ORIGINAL ARTICLE

Etiology, clinical characteristics, and management of

pleural effusion in Ilorin, Nigeria
Peter Oladapo Adeoye, Wahab Rotimi Johnson1, Olufemi Olumuyiwa Desalu2, Chima Pascal Ofoegbu,
Ademola Emmanuel Fawibe2, Alakija Kazeem Salami2, Abayomi Fadeyi3, Akingbade Adebayo Akin‑Dosumu,
Ibraheem M. Rasheedat1, Ilorin Pleural Effusion Study Group

Departments of Surgery, 1Child Health, 2Medicine and 3Medical Microbiology, University of Ilorin Teaching Hospital, Ilorin, Nigeria

ABSTRACT
Background: Pleural effusion (PE) is a primary manifestation or secondary complication of
many disorders. This study reviews the pattern and management of PE in a Nigerian hospital.
Materials and Methods: The medical records of 213 patients with clinical diagnosis of PE over a
period of 3 years were reviewed. Results: PE accounted for 0.5% of the total hospital admissions.
The most common cause of PE was tuberculosis (TB) (32.9%), followed by malignancy (29.1%)
and pneumonia (15.0%). The male to female ratio was 1.3:1. TB was the leading cause of effusion
in males, while it was malignancy in females. Pneumonia accounted for 61.9% of PE in preschool
age and 66.7% in school age. Breathlessness (50.0%), cough (39.4%), and chest pain (24.9%)
were the common presentations. Most (90.1%) of them were exudative effusion and with half
in the right lung. Chest radiography (91.6%), pleural fluid for Ziehl–Neelsen stain (74.7%),
Address for correspondence: cytology (59.2%), and tissue biopsy (57.8%) were the common diagnostic investigations. The
Dr. Olufemi Olumuyiwa Desalu, majority (92.0%) had closed thoracostomy tube drainage, while 9.9% had chemical pleurodesis.
Department of Medicine, University The intra‑hospital mortality was 10 (4.7%). Conclusion: TB, malignancy, and pneumonia are
of Ilorin Teaching Hospital,
the leading causes of PE. A multidisciplinary approach is needed for optimal management.
PMB 1459, Ilorin, Nigeria.
E‑mail: femuy1967@yahoo.co.uk Key words: Etiology, management, Nigeria, pattern, pleural effusion

INTRODUCTION United States is estimated to be at least 1.5 million cases

annually5 and >0.3% of the population each year in the
Pleural effusion (PE) is defined as the excessive UK.1 In Southwest Nigeria, pleural diseases accounted for
accumulation of fluid in the pleural space, resulting 7.7% of respiratory morbidity with the majority between
from an imbalance between pleural fluid formation and the ages of 15 and 44 years.6 Ogunleye et  al. reported
removal.1 It is a common clinical problem which can be 372 cases of the pleural fluid collection over a 55‑month
a primary manifestation or a secondary complication period with male to female ratio of 1:1 and most of them
of many disorders. 2 The PE can be due to either between the ages of 20 and 49 years.7 Patients with PE
exudative or transudative process.3 Common causes of most commonly present with dyspnea, initially on exertion,
transudative effusion are heart failure, liver cirrhosis, and predominantly dry cough, and pleuritic chest pain. To treat
hypoalbuminemia; common causes of an exudative effusion PE appropriately, it is important to determine its etiology
are malignancy, emphysema, parapneumonic effusion, and and distinguish pleural fluid transudate from exudates.8,9
tuberculosis (TB).1‑3 However, the etiology of PE remains There is a paucity of information on the burden of PE and
unclear in nearly 20% of cases.1,2 The estimated prevalence most of the earlier works were on TB‑related effusion.10‑12
of PE is 320 cases per 100,000 people in industrialized There is a need to document our local experiences in order
countries, with a distribution of etiologies related to the
prevalence of underlying diseases.4 The incidence in the This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
Access this article online author is credited and the new creations are licensed under the identical terms.
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How to cite this article: Adeoye PO, Johnson WR, Desalu OO,
DOI: Ofoegbu CP, Fawibe AE, Salami AK, et al. Etiology, clinical
10.4103/0300-1652.219349
characteristics, and management of pleural effusion in Ilorin, Nigeria.
Niger Med J 2017;58:76-80.

