Symptoms & Clinical Features

• Dyspnea (most common), pleuritic chest pain, dry cough
• Physical signs: Dullness to percussion, reduced breath sounds, decreased vocal fremitus
• Traditionally: Egophony (e to a change) above effusion level

Differential Diagnosis

Based on Light's criteria differentiation:

• Transudative: Heart failure, cirrhosis, nephrotic syndrome, hypoalbuminemia
• Exudative: TB, parapneumonic, malignancy (lung, breast, lymphoma), pulmonary embolism

Investigations

1. Diagnostic thoracentesis: Essential for classification
2. Light's criteria: Exudate if pleural/serum protein >0.5, LDH >0.6, or pleural LDH >2/3 ULN
3. Adenosine deaminase (ADA): >40 U/L suggests TB (sensitivity 92%, specificity 90% in high-TB settings)
4. Cytology: For malignant effusions
5. Imaging: Chest X-ray (blunted costophrenic angle), ultrasound (loculations, guidance), CT (underlying pathology)
   Nigerian studies: ADA remains cost-effective first-line test; Xpert MTB/RIF on pleural fluid increases TB yield by 30% (Nwachukwu et al., 2018)

Treatment

• Therapeutic thoracentesis: For symptomatic relief (limit 1.5L per session)
• Treat underlying cause:
  • TB: Standard Anti-tuberculous therapy; steroids controversial
  • Parapneumonic: Antibiotics; tube drainage if pH<7.2 or loculated
  • Malignant: Repeated drainage, pleurodesis (talc/doxycycline), indwelling catheter
• Empyema: Surgical drainage/decortication with or without DNAse/Alteplase as fibrinolytic

Follow-up

• 2-4 weeks post-treatment initiation
• Monitor for re-accumulation, response to therapy
• Repeat imaging until resolution

Prevention & Control

• Early treatment of pneumonia and TB prevents complication to effusion/empyema
• Proper chest tube management to prevent empyema

Conclusion and Experience from the clinic

In Nigeria, a systematic approach with ADA and thoracentesis is crucial for diagnosing TB pleural effusion, the most common cause. Ultrasound availability improves procedural safety and diagnostic accuracy.

Simple uncomplicated pleural effusion may be easily handled; some patients present with all sorts of improvised chest tubes including urethral catheter. These are placed at some PHCs or General Hospitals. Complicated pleural effusion including multiloculated empyema thoracic are nightmare to pulmonologist, eventually a cardiothoracic consult may be required where thoracotomy and decortication of the pockets of pus are paramount. Hence, early presentation and appropriate procedures and use of standard consumables could shorten hospital stay and morbidities and mortalities associations with unsolicited improvisions.