|
| |
 |
|
| REVIEW ARTICLE |
|
| Year : 2018 | Volume
: 7
| Issue : 1 | Page : 1-4 |
|
Black Pleural Effusion
Surya S Palakuru, Praveen Vijhani, Sujith V Cherian
Department of Internal Medicine, Divisions of Pulmonary, Critical Care and Sleep Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| Date of Web Publication | 26-Feb-2018 |
Correspondence Address:
Dr. Sujith V Cherian
Department of Internal Medicine, Divisions of Pulmonary, Critical Care and Sleep Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, Texas 77030
USA
 Source of Support: None, Conflict of Interest: None  | 4 |
DOI: 10.4103/rcm.rcm_24_17
Pleural effusions are common in clinical practice. In general, the diagnostic approach starts with thoracentesis. Serous (yellow) and blood tinged (reddish) pleural effusions are the most common types of pleural fluid at thoracentesis. Black colored pleural effusions are an extremely rare entity and knowledge regarding this entity is limited to case reports. A thorough systemic search on PubMed database was done looking at all reported cases of black pleural effusion. Broadly, dividing black pleural effusion based on etiology, the causes are as follows: (1) infectious – especially fungal – Aspergillus niger, Rhizopus oryzae, (2) malignancy -metastatic melanoma and primary lung cancers, (3) pancreaticopleural fistula, and (4) miscellaneous causes-including crack cocaine use, rheumatoid pleurisy, and charcoal containing empyema. Treatment of these effusions involves treatment of the underlying cause. Black pleural effusions are very rare entities with a limited differential, which the treating clinician should consider when encountered in clinical practice.
Keywords: Black pleural effusion, infection, malignancy, pancreaticopleural fistula
How to cite this article:
Palakuru SS, Vijhani P, Cherian SV. Black Pleural Effusion. Res Cardiovasc Med 2018;7:1-4 |
| Introduction | |  |
Visceral and parietal layers of pleura enclose a potential space called pleural space, which is lined by mesothelial cells. In a normal individual, pleural space is filled with approximately 0.25 ml/kg of pleural fluid at any given time.[1] According to available data, pleural fluid is formed at the rate of 0.6 ml/h from systemic vessels of the pleural membranes and absorbed almost at the same rate by the parietal pleural lymphatic system.[2],[3],[4] Any disturbance in the balance of production and/or absorption of pleural fluid will result into accumulation of a large quantity of pleural fluid called pleural effusion.[5]
As per the Starling equation, excessive production of pleural fluid is due to increased permeability of microvascular membrane and/or imbalance between hydrostatic and osmotic forces across a micro-vascular membrane.[6],[7] Net hydrostatic force is the difference between microvascular pressure and pleural pressure. Positive hydrostatic force favors increase production.[8],[9] An elevation in microvascular pressure is usually caused by an elevation in venous pressure. Examples of increased microvascular pressure include heart failure, pulmonary embolism, superior vena cava syndrome, and brachiocephalic venous obstruction.[10],[11],[12],[13],[14] On the other hand, significant atelectasis will result in a decrease in the pleural pressure and promotes pleural effusion. Hypoalbuminemia (due to nephrotic/nephritic syndromes, malnutrition, or liver disorders) results in a decrease in the plasma oncotic pressure, thereby increasing the forces favoring pleural effusion formation.[15] Decreased absorption of pleural fluid with or without increased production will also result into pleural effusion. Absorption rate is broadly dependent on lymphatic patency, availability of liquid, the pressures influencing pleural pressure, and the systemic venous pressure of lymphatics.[16],[17] Some diseases that result in pleural effusion due to decreased absorption are hypothyroidism, lymphangiomatosis carcinomatosis, pleural fibrosis, and secondary effects of chemotherapeutic agents.
Infection, malignancy, and inflammatory disorders of the pleura increase the permeability and results in a pleural effusion.[18],[19] Drugs have rarely been associated with the development of pleural effusions – the common ones implicated include nitrofurantoin, dantrolene, valproic acid, and propylthiouracil which all have been seen to cause pleural inflammation and pleural fluid eosinophilia. Other drugs, which have been associated with pleural effusions, include methysergide that causes pleural fibrosis and hydralazine, procainamide which has been known to cause lupus with concomitant pleural effusions.[20]
Analyzing the pleural fluid and classifying it as either transudate or exudate helps to narrow the differential diagnosis.[21] Ultrasound-guided thoracentesis permits rapid sampling and visualization of the pleural fluid. The sample is then sent for microbiological evaluation and quantification of chemical and cellular content. On gross evaluation, the color of fluid ranges from white to black; pale yellow, yellow-green, and red are common, brown, dark green, and black are rare.[22] In this review article, we will be discussing the pathophysiology and the causes of the rare black pleural effusion.
