CASE REPORT   Intrapleural Streptokinase in Multiloculated Malignant                       Pleural Effusion               ...
60                         Intrapleural Fibrinolytic Therapy in Multiloculated MPE       Ramakant Dixit et alpatient was t...
2004; Vol. 46               The Indian Journal of Chest Diseases & Allied Sciences                           61Patient rec...
62                         Intrapleural Fibrinolytic Therapy in Multiloculated MPE        Ramakant Dixit et al     multilo...
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  1. 1. CASE REPORT Intrapleural Streptokinase in Multiloculated Malignant Pleural Effusion Ramakant Dixit, Kalpana Dixit and Rani Bansal1 Departments of Respiratory Medicine and Pathology1, Himalayan Institute of Medical Sciences, Dehradun, (Uttaranchal), India ABSTRACT Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic effusions. Its use in multiloculated malignant pleural effusions has been rarely reported. We report a case of malignant multiloculated pleural effusion who failed to respond to standard chest tube drainage but showed dramatic and complete resolution with intrapleural streptokinase. Key words : Malignant pleural effusion, Streptokinase, Intrapleural fibrinolysis. [Indian J Chest Dis Allied Sci 2004; 46 : 59-62] INTRODUCTION parapneumonic pleural effusions, pleural empyema and haemothorax3. This approach of Malignant pleural effusions (MPE) are therapy is, however, largely unknown in thecommon cause of morbidity in cancer patients management of multiloculated malignantwith advanced disease. Most patients present pleural effusions and only two studies havewith progressive dyspnoea, cough or chest pain shown its efficacy in this condition4, 5.that compromises their quality of life 1 . Thedrainage and control of malignant effusions There are few case reports of intrapleuralpromptly relieves symptoms and this can often fibrinolytic therapy in complicated parapneu-be achieved by simple thoracocentesis or tube monic pleural effusion from our country6-8. Thethoracostomy. However, these methods usually present report is the first one on the use offail in patients with multiloculated effusions intrapleural streptokinase in multiloculatedwhere fibrinous adhesions impede free fluid malignant pleural effusions from India.drainage causing persistent effusion anddyspnoea. Thoracoscopic procedures are CASE REPORTusually required in such patients, but may notbe possible in all2. A 60-year-old male smoker presented with Intrapleural administration of fibrinolytic dry cough, right-sided chest pain andagents has been shown to be effective and safe progressively increasing breathlessness of fourfor the management of multiloculated weeks duration. On physical examination,[Received : July 1, 2002; accepted after revision : January 6, 2003]Correspondence and reprints request : Dr Ramakant Dixit, Assistant Professor (TB and Chest Diseases), 36,Professors Quarters, B.J. Medical College and Civil Hospital, Ahmedabad-380 016; Tele. : 91-079-2686822;E-mail : <ramakantdixit@>.
  2. 2. 60 Intrapleural Fibrinolytic Therapy in Multiloculated MPE Ramakant Dixit et alpatient was tachypnoeic and had pallor anddigital clubbing. Clinical examination ofrespiratory system suggested right sided pleuraleffusion. Chest radiograph revealed massiveright-sided pleural effusion with mediastinalshift to the opposite side. In view of massive pleural effusion and torelieve respiratory distress, tube thoracostomywas done under waterseal system and about750 ml straw-coloured clear fluid was drainedimmediately. His dyspnoea was partly relieved.Pleural fluid analysis revealed protein 4.6 gm/dl, sugar 73 mg/dl and cell count of 4500/mm3 Figure 1. Ultrasonography of pleural space(68% lymphocytes and 32% polymorphs). showing pleural effusion with multiple septations.Smear microscopy did not reveal any patho-logical organisms including acid-fast bacilli distribution of the drug in the pleural space.(AFB), on Grams and Ziehl-Neelsen staining. Clamp was removed after two hours andCytological examination of pleural fluid showed drainage was subsequently collected andpoorly differentiated malignant cells forming measured. The same dose of streptokinase wassolid clumps or vague glandular spaces sugges- repeated after 12 hours. There was markedtive of adenocarcinoma. On fiberoptic broncho- improvement in dyspnoea and total drainagescopy, an endobronchial mass was seen in the rose to 2800 ml after two instillations. There wassuperior segmental bronchus of the right lower no haemorrhage or allergic complicationslobe which on histopathological examination related to this treatment. The third dose wasrevealed adenocarcinoma infiltrating the fibrous repeated after another 12 hours and this timestroma. The tumour cells were large with the drainage was 800 millilitre. The therapy waspleomorphic nuclei having prominent nucleoli continued 12 hourly and after fourth dose, theand mitotic figures. A small amount of mucicar- drainage was 200 millilitre. A total of six dosesmine positive material was also seen in some were given after which the drainage wascells. Thus, a final diagnosis of malignant decreased significantly (less than 50 ml/day)pleural effusion due to underlying carcinoma and the patient reported marked improvementlung was made. in dyspnoea. A repeat USG of pleural space this Despite tube thoracostomy, patient remained time revealed complete resolution (Figure 2).breathless and there was total drainage of about300 ml fluid over next two days, although thechest tube was patent and well positioned. Arepeat chest radiograph showed persistentpleural effusion. Ultrasonography (USG) ofpleural space at this stage revealed multi-loculated effusion on right side (Figure 1). In view of multiloculated pleural effusionresulting in poor tube drainage and persistentsymptoms, intrapleural fibrinolytic therapy wasplanned as there was no contraindication tosuch therapy. Streptokinase, 250,00 IU wasdissolved in 100 ml of normal saline and wasinstilled into pleural space through chest tube Figure 2. Ultrasonography of pleural space afterafter clamping it distally. Position of the patient intrapleural streptokinase therapy showingwas changed frequently to allow even complete resolution.
