Background: Polymorphonuclear elastase (PMN-E) is a neutrophilic marker that has been implicated in acute inflammatory responses. Objectives: To evaluate the accuracy of PMN-E in the diagnosis of complicated pyogenic effusions. Patients and Method: We studied 536 patients with pleural effusion of various etiologies. There were 125 pyogenic bacterial effusions (42 typical parapneumonic, 17 borderline complicated parapneumonic and 66 complicated parapneumonic or empyema), 83 tuberculous, 91 malignant, 42 paramalignant, 95 transudates, 28 miscellaneous and 72 effusions of unknown origin. Classic markers (pH, glucose, proteins, adenosine deaminase, LDH, leukocytes and differential count) and the PMN-E level were quantified in pleural fluid. The accuracy of PMN-E as an early marker in the diagnosis of complicated pyogenic infectious effusions was evaluated among pleural effusions that were not diagnosed with classic biochemical markers, radiological findings or Gram stain. Since results of pleural fluid culture and cytological examination are generally available after a 48-hour delay, they were not included as early markers in the initial diagnosis of pleural effusions. Results: Early diagnosis of complicated pyogenic bacterial effusions was achieved in only 48 of 66 cases with classic markers. Among those that were not diagnosed with these parameters, a pleural PMN-E value >3,500 µg/l discriminated between complicated and noncomplicated pyogenic bacterial effusions with a sensitivity of 67% and a specificity of 97%. Conclusions: PMN-E is useful in the early diagnosis and management of complicated pyogenic infectious effusions, which may be delayed with classic markers.

Keywords:
Pyogenic, Pleural effusion, Polymorphonuclear elastase, Empyema, Complicated parapneumonic effusions
1.
Marel M, Stastny B, Melinová L, et al: Diagnosis of pleural effusions. Experience with clinical studies, 1986 to 1990. Chest 1995;107:1598–1603.
2.
Valdés L, Alvarez D, Valle JM, et al: The etiology of pleural effusions in an area with high incidence of tuberculosis. Chest 1996;109:158–162.
3.
Strange C, Sahn S: The definitions and epidemiology of pleural space infection. Semin Respir Infect 1999;14:3–8.
4.
Hamm H, Light RW: Parapneumonic effusion and empyema. Eur Respir J 1997;10:1150–1156.
5.
Light R: A new classification of parapneumonic effusions and empyema. Chest 1995;108:299–301.
6.
Heffner J: Indications for draining a parapneumonic effusion: An evidence-based approach. Semin Respir Infect 1999;14:48–58.
7.
Segura RM, Alegre J, Varela E, et al: Interleukin-8 and markers of neutrophil degranulation in pleural effusion. Am J Respir Crit Care Med 1998;157:1565–1572.
8.
Janoff AJ: Elastase and tissue injury. Annu Rev Med 1985;36:207–216.
9.
Weiss SJ: Tissue destruction by neutrophils. N Engl J Med 1989;320:365–376.
10.
Alegre J, Suriñach JM, Varela E, et al: Diagnostic accuracy of pleural fluid polymorphonuclear elastase in the differentiation between pyogenic bacterial infectious and non-infectious pleural effusions. Respiration 2000;67:426–432.
11.
Ebert W, Bauer H, Bauer E, et al: Significance of microbiological and biochemical analyses in empyema thoracis. Thorac Cardiovasc Surg 1990;38:348–351.
12.
Light RW, MacGregor I, Luchsinger PC, et al: Pleural effusion: The diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507–513.
13.
Ocaña I, Martinez Vazquez JM, Segura RM, et al: Adenosine deaminase in pleural fluids: Test for diagnosis of tuberculous pleural effusion. Chest 1983;83:51–53.
14.
Bouros D, Schiza S, Siafakas N: Utility of fibrinolytic agents for draining intrapleural infections. Semin Respir Infect 1999;14:39–47.
15.
Bouros D, Schiza S, Patsurakis G, et al: Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions. Am J Respir Crit Care Med 1997;155:291–295.
16.
Davies R, Traill Z, Gleeson F: Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52:416–421.
17.
Heffner J, Brown L, Barbieri C, et al: Pleural fluid chemical analysis in parapneumonic effusions. Am J Respir Crit Care Med 1995;151:1700–1708.
18.
Jurado B: Neumonía y derrame pleural. Manejo terapéutico. An Med Intern 1997;14:419–424.
19.
Bryant R, Salmon C: Pleural empyema. Clin Infect Dis 1996;22:747–764.
20.
Jébrack G, Pointet P, Pichot MH: Purulent pleurisy and empyema. With the exception of pleural tuberculosis. Presse Méd 1998;3:1924–1931.
21.
Heffner JE, Mac Donald J, Barbieri C, Klein J: Management of parapneumonic effusions. Arch Surg 1995;130:433–438.
22.
Sahn S: Management of complicated parapneumonic effusions. Am Rev Respir Dis 1993;148:813–817.
23.
Light RW, Girard EM, Jenkinson SG, et al: Parapneumonic effusions. Am J Med 1980;69:507–512.
24.
Martínez MA, Cordero PJ, Cases E, et al: Prognostic features of residual pleural thickening in metapneumonic pleural effusions (in Spanish). Arch Bronconeumol 1999;35:108–112.
© 2003 S. Karger AG, Basel
2003
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