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REVIEW ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 1-4

Black Pleural Effusion


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 Publication26-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
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_24_17

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  Abstract 


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

How to cite this URL:
Palakuru SS, Vijhani P, Cherian SV. Black Pleural Effusion. Res Cardiovasc Med [serial online] 2018 [cited 2018 Oct 16];7:1-4. Available from: http://www.rcvmonline.com/text.asp?2018/7/1/1/226162




  Introduction Top


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 Top


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 Top


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 Top


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 Top


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 Top


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.



 
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