class="elsevierStyleListItem" id="lsti0015">3.Interventionist, surgical or palliative therapies if the conservative measures applied for 2 weeks fail, if severe malnutrition occurs or if the daily loss of chyle exceeds 1–1.5L for 5–7days.<a class="elsevierStyleCrossRefs" href="#bib0200">10–12</a> For high-output chylothorax (>1L/day), we can attempt catheterization of the thoracic duct (after intranodal lymphangiography or percutaneous access to Pecquet's cistern with the use of computed tomography [CT]) and its selective embolization through the insertion of microcoils or liquid glue (cyanoacrylate). Conventional lymphangiography per se can reduce or solve chylous leaks in some patients.<a class="elsevierStyleCrossRef" href="#bib0220">14</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, generally followed by talc pleurodesis. For persistent low-output chylothorax, pleurodesis or the placement of a tunneled pleural catheter may be attempted. Finally, prophylactic ligation of the thoracic duct during esophagectomy is considered an effective measure for reducing the incidence of postoperative chylothorax.<a class="elsevierStyleCrossRef" href="#bib0225">15</a></li></ul>The treatment of cholesterol PEs includes the treatment of the underlying disease, therapeutic thoracentesis for temporary symptomatic relief and, in recurrent cases, pleurodesis or decortication.<a class="elsevierStyleCrossRefs" href="#bib0165">3,5,7</a>Nonexpansible lungNonexpansible lung (NEL) is a mechanical complication resulting from a restriction of the visceral pleura of an inflammatory or malignant nature or resulting from extrapleural diseases (endobronchial obstruction, chronic atelectasis, advanced pulmonary fibrosis), which hinders the normal apposition between the two pleural membranes; in other words, the complete expansion of the lung until it touches the chest wall. The resulting excess negative pleural pressure leads to the onset of a PE.Two forms of NEL have been classically differentiated but actually represent the spectrum of one disease: lung entrapment and trapped lung.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> In the first case, there is active inflammation or tumor invasion of the visceral pleura, which determines the formation of a pleural exudate. 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. In the second case (trapped lung), 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 (lactate dehydrogenase tends to be normal because it is not in an inflammatory phase).<a class="elsevierStyleCrossRefs" href="#bib0230">16,17</a> If therapeutic thoracentesis is performed, the PE will reproduce in a few days until it reaches the same volume it had previously. Thus, a PF analysis in a NEL will show an exudate or transudate depending on when (active inflammation or resolution phase) the thoracentesis is performed. Common causes of NEL are complicated parapneumonic PE and empyema, postaortocoronary bypass surgery PE, postcardiac injury syndrome, pleural tuberculosis, hemothorax, thoracic radiation, uremia and rheumatoid PE.Patients with trapped lung are often asymptomatic but can have dyspnea. Generally, there is a history of a previous predisposing episode of pleural inflammation. The PE tends to be small or moderate, unilateral and consistent over time. Therapeutic thoracentesis produces a pneumothorax or hydropneumothorax ex vacuo (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and usually substernal chest pain during or after the procedure.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>A CT scan with air contrast showing a thickened visceral pleura suggests an NEL.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> Pleural manometry can support the diagnosis if a significant reduction in pleural pressure is observed as the PE is drained (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), although it is not for widespread use.<a class="elsevierStyleCrossRef" href="#bib0240">18</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The treatment for lung entrapment involves treating the underlying disease that produces the condition (e.g., antibiotics and early drainage in a complicated parapneumonic PE, immediate evacuation of a hemothorax and endoscopic resection of an endobronchial tumor). In the context of a malignant PE, the presence of an NEL contraindicates pleurodesis, while favoring the indication for a tunneled catheter if the patient is symptomatic.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> Asymptomatic patients with small PEs due to a trapped lung do not require specific treatment, just observation. For symptomatic patients, the therapeutic alternatives are decortication or insertion of a tunneled pleural catheter.<a class="elsevierStyleCrossRefs" href="#bib0230">16,17</a>Rheumatoid pleural effusionCT identifies PE in 10% of patients with rheumatoid arthritis, although only 4% have a symptomatic pleurisy at some point in the disease progression.<a class="elsevierStyleCrossRefs" href="#bib0245">19,20</a> Rheumatoid pleurisy is more common in men (75–80%) with long-standing rheumatic disease (>10years), subcutaneous nodules (50–80%) and positive rheumatoid factor (95%).<a class="elsevierStyleCrossRefs" href="#bib0245">19,20</a> Only rarely does the PE precede (5%) or occur simultaneously with joint symptoms (10%) in a patient with no previous diagnosis of rheumatic disease.<a class="elsevierStyleCrossRef" href="#bib0250">20</a> Most patients with rheumatoid PE are asymptomatic, but others develop fever, chest pain or dyspnea proportional to the size of the PE and to the underlying lung involvement.The PE is usually small or moderate, unilateral in 75% of cases, and can be loculated. In a third of cases, the PE is associated with parenchymal lung lesions.