| Pathophysiology Of Black Pleural Effusion | | |
Causes of a black pleural effusion can be classified as an infection due to Rhizopus oryzae and Aspergillus niger, malignant-melanoma due to melanoma cells imparting black and adenocarcinoma lung, considered secondary to hemorrhage with hemolysis of blood in the pleural space, pancreaticopleural fistula (PPF), rupture of a pseudopancreatic cyst (also considered secondary to hemorrhage and hemolysis, or others (i.e., charcoal containing empyema or use of crack cocaine).[23]
| Methods | | |
We used PubMed to search for articles/abstracts on black pleural effusion published in English language journals between 1980 and 2016. In total, we found 9 case reports, 3 abstracts, and 1 review, which were used for this review article.
| Results | | |
Black pleural effusion is a very rare condition. It has only been described in a small number of case reports in literature. True incidence of this condition is unknown. The different types of black pleural effusion with respect to etiology are outlined below.
Infection
Fungal infections have been reported to be associated with black pleural effusion.
Metzger et al. reported a patient with bronchopleural fistula and empyema.[24] Thoracentesis revealed black turbid fluid with pH <5.9, glucose 70 mg/dL. A. niger was isolated from pleural fluid cultures. Macroscopically, A. niger colonies appear large, globose, and dark brown to black, which might explain the color of the effusion. Kimmerling et al. reported black, friable, and gritty material confirmed by transbronchial lung biopsy in a patient with invasive aspergillosis.[25] Oxalic acid is a fermentation product of A. niger and oxalate crystals can cause localized tissue damage and severe hemorrhage.[26],[27] Hemolysis leading to hemosiderin-laden macrophages in the pleural fluid is another explanation for the color of the effusion.
Lai et al. reported a case of empyema and black colored pleural effusion in an allogeneic bone marrow transplant patient.[28]Rhizopus oryzae was repeatedly isolated from the pleural fluid. The mechanism was presumed to be due to necrotic debris caused by the fungal infection or liquefaction of old blood from a previous thoracentesis in the setting of coagulopathy.
Malignancy
There have been 3 case reports of black pleural effusion associated with metastatic melanoma.[29],[30],[31] Metastatic melanoma accounts for 5% of all secondary malignancies of the lung.[32] Chen et al. reported an incidence of 2% for malignant pleural effusion in metastatic melanoma.[33] Patients presented with chest pain, shortness of breath and cough. Pleural effusions were noted on either sides or the left side. Pleural fluid analysis revealed an exudate and no evidence of infection (negative pleural fluid cultures).[29],[31] Cytologic examination showed intracytoplasmic deposits of melanin pigment in malignant cells.[29],[30],[31] One patient had successful pleurodesis performed with vincristine.
Black pleural effusion has also reported in patients with primary lung malignancies.[34],[35] Thampy and Cherian reported a patient with metastatic mucinous adenocarcinoma of the lung that presented as a massive left pleural effusion. Jayakrishnan et al. reported a case with lung adenocarcinoma presenting as a massive right pleural effusion. Pleural fluid analysis revealed an exudate with high protein and lactate dehydrogenase (LDH). Pleural fluid revealed groups of neoplastic cells arranged in balls, glandular, and papillioid configuration in a hemorrhagic background with mesothelial cells and mixed population of inflammatory cells.[35]
Pancreaticopleural fistula
PPF is a rare condition whose incidence is unclear. In 90% of cases, it occurs as a complication of chronic pancreatitis.[36],[37] A massive pleural effusion is the most common radiologic finding and it can be left-sided, right-sided, or bilateral (76%, 19%, and 14% of cases, respectively).[37] Disruption of a pseudocyst results in a retroperitoneal fistula which tracks through a natural hiatus in the diaphragm into the mediastinum. Pleural fluid amylase level >1000 IU/L is highly suggestive of this condition. In other causes of amylase-rich pleural effusions such as acute pancreatitis, malignancy, esophageal rupture, and amylase levels are significantly lower (<1000 IU/L). Visualizing the fistula track is sometimes difficult. Computed tomography and magnetic resonance cholangiopancreatography are helpful in diagnosis. Endoscopic retrograde cholangiopancreatography is both diagnostic and therapeutic (stent placement) in certain cases.
