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Communications to the Editor |

Tumor Necrosis Factor-α in Parapneumonic Effusion FREE TO VIEW

Majed Odeh, MD; Arie Oliven, MD
Author and Funding Information

Affiliations: Bnai Zion Medical Center Israel Institute of Technology, Haifa, Israel,  Arnau de Vilanova University Hospital, Lleida, Spain

Correspondence to: Majed Odeh, MD, Department of Internal Medicine B, Bnai Zion Medical Center, PO Box 6477, Haifa 31063, Israel; e-mail: majed.odeh@b-zion.org.il



Chest. 2005;127(5):1868-1869. doi:10.1378/chest.127.5.1868
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To the Editor:

We read with great interest the study by Porcel et al1(January 2004) investigating the role of tumor necrosis factor-α in pleural fluid as a marker of complicated parapneumonic effusions (CPPEs). The results of this study support the results of our previous studies in this regard.23 However, we have some reservations regarding the design, statistical analysis, and, therefore, some of the conclusions of the study.

The authors stated that the final decision concerning pleural space drainage was at the discretion of the attending physician, and patients who underwent pleural space drainage were selected as the group of patients having CPPE. However, the criteria that guided the attending physicians to decide that a patient had a CPPE are given very vaguely. If their decision depended on the current acceptable criteria for discrimination between CPPE and uncomplicated parapneumonic effusion (UPPE) [criteria for CPPE were positive pleural fluid culture result or Gram stain for bacteria, and/or pH < 7.20, and/or the presence of loculations in the pleural cavity],45 it is improper to compare the diagnostic accuracy of the pleural fluid pH for categorizing a parapneumonic effusion (PPE) as complicated, with that of pleural fluid lactate dehydrogenase (LDH), glucose, or tumor necrosis factor-α because, in most patients, the classification of a PPE as complicated or uncomplicated depends, according to the current acceptable criteria,45 mainly on pH value. It is so because the sensitivity of a positive Gram stain or culture result for CPPE is relatively low, and pH is superior to LDH and glucose in this regard. The same statement is valid also for LDH and glucose if the patient selection in the present study depended on pleural fluid levels of LDH or glucose. Furthermore, two patients in the study population were selected as having UPPE, although they had positive pleural fluid culture results for bacteria. This antagonizes the current acceptable criteria for discrimination between CPPE and UPPE in which, by definition, a culture-positive PPE is a CPPE.45 The clinical criteria for discrimination between CPPE and UPPE have to be defined more precisely if the validity of the current acceptable criteria is being reevaluated.

Porcel, JM, Vives, M, Esquerda, A (2004) Tumor necrosis factor-α in pleural fluid: a marker of complicated parapneumonic effusions.Chest125,160-164. [CrossRef] [PubMed]
 
Odeh, M, Sabo, E, Oliven, A, et al Role of tumor necrosis factor-α in the differential diagnosis of parapneumonic effusion.Int J Infect Dis1999;4,38-41
 
Odeh, M, Sabo, E, Srugo, I, et al Correlation between polymorphonuclear leukocyte counts and levels of tumor necrosis factor-α in pleural fluid of patients with parapneumonic effusion.Lung2002;180,265-271. [CrossRef] [PubMed]
 
Colice, GL, Curtis, A, Deslauriers, J, et al Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.Chest2000;18,1158-1171
 
Davies, CWH, Gleeson, FV, Davies, RJO BTS guidelines for the management of pleural infection.Thorax2003;58 (suppl),ii18-ii28
 
To the Editor:

We appreciate the comments of Drs. Odeh and Oliven regarding our study in CHEST (January 2004)1on pleural tumor necrosis factor-α as a marker of complicated parapneumonic effusions (CPPEs). They express concern about the criteria used to classify parapneumonic effusions (PPEs) as uncomplicated or complicated. We followed the definitions established by Light,2 in that the term CPPE refers to those effusions that do not resolve without tube thoracostomy. Drs. Odeh and Oliven failed to recognize that there is no errorless “gold standard” to judge whether the attending physician’s decision for chest tube drainage in the setting of pneumonia is correct. Obviously, clinician judgment about the convenience of tube thoracostomy is a complex process that depends on a variety of either objective criteria (eg, pleural pH, glucose level, lactate dehydrogenase level, culture finding, effusion size, or patient clinical status) or even subjective criteria (eg, physicians’ feeling about the patient’s outcome).