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 Adeoye, et al.: Pattern of pleural effusion

to contribute the body of knowledge in Nigeria. The aims of to female ratio was 1.3:1. Twenty‑six (12.2%) of the patients
this study were to determine the pattern and management were below the age of 18 years and this accounted for
of PE in a Nigerian hospital. approximately 0.3% of the hospital admissions within this
age range; in addition, they also have equal sex distribution.
MATERIALS AND METHODS The median hospital stay was 14 (IQR 9–22) days. The other
characteristics of the patients are shown in Table 1.
This was a retrospective study carried out at the University
of Ilorin Teaching Hospital, Ilorin, Nigeria. The study The most common cause of PE was TB (32.9%), followed by
center is a tertiary hospital that serves as a referral malignancy (29.1%) and pneumonia (15.0%). In the males,
center to four neighboring states. The hospital also runs TB was the leading cause of PE, while it was malignancy
an internship and postgraduate training programs in all among females [Table 2]. Pneumonia was the leading cause
the branches of medicine. We retrieved and reviewed all of PE in the preschool (61.9%) and school age (66.7%),
the medical case records of all patients who had a clinical while it was chest trauma in adolescent (45.0%). There
diagnosis of PE in the hospital between November 2010 were two cases of malignant PE in childhood (one due to
and October 2013 to obtain necessary data. Cases that nephroblastoma and one occult malignancy). TB was the
had complete information and met the clinical criteria for most common cause of PE in adults <50 years (45.0%) and
diagnosis and classification of PE subtypes were studied. malignancy (58.2%) in 50 years and above [Figure 1]. Lung
Sociodemographic information, clinical features, etiology, cancer (49.2%) and advanced breast cancer (25.4%) were
risk factors, comorbid conditions, duration of hospital stay, the leading causes of malignant PE [Figure 2]. Furthermore,
clinical characteristics, diagnostic approach, and modalities 89.1% of the cases had exudative PE. In this study, half of
of managements were extracted from their case records. the cases have their effusion located in the right hemithorax
In addition, physical examination findings at admission, and also presented with difficulty in breathing, while 39.4%
hematological, biochemical, cytological, histopathological, reported a cough [Table 3]. Chest radiography (91.6%)
and microbiological results were obtained. and pleural fluid acid‑alcohol‑fast bacilli (74.7%) were
leading methods of investigations. Nearly two‑third of the
Diagnosis of pleural effusion patients were evaluated by pleural fluid cytology (59.2%)
The diagnosis of PEs in the study participants was based on and tissue (either pleura or lung) biopsy (57.8%) and with
(1) clinical manifestations and (2) radiologic investigation less than half screened for HIV infection [Table 4]. In the
– chest radiography and computed tomography (CT). treatment of PE, 196 (92.0%) cases had closed thoracostomy
tube drainage (CTTD). Twenty‑one cases (9.9%) had
Ethical approval was obtained from the Institution Ethical
Research Committee for the study. Table 1: General characteristics’ of the patients
Characteristics n (%)
Data analysis
Median age (years) 38 (22‑55)
The data were extracted by a postgraduate resident
Median duration of hospitalization (days) 14 (9‑22)
undergoing a clerkship rotation to remove bias; the clinical
Median duration of pleural drainage (days) 7 (4‑9)
information was coded and entered into the computer Age groups
Excel spreadsheet. Medical records with important 0‑5 15 (7.0)
missing information were excluded from the analysis. 6‑10 3 (1.4)
The data were analyzed using the Statistical Package for 11‑17 8 (3.8)
the Social Sciences, version 16 (SPSS Inc., Chicago, IL, ≥18 187 (87.8)
USA). Descriptive and frequency statistics were obtained Sex
for the variables of interest. Etiology of PEs in patients Male 123 (57.7)
was stratified by gender. Chi‑square test was used to test Female 90 (42.3)
The medians are expressed with their Interquartile range (IQR) in parenthesis
for statistical significance between categorical variables.
A P < 0.05 was considered statistically significant.
Table 2: Etiology of pleural effusions in patients
by gender
RESULTS
Etiology Male (n=120) Female Total (n=213)
(n=90)
A total of 40,301 patients were admitted during the period
TB 53 (42.3) 18 (20.0) 71 (32.9)
of review; this included 30,680 adults and 9621 children
Malignancy 22 (17.9) 40 (44.4) 62 (29.1)
and adolescents. Out of the 40,301 admissions, 213 were
Parapneumonic 13 (10.6) 19 (21.1) 32 (15.0)
clinically diagnosed as PE and this figure accounted for 0.5% Trauma 27 (22.0) 3 (3.3) 30 (14.1)
of the total hospital admissions. The age of the patients Congestive heart failure 3 (2.5) 0 3 (1.4)
ranged from 2 months to 90 years, with a median age of Underdetermined 5 (4.1) 9 (10.0) 14 (6.6)
38 (interquartile range [IQR] 22–55) years.One hundred Others 1 (0.8) 3 (3.3) 4 (1.9)
and twenty three patients (57.7%) were males and the male TB – Tuberculosis