Multiple cases of black pleural effusion in patients with PPF have been reported.[38],[39],[40],[41] Pleural effusion in these cases is generally more often left sided. Pleural fluid amylase levels ranged from 5000 to 53,000 IU/L. Cytologic examination of pleural fluid revealed hemosiderin-laden macrophages in one case [40] and elevated indirect bilirubin and red blood cells were noted in the pleural fluid of another case. Bleeding into the pleural cavity followed by hemolysis was presumed to be the etiology in these cases.
Bilious pleural effusion can be mistaken for black pleural effusion due to the appearance of the fluid (dark green). Evidence of biliary obstruction, green color of pleural fluid, presence of glycoholic acid, and indirect bilirubin predominance are characteristic for a bilious effusion.[23]
Other miscellaneous causes
Singh et al. reported two patients with active crack cocaine use who developed black pleural effusions.[42] Both of them had bilateral pleural effusions. The etiology of pleural effusions was thought to be Kaposi sarcoma with pleural involvement in one patient and underlying dilated cardiomyopathy in the other. The presence of carbonaceous material in the cytoplasm of pulmonary alveolar macrophages in bronchoalveolar lavage samples of crack cocaine users has been reported.[43] Carbon-laden macrophages were also noted in the pleural fluid specimens in these two patients hence imparting the black to these effusions, and hypothesized to be secondary to crack cocaine use.
Justiniani et al. reported a case of a young male with alcohol and drug overdose who developed charcoal containing empyema following treatment of a tension pneumothorax.[44] Thoracentesis revealed black purulent fluid and gram stain revealed charcoal particles. Presumed cause was aspiration of activated charcoal, which subsequently leaked into the pleural space through an esophageal tear.
Another case of a black pleural effusion presumed to be secondary to rheumatoid pleurisy has been reported.[45] Pleural fluid was black with fluid analysis suggestive of exudate with low glucose (25 mg/dl), high LDH (3698 units/l), and elevated red blood cell count. Workup was positive for rheumatoid factor and elevated anti-CCP levels. Hemolysis was thought to be the underlying mechanism.
| Treatment and Prognosis | | |
Management of black pleural effusion, as in all pleural effusions, usually involves treatment of the underlying condition. Pancreatic pseudocysts can be managed either conservatively or with invasive interventions (resection of pseudocyst, stent placement in pancreatic duct). There is no clear consensus on the indications for intervention.[46] In cases of empyema, prompt drainage of pleural fluid with a chest tube is recommended along with antibiotics. In patients with malignancies, apart from treatment of underlying malignancies, symptom palliation can be achieved with pleural fluid drainage with small bore pigtail catheter or indwelling pleural catheters.[29],[34] Chemical pleurodesis with vincristine was also found to be successful in one case report.[30] Prognosis differs in individual cases and depends on the underlying disease and overall health status of the patient.
| Conclusion | | |
Black pleural effusions are thus a rare entity of exudative pleural effusions with a very limited differential. Black color to the pleural effusions per se does not imply a poor prognosis, but prognosis in fact depends on the underlying disease. Knowledge of these causes is important to the clinician who encounters such cases in clinical practice. Discrimination from the similar appearing bilious pleural effusion secondary to bilopleural fistula is made based on the presence of elevated indirect bilirubin levels and glychocholic acids in the pleural fluid.[23] This is of importance to treating physicians as management of bilious pleural effusions can pose to be a challenge and time is of the essence due to the high rate of superimposed infections.[47]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Noppen M, De Waele M, Li R, Gucht KV, D'Haese J, Gerlo E, et al. Volume and cellular content of normal pleural fluid in humans examined by pleural lavage. Am J Respir Crit Care Med 2000;162:1023-6.  |
