Objective: To evaluate the best time to perform thoracoscopy for the treatment of complicated parapneumonic pleural effusion in the fibrinopurulent phase in patients ≤ 14 years of age, regarding the postoperative evolution and occurrence of complications. Methods: This was a retrospective comparative study involving patients with parapneumonic pleural effusion presenting with septations or loculations on chest ultrasound who underwent thoracoscopy between January of 2000 and January of 2013. The patients were divided into two groups: early thoracoscopy (ET), performed by day 5 of hospitalization; and late thoracoscopy (LT), performed after day 5 of hospitalization. Results: We included 60 patients, 30 in each group. The mean age was 3.4 years; 28 patients (46.7%) were male; and 47 (78.3%) underwent primary thoracoscopy (no previous simple drainage). The two groups were similar regarding gender, age, weight, and type of thoracoscopy (p > 0.05 for all). There was a significant difference between the ET and the LT groups regarding the length of the hospital stay (14.5 days vs. 21.7 days; p < 0.001). There were also significant differences between the groups regarding the duration of fever in days; the total number of days from admission to the initiation of drainage; and the total number of days with the drain in place. Eight patients (13.6%) had at least one post-thoracoscopy complication, there being no difference between the groups. There were no deaths. Conclusions: Performing ET by day 5 of hospitalization was associated with shorter hospital stays, shorter duration of drainage, and shorter duration of fever, although not with a higher frequency of complications, requiring ICU admission, or requiring blood transfusion.

Keywords: Empyema, pleural; Thoracoscopy; Pneumonia.

Objective: To determine the efficacy of thoracoscopy in the management of children with complicated parapneumonic pleural effusion at the fibrinopurulent stage. Methods: Retrospective study of 99 children submitted to thoracoscopy for the treatment of complicated parapneumonic pleural effusion at the fibrinopurulent stage between November of 1995 and July of 2005. The mean age was 2.6 years (range, 0.4-12 years), and 60% were males. Thoracoscopy was performed at three different hospitals following the same treatment algorithm. Results: Thoracoscopy was effective for 87 children (88%). In 12 (12%), a second surgical procedure was required: another thoracoscopy (n = 6) or thoracotomy/thoracostomy (n = 6). Mean duration of chest tube drainage following successful thoracoscopy was 3 days vs. 10 days in patients submitted to a second procedure (p < 0.001). In all of the children, the pleural infection resolved after treatment. Thoracoscopy-related complications included air leak (30%), chest tube bleeding (12%), subcutaneous emphysema associated with trocar insertion (2%) and surgical wound infection (2%). None of the children required additional surgical procedures due to the complications. Conclusions: The effectiveness of thoracoscopy in children with parapneumonic pleural effusion at the fibrinopurulent stage was 88%. The procedure was safe, with a low rate of severe complications. Thoracoscopy should be the first-choice treatment for children with parapneumonic pleural effusion at the fibrinopurulent stage.

Keywords: Thoracoscopy; Pleural effusion; Empyema, pleural.

Objective: To compare the effects of early tracheostomy and of late tracheostomy in patients with acute severe brain injury. Methods: A retrospective study involving 28 patients admitted to the ICU of the Federal University of Juiz de Fora University Hospital in Juiz de Fora, Brazil, diagnosed with acute severe brain injury and presenting with a Glasgow coma scale (GCS) score < 8 within the first 48 h of hospitalization. The patients were divided into two groups: early tracheostomy (ET), performed within the first 8 days after admission; and late tracheostomy (LT), performed after postadmission day 8. At admission, we collected demographic data and determined the following scores: Acute Physiology and Chronic Health Evaluation (APACHE) II, GCS and Sequential Organ Failure Assessment (SOFA). Results: There were no significant differences between the groups (ET vs. LT) regarding the demographic data or the scores: APACHE II (26 ± 6 vs. 28 ± 8; p = 0.37), SOFA (6.3 ± 2.7 vs. 7.2 ± 3.0; p = 0.43) and GCS (5.4 ± 1.7 vs. 5.5 ± 1.7; p = 0.87). The 28-day mortality rate was lower in the ET group (9% vs. 47%; p = 0.04). Nosocomial pneumonia occurring within the first 7 days was less common in the ET group, although the difference was not significant (0% vs. 23%; p = 0.13). There were no differences regarding the occurrence of late pneumonia or in the duration of mechanical ventilation between the groups. Conclusions: On the basis of these findings, early tracheostomy should be considered in patients with acute severe brain injury.

