Pleural Effusion

[huffing and puffing]

I have been reading the forums on his site and decided to tell my story. I was hospitalized with pleural effusion Dec 2006. They drained the right lung of 2.5 L of clear fluid and the next day drained 1.7L of fluid from the left lung. This was just a start of the chronic condition. That Dec they also found I had kidney cancer after doing a CT while I was still in the hospital. The cancer supposedly was resolved with surgery and the pathology said it was confined to the kidney and did not require further treatment. The problem was the pleural effusion continued. I had a bilateral thorocentesis the following May 2007, Nov2007, Feb 2008, and twice in April of 2008. Each time the fluid was 2.5 in the right and 1.7L in the left until April. The two treatments in April where two weeks apart and in the two weeks the last thorocentesis shed 1.2L in the right and 1L in the left. The next treatment being suggested by the doctors is pleuraldesis. Which bothers me because they are recommending a permanent fix without knowing why this is happening. My question is how can this fluid be continuing at such an alarming rate and all the tests come back negative. They have ruled out cancer, fungus, tb, and mold. The electrocardiograms and echo cardiograms have shown no heart involvement. The biopsies were all negative, except the thorasic surgeon stated the lung was inflammed. When the fluid is high, I am extremely short of breath and my blood oxygen levels drop to 80 and below. Once constant has also been a chronic cough. In the beginning the cough was sever and the doctors concidered whooping cough. As things were treated the cough seemed to morph, each time showing different tendencies such as coughing so hard I would vomit. The cough is also triggered by a tickle or itching in my throat. Right now the cough produces a fair amount of phlem that is froathy white and is directly related to the amount of fluid in my lungs (or I think so)

[Davy9]

It is hard to definitively isolate the underlying cause of your effusions without a lot more information. It is alarming that they're occurring simultaneously with an episode of malignancy. Recurrent effusions are associated with primary and metastatic tumors of the pleura. Yet, you do note that none of the studies on the removed fluid suggest a tumor origin which is encouraging. Ask specifically if the cytology studies are negative.

Effusions are broken down into 2 main categories: Transudates and exudates. Find out which type yours are and if they have always been the same. Exudates are associated with infectious processes and transudates with inflammatory processes and things that back up the drainage of the pleural spaces (heart failure and various problems of the lymph system). Exudates are cloudy and have infectious components/residue in them. Transudates are clear. But the 2 are differentiated by protein content and specific gravities.

Pleuraldesis does seem a bit radical when the primary etiology is not yet understood. Have they done any direct biopsies of the pleura? Have they scoped the pleural cavity to visualize its status? I presume they removed the offending kidney. Is your kidney function adequate? Any chronic electrolyte problems? Do you have swelling anywhere else in your body: do your ankles swell when left dependent: has your gut ever accumulated any free fluid (ascites)? Is your liver function normal?

What is your work history? Have you been exposed to materials that could result in lung scarring or fibrosis? Ever been exposed to asbestos? What is you smoking history?

The bad cough could be associated with heavy lungs or the physical pressures the effusions cause when they push on the lungs. They will push or pull on the upper airways triggering the cough reflex and the coughing will not cure the cause so it becomes intractable and insatiable.

Considering that the frequency of the effusions is increasing you might suggest a hospitalization for an extensive diagnostic work up to be certain that a procedure like the a pleuraldesis is the next best option. It will have its own consequences down the road and if it does not address the primary effusive process they too will continue to be a problem.

[huffing and puffing]

All the fluid has been transudates, the results of the cytology has always come back with the words "No malignante cells", the doctor has been concerned about proteins but again she said the tests were negative. I have resently seen a doctor in infectious diseases but have not had the followup yet. He did multiple cytology and cultures on the sputum and according to my pulmonologist all the results are negative pending the one on TB which takes several weeks. I did have a bought with swollen lymph nodes in 2005 when they thought I had lymphoma but the oncologist said it was not conclusive and eventually diagnosed me as having ebstein bar syndrome which attacked my nervous system and put me in a wheel chair for about 3 months then it went away and I gained all my senses back. The pleural effusion began one year after having an episode of pneumonia. I have had a short bought of swollen lymph nodes in my abdomin in Dec of 2007 but it was short lived and I believe it was caused by taking augmentin because it went away when I stopped taking the medication. I was on augmentin also back in 2005 when they thought I had lymphoma. At that time my immune system was very weak and I was getting a sinus infection at least every other month. Also, back in early 2005 they diagnosed me with allergic asthma and put me on Advair. I remained on the Advair until just resently when I took my self off the medication agains doctors opinion. I never had an asthma attack only shortness of breath and the effusions.

[Davy9]

Your recent health history presents a constellation of events. The bout of Epstein-Barr sounds especially interesting. Epstein-Barr is a viral infection in the herpes family. It causes mononucleosis and is related to, or can be a precursor for, a number of other processes. It is usually self limiting meaning the course of the acute presentation ends after a period of time. But, the virus does not leave the body, it goes recumbent meaning that it says in the body but is dormant and acute episodes can recur.

You are a diagnostic puzzle still in the process of being solved. I really cannot help in this effort. There are too many variables and they need hands on work to sort them out. You have a number of physicians from the appropriate specialties investigating now. They sound as though they are looking in the correct places.

I will tell you that pleuraldesis is commonly reserved for controlling recurrent effusions related to malignancies. It is done to stop the effusions understanding that the patient has a terminal process and it will improve the remaining quality of life. Be certain your physician(s) adequately informs you about the long term complications that may arise from doing this procedure. It will lead to pleural adhesions. That is what it does. Those adhesions have their own set of problems and may require additional procedures to control those. Yes, your effusions could be an odd consequence of your recent spate of medical troubles and pleuraldesis could be the best way to try and stop them. Just be sure you understand what it is about and where it can take you.

Should you want additional input I'll try and help however I can.