<a class="elsevierStyleCrossRefs" href="#bib0245">19–21</a> Although the PE resolves in 4months in two-thirds of patients, the PE can persist (even for years) or relapse in 20% of patients.<a class="elsevierStyleCrossRef" href="#bib0245">19</a> PF is an exudate characterized, particularly in its chronic forms, by a pH<7.20, glucose concentrations <60mg/dL (80%) and high titers of rheumatoid factor.<a class="elsevierStyleCrossRef" href="#bib0255">21</a> Occasionally, false high concentrations of pleural adenosine deaminase can be found. The cytological study of the PF shows the presence of elongated macrophages (tadpole-shaped cells) on a base of amorphous granular material in 60% of cases, a finding considered specific.<a class="elsevierStyleCrossRef" href="#bib0255">21</a> Pleural biopsy has little value, because it shows fibrosis and nonspecific inflammation.The diagnosis of rheumatoid pleurisy first requires ruling out other potential causes of PE in a patient with rheumatoid arthritis: bacterial or mycobacterial infections, drug-induced pleurisy (e.g., methotrexate, lupus induced by biologic agents), pseudochylothorax, secondary amyloidosis and trapped lung.Treatment for rheumatoid PE consists of the therapeutic optimization of the underlying disease. Nonsteroidal anti-inflammatory drugs or corticosteroids are usually prescribed if infection has been ruled out. If the PE is voluminous, the patient could benefit from a therapeutic thoracentesis, and the intrapleural injection of corticosteroids could be attempted.<a class="elsevierStyleCrossRef" href="#bib0245">19</a>Tuberculous empyemaTuberculous empyema is a particular form of NEL and is a rare variant of pleural tuberculosis, due to the withdrawal of therapeutic artificial pneumothorax, which constituted the typical predisposing factor. This condition is a chronic and active mycobacterial infection (lasting for years) of the pleural space characterized by the presence of an loculated empyematous collection, limited by a fibrocalcified pleura along with costal thickening.<a class="elsevierStyleCrossRef" href="#bib0260">22</a> The PF is purulent and neutrophilic and has low pH and glucose concentrations and mostly contains tubercle bacilli, which is demonstrated in direct smears for bacilli and in the cultures. There can be co-infection with conventional aerobic and anaerobic bacteria.<a class="elsevierStyleCrossRef" href="#bib0260">22</a> The presence of a hydropneumothorax in the imaging tests should lead to the suspicion of a bronchopleural fistula. Patients with tuberculous empyema are usually oligosymptomatic, manifesting nonspecific symptoms or consulting for empyema necessitatis (drainage and rupture of the collection toward the subcutaneous tissue and chest wall skin).<a class="elsevierStyleCrossRef" href="#bib0265">23</a>The therapeutic approach for tuberculous empyema follows the same principles as those for bacterial empyema; i.e., drainage and antimicrobials. Antituberculosis agents might not reach therapeutic levels in the pleural space due to the marked thickening of the pleura, which makes extending their duration advisable.<a class="elsevierStyleCrossRef" href="#bib0270">24</a> Decortication, open drainage or pleural window might be necessary if a trapped lung is present.<a class="elsevierStyleCrossRef" href="#bib0275">25</a> Tuberculous empyema should not be confused with classical tuberculosis PE, in which neutrophils can predominate in 10% of cases (a situation that also increases the likelihood of obtaining positives cultures) or low pH and pleural glucose readings can be detected in 25% of cases, conditions in which the PF appearance is not purulent, and thickening and pleural calcification are not detected.<a class="elsevierStyleCrossRef" href="#bib0280">26</a>Benign asbestos pleural effusionBenign asbestos PE (BAPE) is one of the numerous pleuropulmonary manifestations that result from exposure to asbestos (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). A recent Japanese series reported the main clinical characteristics of 110 patients with BAPE.<a class="elsevierStyleCrossRef" href="#bib0285">27</a> All the patients were men, the PE was mostly unilateral (75%), and 40% of the cases were casually discovered in an asymptomatic patient. All patients had a recorded history of prior occupational exposure to asbestos (except in one case in which the exposure was environmental) and a median age of 48years (interquartile range, 17–76years) before the BAPE diagnosis. The PE corresponded to exudates, generally with a predominance of lymphocytes. Most of the patients had other radiological manifestations related to asbestos exposure: pleural plaques (90%), round atelectasis (37%), diffuse pleural thickening (27%) and asbestosis (6%).<a class="elsevierStyleCrossRef" href="#bib0285">27</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, lung cancer and tuberculosis. A follow-up every 1–3years with chest radiography and pulmonary function tests is recommended for these patients.<a class="elsevierStyleCrossRef" href="#bib0290">28</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Yellow nail syndromeYNS is a rare acquired disorder that almost always occurs in adults older than 50years. Fewer than 400cases of YNS have been reported.<a class="elsevierStyleCrossRef" href="#bib0295">29</a> The diagnosis is clinical and is based on the presence of 2 of the following three characteristics, which can appear sequentially or simultaneously<a class="elsevierStyleCrossRef" href="#bib0295">29</a>: (1) xanthonychia or yellow nails (>90%); (2) lymphedema of the lower limbs (70%); and (3) chronic pulmonary manifestations (60%) such as cough, bronchiectasis and PE. The complete triad is only present in approximately 40% of cases; a third of patients also experience acute or chronic rhinosinusitis.