A Patient With Effusion Undergoing Pleural Biopsy
The present case has been reported in the journal CHEST.

A 59-year-old woman presented with acute right-sided chest pain, dry cough, and dyspnea. Initial blood workup revealed leukocytosis with neutrophil predominance. Her D-dimer levels were elevated. A CT pulmonary angiography ruled out the presence of pulmonary embolism but revealed right-sided partially encysted pleural effusion associated with pleural thickening and bilateral multifocal lung consolidations.

A sample of the pleural fluid was aspirated, and physically it was yellowish and slightly turbid. Biochemical analysis of the pleural aspirate showed it to be an exudate with a glucose level of 43.2 mg/dL and a lactate dehydrogenase level of 1,286 International Units/L. Bacterial culture and smear for acid-fast bacilli returned negative.

Given the possibility of pleuropulmonary TB and the nonconclusive test results, an ultrasound-guided cutting-needle pleural biopsy was conducted. Ultrasound confirmed the presence of effusion and lung consolidation (Fig 2, star and arrowhead, respectively). In the routine preprocedural scan, Doppler examination of the intercostal space where the biopsy was planned did not detect any unhidden intercostal vessels. After the second needle biopsy, a plume of echogenicity was seen to arise from the site of pleural puncture (Video available).

Echogenic shadows were seen propagating from a point at the deepest part of the pleura, which is very suggestive of bleeding from the parietal pleura. Doppler examination confirmed pleural bleeding. Finger external compression on the biopsy site was performed for 2 min, and subsequent ultrasound examination confirmed that the bleeding had stopped.

A globular echogenic thrombus was noted at the bleeding site. As per the authors, formed thrombus assumed such a conformation because of the presence of fine septations in the pleural fluid (Fig 3, solid arrow), which likely permitted tamponade of the bleeding site.

To confirm this, a few milliliters of agitated saline were injected into the thrombus via a Tuohy needle. The echogenic air bubbles did not float into the adjacent fluid but rather remained confined inside the thrombus, confirming the presence of fine septations, likely contributing to limitation of blood spillage into the pleural cavity, therefore creating thrombus subsequently tamponading the site of bleeding (Video available).

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