Pleural Effusion: Causes and Concerns of Blood-tinged Fluid

Pulmonary edema

I would like to ask the doctor about my father, who is 61 years old.
At the beginning of June, he experienced symptoms of fever and cold.
After taking medication for a few days at a clinic without improvement, he went to the emergency room one night in mid-June because he felt pain when turning in bed and when sitting up.
It was then discovered that he had pleural effusion on both sides.
He was hospitalized for four to five days and received intravenous fluids, which significantly improved the fluid accumulation.
He no longer had fever or cold symptoms and could sleep normally.
However, during the procedure to drain the pleural effusion, the doctor found that the fluid was bloody, which is not the normal color, causing great concern for the family.
After researching online, we found that normal pleural effusion should be colorless.
I would like to ask the doctor, is bloody pleural effusion very serious? What are the possible causes of bloody pleural effusion, aside from cancer? Are there any other reasons that could lead to bloody pleural effusion? Thank you!

kai, 20~29 year old female. Ask Date: 2010/06/21

Dr. Tao Ruiming reply Pulmonology

1.
Confirm that during thoracentesis for pleural effusion, there was no significant microvascular rupture.
2.
A pleural effusion is classified as a hemothorax when the hematocrit of the pleural effusion is greater than half of that of the blood.
When the hematocrit of the pleural effusion is less than half of that of the blood, it is commonly associated with malignant tumors or metastases, such as lung cancer, breast cancer, lymphoma, leukemia, gastrointestinal malignancies, and ovarian cancer, which can be confirmed through cytological analysis of the pleural effusion.
When the hematocrit of the pleural effusion is greater than half of that of the blood, it is most commonly due to ruptured intrathoracic blood vessels from trauma; other causes are rare bleeding disorders (such as vitamin K deficiency), congenital disorders, pulmonary arteriovenous malformations, connective tissue diseases (such as intrathoracic vascular bleeding), malignant rib tumors, and spontaneous pneumothorax.
Further clinical diagnosis is required for confirmation.

Reply Date: 2010/06/21

More Info

Pleural effusion, or the accumulation of fluid in the pleural space surrounding the lungs, can present in various forms, including blood-tinged fluid, which raises significant clinical concerns. In your father's case, the presence of blood in the pleural effusion is particularly noteworthy and warrants a thorough investigation to determine the underlying cause.

Causes of Blood-Tinged Pleural Effusion
1. Malignancy: While you mentioned a concern about cancer, it is indeed one of the most common causes of bloody pleural effusion. Tumors can invade the pleura or cause irritation, leading to bleeding.

2. Infection: Conditions such as pneumonia or tuberculosis can lead to pleural effusion. In cases of empyema (infected pleural effusion), the fluid may appear bloody due to the presence of inflammatory cells and bacteria.

3. Trauma: Any injury to the chest, including rib fractures or penetrating injuries, can cause bleeding into the pleural space.

4. Pulmonary Embolism: A blood clot in the lungs can lead to hemorrhagic pleural effusion, especially if there is associated lung infarction.

5. Inflammatory Conditions: Diseases like rheumatoid arthritis or lupus can cause pleuritis, leading to bloody effusion.

6. Vascular Issues: Conditions that affect blood vessels, such as vasculitis or certain coagulopathies, can also result in bleeding into the pleural space.

Clinical Significance
The presence of blood in pleural effusion is clinically significant and often indicates a more serious underlying condition. It is essential to differentiate between transudative and exudative effusions, as this can guide further management. The Light's criteria are commonly used to classify pleural effusions based on the protein and lactate dehydrogenase (LDH) levels in the pleural fluid compared to serum levels.

Diagnostic Approach
Given your father's situation, the following steps are typically recommended:
1. Thoracentesis: This procedure not only helps relieve symptoms by removing excess fluid but also allows for analysis of the fluid. Cytology, microbiological cultures, and biochemical analysis can provide critical information regarding the cause of the effusion.

2. Imaging Studies: A chest X-ray or CT scan can help visualize the extent of the effusion and identify any underlying lung pathology.

3. Further Testing: Depending on the initial findings, additional tests such as bronchoscopy or biopsy may be warranted to investigate for malignancy or other conditions.

Management and Prognosis
The management of pleural effusion depends on the underlying cause. If the effusion is due to infection, antibiotics may be necessary. In cases of malignancy, oncological treatment may be required. For symptomatic relief, procedures like pleural drainage or pleurodesis (a procedure to adhere the pleura to prevent future effusions) may be considered.

Conclusion
In summary, while the presence of blood-tinged pleural effusion can be alarming, it is essential to approach the situation with a comprehensive diagnostic strategy. Understanding the underlying cause is crucial for effective management and improving your father's prognosis. It is advisable to maintain close communication with his healthcare providers to ensure that all necessary investigations and treatments are pursued.

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