As a matter of fact, a few reports have noted caveats in determining the need for draining PPEs on the basis of biochemical or microbiological criteria. For example, in a retrospective study3of 62 patients with PPEs, 26 nonpurulent CPPEs (defined as pleural fluid with a pH < 7.20, or a positive Gram stain or culture result) were identified. Thirteen of the 16 patients with CPPEs who were initially treated with antibiotics alone were cured uneventfully. Another retrospective analysis4 of 91 patients with PPEs found that 10 of 22 patients who met one or more criteria for tube thoracostomy (ie, frank purulence, pleural glucose level < 40 mg/dL, pleural pH < 7.00, or pleural lactate dehydrogenase level > 1,000 U/L) recovered without chest tube placement. Undoubtedly, there are some patients with PPEs and poor prognostic variables found in their pleural fluid who can be cured with antibiotic therapy alone. A retrospective update from our series, including 240 patients with PPEs (uncomplicated PPEs, 85 patients; CPPEs, 67 patients; and empyemas, 88 patients; defined as previously reported,1), showed that the American College of Chest Physicians guidelines5and the British Thoracic Society guidelines6 are associated with respective sensitivities of 97% and 98%, and respective specificities of 68% and 56% to discriminate nonpurulent CPPEs from uncomplicated PPEs (unpublished data). Specifically, the conditions of 12 patients with nonpurulent culture-positive pleural fluid samples and 2 patients with empyemas were resolved solely with antibiotic therapy.

Overall, these guidelines perform satisfactorily in the identification of CPPEs, although they lead to some unnecessary chest tube placements, which is a misclassification cost that is acceptable from the clinical standpoint. In conclusion, Drs. Odeh and Oliven are mistaken in suggesting that some pleural fluid characteristics are absolute in dictating a specific clinical action, and they ran afoul of this error in their original report.7 The clinical dilemma of when to drain pleural fluid for sample collection remains, and the current recommendations should be explored in prospective studies.

References
Porcel, JM, Vives, M, Esquerda, A Tumour necrosis factor-α in pleural fluid: a marker of complicated parapneumonic effusions.Chest2004;125,160-164. [CrossRef] [PubMed]
 
Light, RW Pleural disease 4th ed.2001 Lippincott Williams & Wilkins. Philadelphia, PA:
 
Berger, HA, Morganroth, ML Immediate drainage is not required for all patients with complicated parapneumonic effusions.Chest1990;97,731-735. [CrossRef] [PubMed]
 
Poe, RH, Marín, MG, Israel, RH, et al Utility of pleural fluid analysis in predicting tube thoracostomy/decortication in parapneumonic effusions.Chest1991;100,963-967. [CrossRef] [PubMed]
 
Colice, GL, Curtis, A, Deslauriers, J, et al Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.Chest2000;118,1158-1171. [CrossRef] [PubMed]
 
Davies, CWH, Gleeson, FV, Davies, RJO, et al BTS guidelines for the management of pleural infection.Thorax2003;58(suppl),ii18-ii28
 
Odeh, M, Sabo, E, Oliven, A, et al Role of tumor necrosis factor-α in the differential diagnosis of parapneumonic effusion.Int J Infect Dis1999;4,38-41
 

Figures

Tables

References

Porcel, JM, Vives, M, Esquerda, A (2004) Tumor necrosis factor-α in pleural fluid: a marker of complicated parapneumonic effusions.Chest125,160-164. [CrossRef] [PubMed]
 
Odeh, M, Sabo, E, Oliven, A, et al Role of tumor necrosis factor-α in the differential diagnosis of parapneumonic effusion.Int J Infect Dis1999;4,38-41
 
Odeh, M, Sabo, E, Srugo, I, et al Correlation between polymorphonuclear leukocyte counts and levels of tumor necrosis factor-α in pleural fluid of patients with parapneumonic effusion.Lung2002;180,265-271. [CrossRef] [PubMed]
 
Colice, GL, Curtis, A, Deslauriers, J, et al Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.Chest2000;18,1158-1171
 
Davies, CWH, Gleeson, FV, Davies, RJO BTS guidelines for the management of pleural infection.Thorax2003;58 (suppl),ii18-ii28
 
Porcel, JM, Vives, M, Esquerda, A Tumour necrosis factor-α in pleural fluid: a marker of complicated parapneumonic effusions.Chest2004;125,160-164. [CrossRef] [PubMed]
 
Light, RW Pleural disease 4th ed.2001 Lippincott Williams & Wilkins. Philadelphia, PA:
 
Berger, HA, Morganroth, ML Immediate drainage is not required for all patients with complicated parapneumonic effusions.Chest1990;97,731-735. [CrossRef] [PubMed]
 
Poe, RH, Marín, MG, Israel, RH, et al Utility of pleural fluid analysis in predicting tube thoracostomy/decortication in parapneumonic effusions.Chest1991;100,963-967. [CrossRef] [PubMed]
 
Colice, GL, Curtis, A, Deslauriers, J, et al Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.Chest2000;118,1158-1171. [CrossRef] [PubMed]
 
Davies, CWH, Gleeson, FV, Davies, RJO, et al BTS guidelines for the management of pleural infection.Thorax2003;58(suppl),ii18-ii28
 
Odeh, M, Sabo, E, Oliven, A, et al Role of tumor necrosis factor-α in the differential diagnosis of parapneumonic effusion.Int J Infect Dis1999;4,38-41
 
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