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 Adeoye, et al.: Pattern of pleural effusion

Figure 2: Etiology of malignant pleural effusion

Figure 1: Etiology of pleural effusions in patients by age group

CTTD and chemical pleurodesis (2 g of tetracycline or Table 3: Clinical presentations of patients with
2 g of doxycycline in 60 ml slurry of 0.5% lidocaine). pleural effusion
Seventeen out of 21 (81%) cases who had CTTD and Clinical presentations n (%)
chemical pleurodesis reported pleural drainage of ≤3 days Difficulty in breathing 107 (50.2)
postpleurodesis. Chemical pleurodesis was performed Cough 84 (39.4)
Chest pain 53 (24.9)
only in patients with malignant etiology. There was no
Fever 39 (18.3)
significant difference (P = 0.573) in duration of drainage
Weight loss 35 (16.4)
postpleurodesis between tetracycline (mean = 2.9 days) Location of effusion*
and doxycycline (mean = 2.5 days). The majority (67.1%) Right unilateral 107 (50.2)
of the patients were treated with antimicrobials which Left unilateral 91 (42.7)
consisted of antibiotics and anti‑TB medication [Table 5]. Bilateral 12 (5.6)
A total ten patients with PE died within the period of Stony dull percussion note 193 (90.6)
admission in the hospital giving an intra‑hospital mortality Reduced breath sound 174 (82.2)
of 4.7% and 3 (1.4%) discharge themselves against medical Absent breath sound 19 (8.9)
advice. Tracheal shift 6 (2.8)
Bronchial breath sound 5 (2.3)
*Missing
DISCUSSION
Our study was conceived to determine the pattern and Table 4: Diagnostic approach to pleural effusion
management of PE. Overall, PE accounted for 0.5% of the Diagnostic approach n (%)
total hospital admissions meaning 5 out of every 1000 Chest radiography 195 (91.6)
hospital admissions. The occurrence of PE varies across Pleural fluid AAFB 159 (74.7)
the Francophone West Africa countries from 1%–7% to Pleural fluid cytology 126 (59.2)
23%.13-16 In Ibadan, Nigeria, Onadeko et al noted that 56% of Tissue biopsy (pleura and lung) 123 (57.8)
PE was caused by TB.17 However, there is a lack of uniformity Pleural fluid MCS 84 (39.4)
Sputum AAFB 84 (39.4)
in the methods or criteria used in reporting the burden of
Sputum MCS 84 (39.4)
this condition making it difficult to compare results of study
HIV screening 45 (21.1)
across different study populations. The demography in this VATS 24 (11.3)
study showed that the median age of the cases with PE was CT chest 4 (1.8)
38 years and this figure is similar to 37.8 years which was Chest ultrasound scan 0
reported in Lagos, Nigeria,7 and 34.7 years reported from AAFB – Acid‑alcohol‑fast bacilli; MCS – Microscopy culture sensitivities;
our center earlier,8 but it was less what was report from VATS – Video‑assisted thoracoscopic surgery; CT – Computed tomography

another part of the world.18‑22 These variations may be

attributed to the variation in the study population and the Table 5: Treatment modalities in pleural effusion
etiology and frequency of predisposing factors for PE in the Treatment modalities n (%)
different parts of the world. We also found a predilection for CTTD 196 (92.0)
males in our study and this is in agreement with many other Chemical pleurodesis (using tetracycline or doxycycline) 21 (9.9)
studies.7,8,18,19,21‑23 The reason for this was due to more males Thoracentesis 1 (0.5)
high prevalence of smoking of tobacco and consumption of Antimicrobials 143 (67.1)
alcohol compared to female in our setting.24‑25 CTTD – Closed tube thoracostomy drainage

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 Adeoye, et al.: Pattern of pleural effusion

