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CASE REPORT
Year : 2006  |  Volume : 23  |  Issue : 2  |  Page : 87-89 Table of Contents   

Intrapleural Streptokinase in Management of Multiloculated Uraemic Pleural Effusion- A case report


1 Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Dehradun., India
2 Department of Nephrology, Himalayan Institute of Medical Sciences, Dehradun., India

Correspondence Address:
G Sindhwani
c/o Mr. Y. P. Joshi, 135/1, Shiva Enclave, Near Awas Vikas Colony, Rishikesh, Uttaranchal.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.44417

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   Abstract 

Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. It's use in multiloculated uraemic effusion has been rarely reported. We report a case of uraemic multiloculated pleural effusion who failed to respond to standard chest tube drainage but showed dramatic and complete resolution with intrapleural streptokinase.

Keywords: Streptokinase, Pleural effusion, Uraemic.


How to cite this article:
Rawat J, Sindhwani G, Gaur S, Singh V. Intrapleural Streptokinase in Management of Multiloculated Uraemic Pleural Effusion- A case report. Lung India 2006;23:87-9

How to cite this URL:
Rawat J, Sindhwani G, Gaur S, Singh V. Intrapleural Streptokinase in Management of Multiloculated Uraemic Pleural Effusion- A case report. Lung India [serial online] 2006 [cited 2020 Oct 25];23:87-9. Available from: https://www.lungindia.com/text.asp?2006/23/2/87/44417


   Introduction Top


Most patients of multiloculated pleural effusion present with progressive dyspnoea, cough or chest pain that compromise their quality of life. The drainage and control of pleural effusion promptly relieves symptoms and this can often be achieved by simple thoracentesis or tube thoracostomy. However, these methods usually fail in patients with multiloculated effusions whose fibrinous adhesions impede free fluid drainage causing persistent effusion and dyspnoea. Thoracoscopic procedures are usually required in such patients, but may not be possible in all [1] .

Intrapleural administration of fibrinolytic agents has been shown to be effective and safe for the management of multiloculated parapneumonic effusion, pleural empyema and hemothorax [2] . There are few case reports of intrapleural fibrinolytic therapy in parapneumonic pleural effusion from our country [3],[4],[5] .The present report is the first one on the use of intrapleural Streptokinase in multiloculated uraemic pleural effusion from India.


   Case Report Top


A 60yrs. old male, known case of diabetic triopathy with hypertension, was on regular hemodialysis. Patient was previously diagnosed to be having uraemic pleural effusion, which used to respond to conservative treatment and hemodialysis, but this time, patient came with complains of increased cough, breathlessness, left sided chest pain. There was no history of fever, malaise and other systemic symptoms. On physical examination, patient was tachypnoeic, had pallor and raised JVP. Clinical examination of the patient revealed left sided pleural effusion.

X-Ray chest PA view revealed massive left sided pleural effusion without mediastinal shift [Figure 1] Pleural aspiration tried, but only 10-15 ml fluid could be aspirated with difficulty. Ultrasonography (USG) of pleural space at this stage revealed multiloculated pleural effusion on left side. Patient was not willing for C.T Scan thorax due to financial constraints.

To relieve respiratory distress, tube thoracostomy was done under water seal and only about 100 ml fluid drained in 24 hours. Pleural fluid was exudative with lymphocytic predominance. (Protein - 4.3gm/dl, Sugar - 72mg/dl, Cell count of 4300/mm 3 , DLC -Lymphocytes-90%, polymorphs­10%, LDH - 220 I.U.). Smear microscopy did not reveal any pathological organisms including acid-fast Bacilli (AFB). Pleural fluid was negative for malignant cells. In view of multiloculated pleural effusion, fibrinolytic therapy was planned, as there was no contraindication to such therapy. Streptokinase 2.5 I.U. was dissolved in 100ml of normal saline and was instilled into pleural space through chest tube. Position of patient was changed frequently to allow even distribution of the drug in the pleural space. Clamp was removed after two hours and drainage was subsequently collected and measured. The same dose of streptokinase was repeated after 12 hours. There was marked improvement in dyspnea and total drainage rose to 3300m1 after two instillations. There was no complication related to this treatment. The third dose was repeated after another 24 hours and this time the drainage was 550m1. A total of five doses were given after which the drainage was decreased significantly (less than 50m1/day) with marked improvement in dyspnea. A repeat USG of pleural space this time revealed marked resolution. X-Ray chest PA view showed improvement [Figure 2] Patient remained asymptomatic there after and discharged after 12 days. Patient was not given anti-tubercular treatment in view of lack of any evidence supporting tubercular etiology and patient responded without ATT.


   Discussion Top


Intrapleural administration of fibrinolytic agent has been in use for more than fifty years; it has, however, been of clinical importance only for the last twenty years. Interapleural fibrinolytic agent was used for the first time by Tillent & Sherry [6] in 1949. It is considered as a viable alternative to facilitate drainage and lung expansion in empyemas inadequately treated by chest tube alone [6] . Many studies have been published in the last few years with encouraging results of this therapy in complicated parapneumonic pleural effusion, pleural empyema, hemothorax [2] and multiloculated malignant pleural effusion.

However this approach has rarely been reported in the management of multiloculated uraemic pleural effusion. The exact mechanism of multiseptations and multiloculation in uremic pleural effusion is not known. There may be an inflammatory response between the visceral and parietal pleural surfaces in the procoagulant state, thus depressing the fibrinolytic activity leading to deposition of fibrin sheets which impairs the free fluid drainage. With increasing reports of successful intrapleural fibrinolytic therapy in complicated parapneumonic pleural effusion, we tried intrapleural streptokinase in multiloculated uremic pleural effusion and found it safe and successful.

Streptokinase, the first Fibrinolytic agent described by Aye et a1 [3] , is a purified proteolytic enzyme derived from bacterial protein of group C beta hemolytic streptococci, plasminogen is converted into proteolytic enzyme plasmin by streptokinase. Plasmin then degrades fibrin clots and fibrinogen.

We conclude with remark that intrapleural fibrinolytic therapy may be considered in multiloculated uremic pleural effusion also, who fail to drain adequately with chest tube drainage, so as to improve dyspnoea and quality of life in these terminally ill patients.

 
   References Top

1.Lynch TJ. Management ofmalignantpleural effusions. Chest 1993; 103 (suppl. 4): 385S-389S.  Back to cited text no. 1    
2.Kemper P, Kohler D. Current value of intrapleural fibrinolysis in the treatment ofexudative fibrinous pleural effusions, pleural empyema and hemothorax. Pneumologie 1999,53373-84.  Back to cited text no. 2    
3.Sharma VP, Guleria R, Gupta R, Sharma SK, Pande IN. Intrapleural streptokinase in multiloculated empyema thoracic. JAssoc Physicians India 1998; 46:227-29.  Back to cited text no. 3    
4.Barthwal MS. Thrombolytic therapy in complicated parapneumonic effusion. JAssoc Physicians India 1998; 46: 907-08.  Back to cited text no. 4    
5.Barth wal MS. Intrapleural streptokinase in a two-year-old child with a parapneumonic effusion. Indian I Chest Dis Allied Sci 2001; 43:165-68.  Back to cited text no. 5    
6.Dixit R, Dixit K, Bansal R. Intrapleural Streptokinase in multiloculated malignant pleural effusion. Indian I Chest Dis Allied Sci 2004; 46:59-62.  Back to cited text no. 6    


    Figures

  [Figure 1], [Figure 2]



 

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