Keywords: Tracheostomy; Pulmonary ventilation; Coma.

Objective: To evaluate Light's criteria for drainage in children with parapneumonic pleural effusion. Methods: Prospective cross-sectional study on 85 children who were admitted to Hospital da Criança Santo Antônio, State of Rio Grande do Sul, Southern Brazil, presenting pneumonia with pleural effusion confirmed by chest X-ray and/or chest ultrasonography. The exclusion criteria were: previous drainage, pleural effusions associated with other disorders. The pH analysis was performed with a blood gas analyzer. Glucose and LDH were analyzed by spectrophotometry. The decision to perform pleural drainage was made by the attending physician without the participation of the researchers. Results: Pleural fluid in parapneumonic effusion with pH < 7.2 and glucose < 40 mg/dl presented higher drainage rate than LDH > 1,000 UI/l. The pH and glucose had high specificity (89% and 88%) and above the LDH (65%). The same results were observed when non-purulent fluids were analyzed (pH < 7.2 94%, glucose 88%, LDH 68%). In patients with pH < 7.2 LDH > 1,000 UI/l and glucose < 40 mg/dl predominated fluid with cloudy or purulent aspect. In more than 21% of patients who have indication of drainage by the classic criteria, was found limpid aspect. Conclusions: These data indicate that biochemical test support indication of drainage in children presenting with parapneumonic pleural effusion in non-purulent fluid. The specificity for drainage was 89% for pH and 88% for glucose and around 65% for LDH.

Keywords: Pleural effusion. Pleural empyema. Postural drainage.

Objective: To determine the prevalence and the characteristics of Mycoplasma pneumoniae-related community-acquired pneumonia (CAP) and parapneumonic pleural effusion (PPE) in children and adolescents. Methods: This was a retrospective observational study involving 121 patients with CAP/PPE hospitalized in a tertiary referral hospital between 2000 and 2008, divided into six groups according to the etiologic agent (G1 to G6, respectively): M. pneumoniae with or without co-infection, in 44 patients (group 1); etiologic agents other than M. pneumoniae, in 77 (group 2); M. pneumoniae without co-infection, in 34 (group 3); Streptococcus pneumoniae, in 36 (group 4); Staphylococcus aureus, in 31 (group 5); and M. pneumoniae/S. pneumoniae co-infection, in 9 (group 6). Results: In comparison with group 2, group 1 showed higher frequencies of females, dry cough, and previous use of beta-lactam antibiotics; longer duration of symptoms prior to admission; and lower frequencies of use of mechanical ventilation and chest tube drainage. In comparison with groups 4 and 5, group 3 showed higher frequencies of previous use of beta-lactam antibiotics and dry cough; longer duration of symptoms prior to admission; a lower frequency of use of chest tube drainage; a higher mean age and a lower frequency of nausea/vomiting (versus group 4 only); and a lower frequency of use of mechanical ventilation (versus group 5 only). M. pneumoniae/S. pneumoniae co-infection increased the duration of symptoms prior to admission. Conclusions: In this sample, the prevalence of M. pneumoniae-related CAP/PPE was 12.75%. Although the disease was milder than that caused by other microorganisms, its course was longer. Our data suggest that M. pneumoniae-related CAP/PPE in children and adolescents should be more thoroughly investigated in Brazil.

Keywords: Pleural effusion; Empyema, pleural; Pneumonia; Mycoplasma pneumoniae.