  3. 3. 2004; Vol. 46 The Indian Journal of Chest Diseases & Allied Sciences 61Patient received mitoxantrone pleurodesis Intrapleural fibrinolytic treatment does notbefore removal of the chest tube. He remained appear to alter the systemic coagulationasymptomatic thereafter and discharged after 14 parameter11 and has been claimed to be safedays. He subsequently survived for six months, even in the early post-traumatic or post-and there was no recurrence of pleural effusion operative period 12 . Systemic absorption oftill death. fibrinolytic agents in malignant pleural effusion seems less likely because of abnormal pleural surfaces and decreased lymphatic drainage. DISCUSSION Similar to our case, none of the cases of Intrapleural administration of fibrinolytic multiloculated malignant pleural effusionagents has been in use for more than 50 years; it reported so far, experienced systemic side effectshas, however, been of clinical importance only after intrapleural fibrinolytic therapy. However,for the last 20 years. Many studies have been it seems wise to exclude the other causes ofpublished in the last few years with very drainage failure, i.e. improper tube positioning,encouraging results of this therapy in complica- kinking of tube, etc. and relative contraindi-ted parapneumonic effusions, pleural empyema cations of fibrinolytic agents before applyingand haemothorax3. However, this approach has this therapy to ensure safe and successfulrarely been reported in the control of multilocu- results.lated malignant pleural effusion and a recent We conclude with remark that intrapleuraleditorial opinion has suggested that intrapleural fibrinolytic therapy may be considered infibrinolytic therapy should be avoided in multiloculated malignant pleural effusion also,patients with malignant pleural effusion, who fail to drain adequately with chest tubedespite a lack of evidence in the literature to drainage so as to improve dyspnoea and qualitysupport this view 9. There are only two publi- of life in these terminally ill patients.shed reports supporting use of intrapleuralfibrinolytic therapy in patients with multilo-culated malignant pleural effusion 4, 5 . The REFERENCESpresent report is additional one and first one ofthis type from our country supporting the safety 1. Sahn SA. Pleural effusion in lung cancer. Clinand efficacy of intrapleural fibrinolytic agents in Chest Med 1993; 14 : 189-200.multiloculated malignant pleural effusion. 2. Lynch TJ. Management of malignant pleural effusions. Chest 1993; 103 (suppl. 4) : 385S-389S. The exact mechanism of multiseptations andmultiloculations in malignant pleural effusion is 3. Kemper P, Kohler D. Current value ofnot known. There may be an inflammatory intrapleural fibrinolysis in the treatment ofresponse between the visceral and parietal exudative fibrinous pleural effusions, pleuralsurfaces increasing the procoagulant and empyema and hemothorax. Pneumologie 1999; 53 : 373-84.depressing the fibrinolytic activity leading todeposition of fibrin sheets which impairs the 4. Jerjes-Sanchez C, Ramirez-Rivera A, Elizalde JJ,free fluid drainage10. Thus, control of dyspnoea et al. Intrapleural fibrinolysis with strepto-become difficult in these terminally ill patients kinase as an adjunctive treatment ineven with chest tube drainage because these hemothorax and empyema : A muticentre trial. Chest 1996; 109 : 1514-19.effusions usually re-form rapidly. Withincreasing reports of successful intrapleural 5. Davies CW, Traill ZC, Gleeson FV, Davies RJ.fibrinolytic therapy in complicated Intrapleural streptokinase in the managementparapneumonic effusion, we tried intrapleural of malignant multiloculated pleural effusions.streptokinase in multiloculated malignant Chest 1999; 115 : 729-33.pleural effusion and found it safe and 6. Sharma VP, Guleria R, Gupta R, Sharma SK,successful. Pande JN. Intrapleural streptokinase in
  4. 4. 62 Intrapleural Fibrinolytic Therapy in Multiloculated MPE Ramakant Dixit et al multiloculated empyema thoracis. J Assoc 10. Idell S, Girard W, Koenig KB, McLarty J, Physicians India 1998; 46 : 227-29. Fair DS, et al. Abnormalities of pathways of fibrin turnover in the human pleural space. Am7. Barthwal MS. Thrombolytic therapy in Rev Respir Dis 1991; 144 : 187-94. complicated parapneumonic effusion. J Assoc Physicians India 1998; 46 : 907-08. 11. Davies CW, Lok S, Davies RJ. The systemic fibrinolytic activity of intrapleural strepto-8. Barthwal MS. Intrapleural streptokinase in a kinase. Am J Respir Crit Care Med 1998; 157 : two-year-old child with a parapneumonic 328-30. effusion. Indian J Chest Dis Allied Sci 2001; 43 : 165-68. 12. Berglin E, Ekroth R, Teger-Nilsson A, William- Olsson G. Intrapleural instillation of strepto-9. Anonymous. Intrapleural streptokinase for kinase: Effects on systemic fibrinolysis. Thorac empyema? Drug Ther Bull 1997; 35 : 95. Cardiovasc Surg 1981; 29 : 124-26.