| 2. | Miserocchi G, Negrini D, Mariani E, Passafaro M. Reabsorption of a saline-or plasma-induced hydrothorax. J Appl Physiol Respir Environ Exerc Physiol 1983;54:1574-8. [ PUBMED] |
| 3. | Broaddus VC, Wiener-Kronish JP, Berthiaume Y, Staub NC. Removal of pleural liquid and protein by lymphatics in awake sheep. J Appl Physiol (1985) 1988;64:384-90. |
| 4. | Staub NC, Wiener-Kronish JP, Albertine KH. Transport through the Pleura: Physiology of Normal Liquid and Solute Exchange in the Pleural Space. New York: Marcel Dekker; 1985. |
| 5. | Broaddus VC, Light RW. Pleural Effusion. Murray & Nadel's Textbook of Respiratory Medicine. 6 th ed. Philadelphia, PA: Elsevier; 2016. p. 1396. |
| 6. | Starling EH. On the absorption of fluids from the connective tissue spaces. J Physiol 1896;19:312-26. [ PUBMED] |
| 7. | Staub NC. Pulmonary edema. Physiol Rev 1974;54:678-811. [ PUBMED] |
| 8. | Albertine KH, Wiener-Kronish JP, Staub NC. The structure of the parietal pleura and its relationship to pleural liquid dynamics in sheep. Anat Rec 1984;208:401-9. [ PUBMED] |
| 9. | Lai-Fook SJ. Pleural mechanics and fluid exchange. Physiol Rev 2004;84:385-410. [ PUBMED] |
| 10. | Rice TW. Pleural effusions in superior vena cava syndrome: Prevalence, characteristics, and proposed pathophysiology. Curr Opin Pulm Med 2007;13:324-7. [ PUBMED] |
| 11. | Good JT Jr., Moore JB, Fowler AA, Sahn SA. Superior vena cava syndrome as a cause of pleural effusion. Am Rev Respir Dis 1982;125:246-7. |
| 12. | Mellins RB, Levine OR, Fishman AP. Effect of systemic and pulmonary venous hypertension on pleural and pericardial fluid accumulation. J Appl Physiol 1970;29:564-9. [ PUBMED] |
| 13. | Wiener-Kronish JP, Goldstein R, Matthay RA, Biondi JW, Broaddus VC, Chatterjee K, et al. Lack of association of pleural effusion with chronic pulmonary arterial and right atrial hypertension. Chest 1987;92:967-70. [ PUBMED] |
| 14. | Wright RS, Quinones-Baldrich WJ, Anders AJ, Danovitch GM. Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization and arteriovenous fistula formation for hemodialysis. Chest 1994;106:950-2. [ PUBMED] |
| 15. | Joseph J, Strange C, Sahn SA. Pleural effusions in hospitalized patients with AIDS. Ann Intern Med 1993;118:856-9. [ PUBMED] |
| 16. | Quick CM, Venugopal AM, Dongaonkar RM, Laine GA, Stewart RH. First-order approximation for the pressure-flow relationship of spontaneously contracting lymphangions. Am J Physiol Heart Circ Physiol 2008;294:H2144-9. [ PUBMED] |
| 17. | Hosking B, Makinen T. Lymphatic vasculature: A molecular perspective. Bioessays 2007;29:1192-202. [ PUBMED] |
| 18. | Kraft A, Weindel K, Ochs A, Marth C, Zmija J, Schumacher P, et al. Vascular endothelial growth factor in the sera and effusions of patients with malignant and nonmalignant disease. Cancer 1999;85:178-87. [ PUBMED] |
| 19. | Bradshaw M, Mansfield A, Peikert T. The role of vascular endothelial growth factor in the pathogenesis, diagnosis and treatment of malignant pleural effusion. Curr Oncol Rep 2013;15:207-16. [ PUBMED] |
| 20. | Morelock SY, Sahn SA. Drugs and the pleura. Chest 1999;116:212-21. [ PUBMED] |
| 21. | Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: The diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13. [ PUBMED] |
| 22. | Sahn SA, Huggins JT, San Jose E. The art of pleural fluid analysis. Clin Pulm Med 2013;20:77-96. |
| 23. | Saraya T, Light RW, Takizawa H, Goto H. Black pleural effusion. Am J Med 2013;126:641. e1-6. |
| 24. | Metzger JB, Garagusi VF, Kerwin DM. Pulmonary oxalosis caused by Aspergillus niger. Am Rev Respir Dis 1984;129:501-2. [ PUBMED] |
| 25. | Kimmerling EA, Fedrick JA, Tenholder MF. Invasive Aspergillus niger with fatal pulmonary oxalosis in chronic obstructive pulmonary disease. Chest 1992;101:870-2. [ PUBMED] |
| 26. | Raper KB. Charles Thom, november 11, 1872-may 24, 1956. Biogr Mem Natl Acad Sci 1965;38:309-44. [ PUBMED] |