Objective: Talc pleurodesis is a widely used treatment option for malignant pleural effusion (MPE). However, the optimal form of administration remains controversial. Thus, we performed a systematic review and meta-analysis to assess the effectiveness of talc slurry (TS) in comparison with thoracoscopic talc insufflation/poudrage (TTI) for MPE treatment. Methods: We searched PubMed, EMBASE, and Cochrane Library databases for studies that compared TS with TTI in patients with MPE. We used a random-effects model with a 95% CI to pool the data. Heterogeneity was assessed with I² statistics. Results: We included eight studies involving 1,163 patients, 584 of whom (50.21%) underwent TS. Pleurodesis failure rates were similar between the procedures (OR = 1.07; 95% CI: 0.56-2.06; p = 0.83; I² = 62%); and 68% of patients (95% CI: 0.31-1.47; p = 0.33; I² = 58%) had postoperative complications, which were lower in patients in the TS group than in the TTI group. In a subgroup analysis considering only randomized clinical trials, the failure rate was significantly lower in the TS treatment group (OR = 0.62; 95% CI: 0.42-0.90; p = 0.01; I² = 0%). Similarly, dyspnea was less common in the TS group (OR = 0.74; 95% CI: 0.41-1.34; p = 0.32; I² = 55%). Adverse effects were reported in 86 patients, and no significant difference was seen between the TS and TTI groups: empyema (OR = 1.43; 95% CI: 0.36-5.64; p = 0.86; I² = 0%), pain (OR = 1.22 (95% CI: 0.67-2.21; p = 0.51; I² = 38%), and pneumonia (OR = 1.15; 95% CI: 0.30-4.46; p = 0.86; I² = 27%). Conclusions: Our findings suggest that TS is an effective treatment for MPE, with no significant increase in adverse events. Results suggest equivalent efficacy and safety for both procedures.

Keywords: Talc; Pleurodesis; Pleural effusion, malignant.

Background: The decision to drain parapneumonic pleural effusion in children is still controversial. An indicative scoring system to assess the need for chest-tube drainage arose from a partnership between pediatricians and surgeons. Objective: To evaluate the utility of the score in indicating whether drainage should be performed in pediatric patients with parapneumonic effusion. Method: A cross-sectional study involving 250 inpatients with parapneumonic effusion, treated in a tertiary-care hospital between 1994 and 1999. The following variables were analyzed: clinical presentation, chest X-rays, pleural fluid culture and biochemical analysis of the pleural fluid, as well as the score and treatment. The score was based on four categories: general appearance of the pleural fluid, chest X-rays, laboratory findings, and the second thoracentesis. Drainage was recommended for patients scoring higher than 5.5. Results: Of 941 children with pneumonia, parapneumonic effusion occurred in 304 (32.2%), 250 of which were included in the study. Of those, 146 (58.4%) were male, with mean of age of 3 years (median, 2 years). The cutoff points (determined through receiver operating characteristic curve analysis) for suggesting pleural drainage were pH < 7.29 (89.2% sensitivity and 76.5% specificity), score > 5.0 (68.7% sensitivity and 81.7% specificity). These values were more strongly correlated with the need for drainage (p = 0.001), as were those reported in the literature (pH = 7.0 and glucose < 40). The lactate dehydrogenase did not prove to be a good parameter for indicating a need for drainage. Conclusion: In addition to the purulent aspect, pH = 7.29 and score were the best indicators of the need for chest-tube drainage in pediatric patients with parapneumonic effusion. However, we suggest that some score variables be readjusted to improve the usefulness of this particular scoring system.

Keywords: Empyema. Pleural effusion. Pneumonia.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Keywords: Fertilization in vitro; Ovarian hyperstimulation syndrome; Pleural effusion.

The authors report a case of pancreatic pseudocyst associated with massive pleural effusion. The patient was submitted to X rays, REED, ultrasonography, thoracoabdominal computerized tomography and amylase dosing in the pleural liquid. Clinical treatment included dietary support and thoracocentesis with drainage of about 3,200 ml. Patient was submitted to laparotomy to remove the pseudocyst, and was discharged in good clinical conditions. Based on this report, the authors analyze and review the literature for the occurrence of pleural effusion associated with pancreatic diseases and diagnoses.

Keywords: Pancreatic pseudocyst. Pleural effusion. Computerized X-ray tomography. Laparotomy.

Mycobacterium kansasii, a nontuberculous mycobacterium, can cause pulmonary disease presenting clinical and radiological similarities to tuberculosis. M. kansasii infection has been associated with risk factors such as bronchiectasis, chronic obstructive pulmonary disease, tuberculosis sequelae, pneumoconiosis and immunosuppression. Herein, we describe a case of pleural effusion in a 67-year-old patient with chronic obstructive pulmonary disease and a history of pulmonary tuberculosis. The histological analysis demonstrated a granulomatous chronic process and acid-fast bacilli positivity, suggesting a diagnosis of pleural tuberculosis. M. kansasii was detected both in pleural fluid cultures and in cultures of tissue samples. We discuss the differential etiologic diagnosis with other infectious agents of granulomatous diseases, and we address treatment options.

