Pleural Fluid Biomarkers: Beyond the Light Criteria

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Key points

  • Accurate diagnosis of the cause of a pleural effusion can be challenging.

  • Analysis of soluble biomarkers from effusions may be a useful adjunctive.

  • Ideal biomarkers should be both sensitive and specific to the disease state being examined and be available at the bedside.

  • None of the many reported biomarkers for pleural infection have yet been shown to be more effective than pH in predicting which parapneumonic effusions are complicated.

  • The value of pleural fluid tumor markers in diagnosing

Biomarkers of HF

HF causes more pleural effusions than any other disease. The finding of a transudate by applying the Light criteria reinforces its diagnosis, because HF accounts for 80% of all transudates. However, HF-related effusions in patients who receive diuretics or have bloody fluids frequently meet the Light exudative criteria by a narrow margin.5 In addition, differentiating cardiac from noncardiac transudates requires the use of specific disease biomarkers.

Biomarkers of pleural infection

The terms pleural infection and parapneumonic effusions are used interchangeably, although one-fourth of pleural infection cases occur without a concurrent bacterial pneumonia. The typical patient with pleural bacterial infection presents with symptoms of pneumonia (ie, fever, chest pain, dyspnea, cough) along with leukocytosis, raised serum C-reactive protein (CRP) levels, and a chest radiograph showing the effusion and radiological lung infiltrates. However, patients may have a more indolent

Biomarkers of tuberculosis

The need for biomarkers in pleural tuberculosis (TB) is justified by the low yield of conventional microbiological studies caused by the paucity of Mycobacterium tuberculosis in pleural fluid, and the 6 to 8 weeks required to obtain results. For example, in a retrospective analysis of 214 patients with pleural tuberculosis, solid culture media for mycobacteria were positive in just 28% of sputum and 15% of pleural fluid samples.31 The respective figures for acid-fast bacilli staining, a more

Biomarkers of malignancy

The diagnosis of malignant pleural effusions is most easily established by showing malignant cells in the pleural space. However, pleural fluid cytology is positive in only 60% of cases, leading to the need for further diagnostic tests.15 The cytology is more likely to be positive with adenocarcinoma than squamous cell carcinoma or lymphoma. Moreover, it provides a definitive diagnosis of mesothelioma in only one-third of cases and a suspected diagnosis in a further 20%.42

Summary

Accurate diagnosis of the cause of a pleural effusion can be challenging. Analysis of soluble biomarkers from effusions may be a useful adjunctive.47 Ideal biomarkers should be sensitive and specific to the disease state being examined, and available at the bedside. These characteristics are met by the natriuretic peptide NT-proBNP and the enzyme ADA. Pleural fluid NT-proBNP levels more than 1500 pg/mL are practically diagnostic of HF, whereas an ADA activity greater than 35 to 40 U/L in the

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