| 27. | Kurrein F, Green GH, Rowles SL. Localized deposition of calcium oxalate around a pulmonary Aspergillus niger fungus ball. Am J Clin Pathol 1975;64:556-63. [ PUBMED] |
| 28. | Lai CC, Liaw SJ, Hsiao YC, Chiu YS, Laio WY, Lee LN, et al. Empyema thoracis due to Rhizopus oryzae in an allogenic bone marrow transplant recipient. Med Mycol 2006;44:75-8. [ PUBMED] |
| 29. | Liao WC, Chen CH, Tu CY. Black pleural effusion in melanoma. CMAJ 2010;182:E314. [ PUBMED] |
| 30. | Mohan KM, Gowrinath K. Unusual thoracic manifestation of metastatic malignant melanoma. Lung India 2010;27:96-8. [ PUBMED] [Full text] |
| 31. | Chhabra A, Mukherjee V, Chowdhary M, Danckers M, Fridman D. Black pleural effusion: A Unique presentation of metastatic melanoma. Case Rep Oncol 2015;8:222-5. [ PUBMED] |
| 32. | Libshitz HI, North LB. Pulmonary metastases. Radiol Clin North Am 1982;20:437-51. [ PUBMED] |
| 33. | Chen JT, Dahmash NS, Ravin CE, Heaston DK, Putman CE, Seigler HF, et al. Metastatic melanoma in the thorax: Report of 130 patients. AJR Am J Roentgenol 1981;137:293-8. [ PUBMED] |
| 34. | Thampy E, Cherian SV. Black pleural effusion. QJM 2016;109:761. [ PUBMED] |
| 35. | Jayakrishnan B, Dildar B, Rizavi DM, Al Mubaihsi SM, Al Kindi A. Black pleural effusion. Lancet 2015;386:e7. [ PUBMED] |
| 36. | Fulcher AS, Capps GW, Turner MA. Thoracopancreatic fistula: Clinical and imaging findings. J Comput Assist Tomogr 1999;23:181-7. [ PUBMED] |
| 37. | Altasan T, Aljehani Y, Almalki A, Algamdi S, Talag A, Alkattan K, et al. Pancreaticopleural fistula: An overlooked entity. Asian Cardiovasc Thorac Ann 2014;22:98-101. |
| 38. | Koide T, Saraya T, Nakajima A, Kurai D, Ishii H, Goto H, et al. A54-year-old man with an uncommon cause of left pleural effusion. Chest 2012;141:560-3. |
| 39. | Kaur D, Singh G, Banas E, Savici D. Black pleural effusion in an alcoholic: Make the connection. Chest 2014;146:467A. |
| 40. | Huang TY, Tsai MJ. Education and imaging. Gastrointestinal: Black pleural effusion induced by pancreaticopleural fistula. J Gastroenterol Hepatol 2013;28:1798. [ PUBMED] |
| 41. | Mookherjee S, Minkoff N, Shah V, Changlai B. A curious case of a reaccumulating black colored pleural effusion. Chest 2014;146:482A. |
| 42. | Singh B, Greenebaum E, Cole R. Carbon-laden macrophages in pleural fluid of crack smokers. Diagn Cytopathol 1995;13:316-9. [ PUBMED] |
| 43. | Greenebaum E, Copeland A, Grewal R. Blackened bronchoalveolar lavage fluid in crack smokers. A preliminary study. Am J Clin Pathol 1993;100:481-7. [ PUBMED] |
| 44. | Justiniani FR, Hippalgaonkar R, Martinez LO. Charcoal-containing empyema complicating treatment for overdose. Chest 1985;87:404-5. [ PUBMED] |
| 45. | Jacob AG, George AM, John T. Rheumatoid pleurisy presenting as black pleural effusion. Chest 2014;146:471A. |
| 46. | Bergman S, Melvin WS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2007;87:1447-60. [ PUBMED] |
| 47. | Begum S, Mukherjee S, Biswas D, Misra AK, Ghosh P, Bhanja P, et al. Arare pleural effusion in a young male. Lung India 2015;32:389-91. [ PUBMED] [Full text] |
| This article has been cited by | | 1 |
A Hydropneumothorax That Was! |
|
| Ishan Lalani, Ziad Shaman, Ismini Kourouni | | Chest. 2022; 161(6): e387 | | [Pubmed] | [DOI] | | | 2 |
Etiology, pathological characteristics, and clinical management of black pleural effusion |
|
| Zohaib Yousaf, Fateen Ata, Haseeb Chaudhary, Florian Krause, Ben Min-Woo Illigens, Timo Siepmann | | Medicine. 2022; 101(8): e28130 | | [Pubmed] | [DOI] | | | 3 |
Black Pleural Effusion: When Lung White(out) Turns Black |
|
| Ziqin Ng,Geak Poh Tan,Kim Hoong Yap | | Annals of the Academy of Medicine, Singapore. 2020; 49(9): 717 | | [Pubmed] | [DOI] | | | 4 |
Black pleural effusion: an unusual presentation of metastatic melanoma diagnosed by medical thoracoscopy |
|
| Kamran Khan Sumalani,Uneeba Rehman,Nousheen Akhter,Nadeem Ahmed Rizvi | | Respirology Case Reports. 2019; 7(9) | | [Pubmed] | [DOI] | |
|
 |
|
|
|
Search Pubmed for