TB accounted for one‑third of effusion (32.9%) and is of comorbidity and concurrent management of immune
the leading cause of PE, followed by malignancy (18.7%). depressive illness can improve the outcome of cancer
Lung cancer was responsible for half of the malignant PE. cases. There was a right‑sided dominance of PEs in this
This is observation is in agreement with other previous study which is similar to the findings of other previous
studies;18,19,21‑23,26‑28 however, it is in contrast to the study studies.7,13,19‑22,26‑28,35 This result can be partly ascribed to the
by Ogunleye et al.,7 which reported breast cancer as the anatomy of the right bronchus, because the right bronchus
leading cause of cancer‑related effusion. TB was the leading is wider and shorter and runs more vertically than the left
cause of PE in males while it was malignancy among bronchus, aspirated microbes and biochemical particles are
females. The preponderance of TB as a leading cause of more likely to enter and lodge in it or one of its branches.
PE in this study was also reported previously from our There is also the hypothesis that greater blood volume is
center and other developing countries.8,18‑22,26‑28 On the circulated through the right lung than the left.
other hand, this result is different from what is reported
in Lagos, Nigeria, the Islamic Republic of Iran, and other The majority (67.1%) was treated with antibiotics
developed countries.7,23,29,30 The second leading cause of and anti‑TB medication, 92.0% had CTTD, and 9.9%
PE was a malignancy and this result is similar to other had chemical pleurodesis. Malignant PE commonly
observation18,20‑22 and is in contrast to other studies that complicates advanced cancer, especially in those with
lung cancer, metastatic breast carcinoma, and lymphoma.
reported pneumonia.19‑20 These etiological differences
This complication usually leads patients to suffer from
in PE causes could be explained by the fact that TB, HIV
troublesome dyspnea, which may impair their mobility
endemicity, and low socioeconomic status which are
and reduce their quality of life.36 A total ten patients with
the risk factors for TB development are very common
PE died during the period of admission in the hospital
in this settings compared to the developed countries.
giving an intra‑hospital mortality of 4.7%. This was lower
In those studies that reported a contrasting result, this
than 16.6% reported in Eastern Nigeria, 6.4% in Ethiopia,
can be explained by the epidemiologic transition from
and 13% in the Benin Republic.26‑28 In view of the fact that
communicable diseases to noncommunicable diseases
the common causes of PE in this study are similar to the
such as cancer. Other factors might also be due to the type
etiologies in these three latter studies, the lower mortality
of patient’s referral and clinic, the level of collaboration
recorded may be due to the level care as a result of the
between the general and cardiothoracic surgeons, and the
collaboration of the physicians, surgeon, pathologies, and
availability of video‑assisted thoracoscopic surgery (VATS).
other healthcare workers in the PE study group. Other
Before this study, only 8.9% of cases of PE were reported
contributory factors are associated comorbidity and early
to be of malignant etiology in our institution when VATS
presentation and diagnosis.
and percutaneous transthoracic biopsy were not available.8
In the center where VATS is not available, the diagnosis of Limitations of the study
malignant effusion is reportedly low6 and often patients The study is retrospective in conduct and it is confronted
with unexplained PE are made to undergo a therapeutic with the problems of inability to carry out some studies
trial of anti‑TB medication. In childhood, the leading cause such as CT scan, magnetic resonance imaging, tumor
of PE in the first decade of life is pneumonia, TB was the markers, which would have been useful in some cases
most common cause in adults <50 years, and malignancy due to out‑of‑pocket cost to the patients. Despite these
in 50 years and above. This result is comparable to other limitations, we have been able to report the pattern of PE
studies in developed and developing countries.10,18,19,21,22 in our setting.
The risk of developing malignant effusion increases with
age.2,3 Parapneumonic effusion is common in childhood
CONCLUSION
because of the high incidence of acute respiratory
infection in this age group. There is 8%–40% prevalence PE is a common clinical problem confronting physicians
of parapneumonic effusions among the children with in Nigeria. TB, malignancy, and pneumonia are the
pneumonia in several other studies.31‑34 leading causes of PE. A combination of clinicolaboratory
and endoscopic approach is required for diagnosis. HIV
The combination of clinical information, microbiological,
screening is recommended as part of workup in patients
and histological examination was the useful diagnostic tests
with PE in our setting. Therefore, a multidisciplinary
for PE in this study. We did not determine the diagnostic
approach is needed for proper management.
yield of each diagnostic test because of the nature of the
study, the role of predictive value in evidenced‑based Financial support and sponsorship
medicine may implicate the need for a future prospective Nil.
study on PE. In the evaluation of the cases, it was an
irony that 21% had HIV screening considering the fact Conflicts of interest
that TB was the leading cause of PE. Early identification There are no conflicts of interest.

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 Adeoye, et al.: Pattern of pleural effusion

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