<a class="elsevierStyleCrossRef" href="#bib0295">29</a>The etiology of YNS is unknown, although morphofunctional abnormalities of the lymphatic vessels, microvasculopathy with protein leakage and exposure to titanium dioxide have been implicated.PE is observed in approximately 40% of patients with YNS.<a class="elsevierStyleCrossRef" href="#bib0295">29</a> A systematic review assessed the clinical characteristics of 150 patients with PE secondary to YNS.<a class="elsevierStyleCrossRef" href="#bib0300">30</a> The mean age was 60years, with no predominance by sex. All patients had lymphedema; however, xanthonychia was not detected in 14% of the patients. The PEs were bilateral in two-thirds of the patients, had a serous appearance in 75% and a milky appearance in 20%. The PEs corresponded to exudates with lymphocytic predominance in 95% of the cases.<a class="elsevierStyleCrossRef" href="#bib0300">30</a> The pleural biopsies showed nonspecific data or chronic pleurisy.Treatment for YNS is supportive. In the specific case of PE, the general recommendations described above for this condition are followed if the patient has a chylothorax. For the other persistent and symptomatic PEs, we can opt for inserting a tunneled pleural catheter, a pleurodesis or, in highly selected cases, pleurectomy/decortication.Conflict of interestsThe author declares that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres875317" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec863511" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres875316" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec863512" "titulo" => "Palabras clave" ] 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" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Yellow nail syndrome" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-25" "fechaAceptado" => "2017-03-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec863511" "palabras" => array:8 [ 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" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec863512" "palabras" => array:8 [ 0 => "Quilotórax" 1 => "Derrame de colesterol" 2 => "Pulmón atrapado" 3 => "Derrame pleural reumatoide" 4 => "Empiema tuberculoso" 5 => "Derrame pleural asbestósico benigno" 6 => "Síndrome de las uñas amarillas" 7 => "Catéter pleural tunelizado" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "In this narrative review we describe the main aetiologies, clinical characteristics and treatment for patients with benign pleural effusion that characteristically persists over time: chylothorax and cholesterol effusions, nonexpansible lung, rheumatoid pleural effusion, tuberculous empyema, benign asbestos pleural effusion and yellow nail syndrome." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En esta revisión narrativa se describen las principales etiologías, características clínicas y tratamiento de los derrames pleurales de naturaleza benigna que, característicamente, pueden persistir en el tiempo: quilotórax y derrames de colesterol, pulmón no expansible, derrame pleural reumatoide, empiema tuberculoso, derrame pleural asbestósico benigno y síndrome de las uñas amarillas." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Porcel JM. Derrames pleurales benignos persistentes. Rev Clin Esp. 2017;217:336–341." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1778 "Ancho" => 1333 "Tamanyo" => 326716 ] ] "descripcion" => array:1 [ "en" => "Typical milky appearance of a chylothorax." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1174 "Ancho" => 2500 "Tamanyo" => 223784 ] ] "descripcion" => array:1 [ "en" => "Nonexpansible lung of malignant nature. A right pleural effusion can be seen (A), with the onset of an ex vacuo pneumothorax after the therapeutic thoracentesis (B)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 985 "Ancho" => 1333 "Tamanyo" => 166263 ] ] "descripcion" => array:1 [ "en" => "Digital pleural manometry system during a thoracentesis." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1270 "Ancho" => 2500 "Tamanyo" => 222015 ] ] "descripcion" => array:1 [ "en" => "Small benign left asbestos pleural effusion, associated with calcified pleural plaques (arrowheads), visible in the posteroanterior radiological projections (A) and lateral (B)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparing approaches to the management of malignant pleural effusions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.M. 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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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          "titulo" => "Chylothorax and cholesterol effusions"
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          "identificador" => "sec0010"
          "titulo" => "Nonexpansible lung"
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          "identificador" => "sec0015"
          "titulo" => "Rheumatoid pleural effusion"
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          "identificador" => "sec0020"
          "titulo" => "Tuberculous empyema"
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          "titulo" => "Benign asbestos pleural effusion"
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            4 => "Tuberculous empyema"
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            5 => "Derrame pleural asbest&#243;sico benigno"
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        "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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