Keywords: Mycobacterium kansasii; Mycobacterium infections; Pleural effusion; Case reports

Castleman's disease is a rare disorder of the lymphoid tissue. We report the case of a female patient with bilateral otosclerosis, no respiratory symptoms, and pleural effusion discovered as an incidental finding on a chest X-ray. Computed tomography of the chest revealed a mediastinal mass. The biopsy findings demonstrated that it was a plasmacytic variant of Castleman's disease. The patient underwent mediastinal mass resection. This resulted in near-total resolution of the effusion, which remained as a small loculation within the left pleural space.

Keywords: Giant lymph node hyperplasia; Pleural effusion; Case reports.

Objective: To evaluate the results of thoracoscopy for the treatment of pleural empyema in pediatric patients. Methods: A retrospective study of 117 patients who underwent mediastinoscopy or video-assisted thoracoscopy for pleural empyema treatment. General anesthesia and single-lumen oral intubation were used. Surgery was indicated when there was pleural effusion and no clinical and radiological response to clinical treatment (antibiotics, physiotherapy and thoracocentesis) or severe sepsis, together with loculated pleural effusion (confirmed through ultrasound or computed tomography of the chest). Results: Between February of 1983 and July of 2006, 117 thoracoscopies were performed in patients ranging in age from 5 months to 17 years (mean, 4 years). Mean time for thoracic drainage was 9 days (range, 2-33 days), and mean period of hospitalization was 16.4 days (range, 4 to 49 days). One patient (0.8%) died after surgery, and persistent fistula was observed in 33 patients (28%). In 7 cases (6%), open thoracotomy with pulmonary decortication was performed due to the disposition of the empyema. Conclusions: Management of pleural empyema in this age bracket is still controversial, and surgical indication is often delayed, particularly when there are multiple loculations or severe sepsis. Early thoracoscopy yields a better clinical outcome for pediatric patients with pleural empyema, with apparent decreased morbidity and mortality, earlier chest tube removal, earlier hospital discharge and improved response to antibiotic therapy.

Keywords: Empyema, pleural; Pediatrics/instrumentation; Thoracoscopy; Thoracic surgery, video-assisted.

A 34-year-old patient had had Crohn's disease (CD) for eight years; she was seen for complaints of thoracic pain and fever, without gastrointestinal manifestations. Initial laboratory exams were compatible with the presence of inflammatory activity (VHS = 45 mm for normal value of 20 mm and PCR+). The physical exam revealed signs of pleural effusion in the left hemithorax base, which was confirmed by thoracic RX. The pleural liquid analysis showed that the cells were 100% of lymphocytes, with negative BAAR research. The pleural biopsy evidenced non caseous granuloma. Despite the tuberculosis treatment, the patient only got better when corticotherapy was introduced in high doses, suggesting the activity of CD as the cause of the pleural effusion. This case establishes a connection between activity of CD and manifestations of lung disease.

Primitive neuroectodermal tumor is an invasive neoplasm with neuronal differentiation, which frequently results in metastasis in various organs. We report the case of a patient with primitive neuroectodermal tumor whose primary site was the axilla. The patient presented with metastases in the lung, pleura, bone, iliac muscle and bone marrow. We highlight the uncommon finding in the pleural fluid cytology.

Keywords: Neuroectodermal tumors, primitive; Neoplasm metastasis; Cytology; Pleural effusion.

Teratomas account for 8-13% of all mediastinal tumors. A 27-year-old patient presented with chest pain and dyspnea of prolonged evolution. A chest X-ray revealed near total opacification of the right hemithorax. On a tomography scan of the chest, a collection of heterogeneous fluid, with irregular borders and 10.1 x 11.7 cm in size, was seen in the pleura of the lower two-thirds of the right hemithorax but was not encroaching on any of the adjacent structures. Based on the hypothesis that these findings represented a benign mediastinal teratoma, an exploratory thoracotomy was performed, during which such a teratoma was found and completely excised. The post-operative evolution was favorable. The atypical presentation and considerable growth of the tumor hindered the pre-operative diagnosis.

Keywords: Teratoma; Mediastinal neoplasms; Pleural effusion; Radiography thoracic