Pleural Effusion in Children: Clinical Case and Viva QnA

Clinical Case: Pleural Effusion in Children

Case Presentation

A 7-year-old boy is brought to the emergency department with a 5-day history of fever, cough, and progressive shortness of breath. His parents report that he has been less active than usual and has had a poor appetite. On examination, the child appears pale and tachypneic, with a respiratory rate of 32 breaths per minute. His temperature is 39.2°C, heart rate 110 beats per minute, and oxygen saturation 94% on room air.

On auscultation, there are decreased breath sounds and dullness to percussion over the right lower lung field. The child winces when the right side of his chest is palpated. A chest X-ray reveals a large right-sided pleural effusion with some compression of the right lung.

Diagnostic Workup

• Complete blood count: WBC 18,500/µL with neutrophil predominance, Hb 10.8 g/dL, Platelets 450,000/µL
• C-reactive protein: 85 mg/L
• Blood cultures: Pending
• Chest ultrasound: Confirms large right-sided pleural effusion with internal echoes suggesting exudative fluid

Management

The child undergoes thoracentesis, which yields 350 mL of cloudy, yellowish fluid. Analysis of the pleural fluid shows:

• pH: 7.1
• Protein: 4.5 g/dL
• LDH: 1200 U/L
• Glucose: 40 mg/dL
• WBC count: 15,000/µL with 85% neutrophils
• Gram stain: Gram-positive cocci in chains

Based on these findings, a diagnosis of complicated parapneumonic effusion is made. The child is started on intravenous antibiotics and a chest tube is placed for continuous drainage. Over the next few days, the child's clinical condition improves, and he is discharged after a week with oral antibiotics to complete a 3-week course.

Varieties of Presentation of Pleural Effusion in Children

1. Parapneumonic Effusion (Infectious)

   Most common in children. Presents with fever, cough, chest pain, and respiratory distress. Often follows bacterial pneumonia, with Streptococcus pneumoniae being the most frequent causative organism.

2. Malignant Effusion

   Associated with cancers like lymphoma or metastatic disease. May present with gradual onset of respiratory symptoms, weight loss, fatigue, and sometimes fever. Effusion may be unilateral or bilateral.

3. Tuberculous Pleurisy

   More common in endemic areas or immunocompromised children. Presents with low-grade fever, weight loss, night sweats, and gradual onset of respiratory symptoms. Effusion is typically unilateral.

4. Chylothorax

   Can be congenital or acquired (e.g., post-surgical). Presents with gradual onset of respiratory distress. Effusion fluid is characteristically milky white due to high lipid content.

5. Transudative Effusion (e.g., due to Congestive Heart Failure)

   Presents with gradual onset of dyspnea, orthopnea, and sometimes peripheral edema. May be bilateral. Often associated with underlying cardiac conditions or hypoproteinemic states.

Knowledge Check: Question and Answers

This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.

Question 1 of 30

Image Gallery

These medical images are collected from various internet sources for educational purposes. Each image includes a source link; by clicking the source, you will be taken to the corresponding source website page.

Parapneumonic Pleural Effusion

Excavated pneumonia in the lower left lobe (arrow 1) with a pleural effusion of 3 cm thick (arrow 2).(source)

Severe community-acquired adenovirus pneumonia

A chest X-ray on hospital day 2 showed rapid progression of the consolidation and pleural effusion (A). After administration of ribavirin, the lesions were completely resolved on hospital day 13 (B).(source)

Boerhaave's Syndrome

Chest X-ray, 2 h after admission, revealing a rapidly evolving right pleural effusion.(source)