Trop Doct 2008;38:219-220
doi:10.1258/td.2007.070275
© 2008 Royal Society of Medicine Press
The characteristics and causes of pleural effusions in Kumasi Ghana – a prospective study
Benjamin Afful *
Stephen Murphy 
George Antunes
Vytis Dudzevicius
* Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana;
Department of Respiratory Medicine, The James Cook University Hospital, Middlesbrough, UK
Correspondence to: Benjamin Afful, Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana Email: benjieaab{at}yahoo.com
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Introduction
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Pleural effusion is a common clinical presentation with a broad
differential diagnosis. The aetiology of pleural effusions varies
geographically, but most investigation guidelines are based
upon factors pertinent to the industrialized societies where
malignancies predominate.
1–3 However, in developing nations
infections – especially TB and parapneumonic effusions
(PPE) are more prevalent.
4–7 The purpose of this study
was to determine the characteristics and causes of pleural effusions
in adults in Kumasi, and to develop a diagnostic algorithm that
precludes the need for investigations which may not be available.
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Methods
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This prospective study was done at the Komfo Anokye Teaching
Hospital (KATH) Kumasi, Ghana. Adults (>15 years) admitted
to the hospital with pleural effusion were considered eligible
for the study. The investigations included chest X-rays, full
blood count, HIV serology, sputum microscopy and culture (including
TB), pleural aspiration for protein, lactate dehydrogenase (LDH),
microscopy, differential cell count and culture (including TB)
and cytology. Effusions were classified radiologically as large
unilateral (L > 50% of hemithorax) small unilateral (S <
50% of hemithorax) and bilateral (B). They were also classified
as exudates (pleural fluid protein >30 g/dL) or transudates.
Pleural biopsy is not available at KATH; the diagnosis of TB
was based upon clinical assessment and responses to trials of
standard anti-TB chemotherapy.
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Results
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We assessed120 consecutive adults with pleural effusion. Nineteen
were excluded due to: no evidence of informed consent (8), the
patient being too unwell (9), pleural fluid had not obtained
(2). Forty-seven men and 54 women were included in the analysis
(Table
1). The men were younger than the women and more
likely to have smoked, but none had been exposed to asbestos.
HIV serology was positive in 38.6% with a slight female predominance,
and there was a high prevalence of anaemia. The common symptoms
were:
- cough (90.1%), usually productive (82.4%);
- dyspnoea (89%);
- fever (72.3%);
- chest pain (70%);
- weight loss (60%).
Most effusions were unilateral (78.6%) and right-sided (59.7%).
Effusions were exudates in 84.2% of total and 100% if HIV positive.
The causes of exudates were: TB 63.5% (54), PPE 21.2% (18),
non-TB empyema (6), malignancy (6) and fungal infection (1).
The causes of bilateral effusions were: cardiac failure (8),
TB (8), chronic renal failure (1), PPE (2), non-TB empyema (1)
and carcinoma of the breast (1). There were 26 (25.7%) haemorrhagic
effusions, the causes of which included TB (15), malignancy
(4), PPE (2) and fungal infection (1). Pleural fluid cultures
for TB were negative in all cases and only two were sputum culture
positive. The characteristics most associated with diagnosis
of TB were large unilateral exudates and positive HIV serology
(Table
2). Plasma LDH and differential cell count were
none discriminating.
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Discussion
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Studies of pleural effusion in adults in sub-Saharan Africa
have established that the differential diagnosis is between
TB and other causes. In previous studies TB was the cause of
pleural effusion in 66–95%, with positive HIV serology
in 42–72%.
4–7 Our findings were similar: we attributed
63.5% of pleural exudates to TB of which 55.5% were HIV positive.
However, in this study the diagnosis of TB was based almost
entirely on clinical judgement and the response to anti-tuberculous
chemotherapy. Pleural biopsy is not available at KATH but pleural
fluid is routinely aspirated for culture and biochemistry. However,
of the investigations performed only the effusion size (on chest
X-ray), HIV serology and pleural protein had any discriminating
value. Most patients with transudates could have been identified
clinically and would not have required pleural aspiration. Similarly,
most PPE are associated with a clinical evidence of pneumonia;
pleural aspiration is necessary only if effusions are large
or if empyema is suspected. For patients with malignant effusions
there is often other clinical evidence of malignancy.
We propose a simple algorithm that would ensure that patients are treated appropriately while minimizing the need for laboratory investigations (Figure 1). The most important laboratory test is HIV serology. HIV-positive patients with large effusions should be given a trial of anti-TB therapy without further investigation. Other HIV-positive patients should also be treated for TB if an alternative cause for the effusion is not apparent after minimal investigation. Only HIV-negative patients (with a pleural exudate) would require further diagnostic investigations. Had we followed this algorithm less than half of the patients would have required diagnostic pleural aspiration and few would have required further investigation. However, this algorithm requires further evaluation.
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Figure 1 An algorithm for pleural effusions. Numbers in parentheses: number of cases with TB/total for each group. CCF, congestive cardiac failure; CRF, chronic renal failure
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Conclusions and recommendations
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Pleural effusions in Ghanaian adults are usually due to TB and
are associated with HIV infection. Minimal laboratory investigations
are required to establish a diagnosis.
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References
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- Antunes G, Neville E, Duffy J, et al. BTS guidelines for the management of malignant pleural effusions. Thorax 2003; 58(Suppl. II):ii29–38[Free Full Text]
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- Maher GG, Berger HW. Massive pleural effusion: malignant and nonmalignant causes in 46 patients. Am Rev Respir Dis 1972; 105:458–60[Medline]
- Batungwanayo J, Taelman H, Allen S, et al. Pleural effusion, tuberculosis and HIV-1 infection in Kigali, Rwanda. AIDS 1993;7:73–9[Medline]
- Richter C, Perenboom R, Mtoni I, et al. Clinical features of HIV seropositive and HIV-seronegative patients with tuberculous pleural effusion in Dar es Salaam, Tanzania. Chest 1994; 106:1471–5[Medline]
- Owino EA, McLigeyo SO, Gathua SN, et al. Prevalence of human immuno-deficiency virus infection: its impact on the diagnostic yields in exudative pleural effusions at the Kenyatta National Hospital, Nairobi.East Afr Med J 1996;73:575–8[Medline]
- Koffi N, Aka-Danguy E, Kouassi B, et al. Etiologies of pleurisies in African milieu. Experience of the Cocody Pneumology department (Abidjan-Cote d'Ivoire). Rev Pneumol Clin 1997;53:193–6[Medline]
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Introduction
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