med 610 clinical respiratory diseases & critcare med

Pleural Effusions

Case 8

A 45 year-old man is seen in clinic for fever, productive cough and dyspnea on exertion of several days duration. A chest x-ray shown below (top film) revealed a left lower lobe pneumonia but he was deemed stable for outpatient treatment and was sent home on oral levofloxacin. Two days later, he returns complaining of increasing fevers, worsening left-sided chest pain and increasing dyspnea. A chest x-ray is obtained and is shown below (bottom film):

chest x-ray

chest x-ray

How would you interpret the chest x-rays?


What should be your next step in the work-up?


You do the appropriate diagnostic study and then perform a thoracentesis. The pleural fluid is cloudy appearing. Pleural fluid LDH is 1050 (serum value 135) with a total protein of 4.8 (serum value 7.8). Gram’s stain reveals 3+ WBC with gram positive cocci in chains. The WBC differential includes 75% polymorphonuclear cells, and 20% monocytes.  The pH of the pleural fluid is 7.15 and the pleural fluid glucose is 25.

How do you interpret these results?


How do you interpret the pleural fluid pH and pleural fluid glucose?


What is the next most appropriate management step for this patient? For what problem is this patient at risk if you fail to take the appropriate action in this case?


Return to Case Index | Go to Case 8 answers

Top of Page