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Vol.17 No.1 | January - April, 2024 | Pages 42 - 48

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Pattern and outcome of paediatric pleural effusion seen at Usmanu Dafodiyo University Teaching
Hospital, Sokoto: A 5-year retrospective study
Abubakar FI1, Rufai AI1, Ahmed HK1, Adamu A1, Ukwuni SI2
1
Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto
2
Department of Cardiothoracic Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Abstract

Background: Pleural effusion is an abnormal accumulation of fluid in the pleural cavity which present
with spectrum of clinico-aetiological manifestations often requiring multidisciplinary approach.
Objectives: This study set out to determine the prevalence, aetiology, clinical presentation, treatment
modalities and outcome of pleural effusion in children.
Materials and Methods: This was a retrospective study where records of children with diagnosis of
pleural effusion admitted at UDUTH, Sokoto were obtained between January 2017 and December 2022
and reviewed. Diagnosis was based on clinical presentation and radiological confirmation of pleural
effusion. Data was analyzed with SPSS version 20.0.
Results: A total of 49 cases were retrieved. The prevalence of pleural effusion was 0.54% (9,056). It was
more prevalent in males with ratio of 2.5:1 (χ² = 9.833, P = 0.007). The median age was 9 years (IQR 7).
The most common cause of pleural effusion was pneumonia 26 (53.1%) followed by tuberculosis 16
(32.6%), malignancy 3 (6.1%), cardiac and renal causes accounted for 2 (4.1%) each. Cough (100.0%),
difficulty in breathing (100.0%), tachypnea (100.0%), respiratory distress (100.0%), and desaturation
(98.0%) were the common presentations. Most (77.5%) of them presented with right sided pleural
effusion. The majority (93.9%) had closed thoracostomy tube drainage. The outcome showed majority
(83.7%) of the cases been discharged, with a median duration of hospital stay of 22days (IQR 17).
However, mortality rate for the malignant causes was 100.0%.
Conclusion: Infections were the major cause of paediatric pleural effusion with relatively good outcome.
Surgical intervention and multidisciplinary team approach are needed to reduce the morbidity and
mortality in patients with pleural effusion especially for the malignant causes.

Keywords: Pleural effusion, Aetiology, Clinical manifestation, Pneumonia

Introduction
Pleural effusion is the commonest manifestation of pleural diseases.1 The pleural cavity is the potential
space between the visceral and parietal pleurae. Pleural effusion is the collection of excessive fluid and/or
reduced lymphatic absorption in the pleural cavity.2,3 The mechanism of pleural effusion formation results
from an imbalance between the oncotic and hydrostatic pressure as well as impairment in lymphatic
drainage. Increased capillary permeability, altered pleural membrane permeability and decrease pleural
2,3
cavity pressure have also been implicated. The fluid could either be exudative, transudative or mixed

2,3
Corresponding Author: depending on the aetiological factors.
Dr Fatima Abubakar Ishaq, The presentation of pleural effusion in children
Department of Paediatrics, Usmanu Danfodiyo University indicates an ongoing disease, of which the
Teaching Hospital, Sokoto, Nigeria.
prevalence reflects that of the causative disease.3
[email protected] | +2347032100401 The prevalence of pleural infections is increasing
DOI: 10.61386/imj.v17i1.375
globally even in the industrialized countries like

42
Abubakar FI et al Pattern and outcome of paediatric pleural effusion...

United States with a rate of 70% increment between Teaching Hospital UDUTH, in Sokoto state, North
1997 and 2006 (2.2 and 3.7per 100,000 western Nigeria. The hospital serves as a referral
respectively), with dearth of studies on paediatric centre for hospitals within Sokoto and neighboring
pleural effusion in developing nations. Effusion states including Kebbi, Zamfara, Niger, Katsina
associated with bacterial pneumonia accounted for states and neighboring countries like Niger and
4,5
about 0.6-2 % of the cases. Tuberculous pleural Benin Republic.
effusion is common in developing countries like Method of data extraction: The records of all
ours which have many cases of tuberculosis children with pleural effusion admitted into the
6-8
infection. department between 1st January 2017 and 31st
Pleural effusion is commonly caused by infective December 2022 were retrieved and reviewed from
processes such as pulmonary tuberculosis, the admission registers and case folders. Other
Staphylococcal, Streptococcal and Klebsiella details such as complications, comorbid illness
infections and non- infective causes like nephrotic were retrieved from the case notes of the patient.
syndrome, cardiopulmonary diseases, connective The total number of patient admissions per year and
tissue disorders, malignancies, chest trauma, the overall admissions of children with pleural
sarcoidosis among others.3,9 effusion were recorded.
Para-pneumonic effusion is caused by bacterial Diagnosis of pleural effusion was based on a
pneumonia while empyema thoracis (pyothorax), is combination of clinical evaluation including
a complication of pleural effusion, which is a thoracocentesis and chest radiographs in all patients
purulent effusion.3,9,10 Most cases of empyema are and other investigations, including chest ultrasound
closely linked with para-pneumonic effusion due to scan, Mantoux test, blood/aspirate/sputum cultures,
necrotizing pathogens especially Staphylococcus Gene-Xpert tests, blood counts and differentials,
aureus. Other associated risk factors for pyothorax erythrocyte sedimentation rate, urinalysis and
include infancy, malnutrition and measles.9,10,11 echocardiograms, where necessary. The data
Pleural effusion is associated with significant extracted from the records included the age, sex,
morbidity and mortality, including prolonged domicile, risk factors (contact with chronically
hospital stay, exposure to surgical procedures with coughing adult, immunization status, nutritional
attendant complications (such as hemothorax, status, anthropometric measurements), examination
pneumothorax), atelectasis, heart failure, empyema findings on admission, diagnosis, complications
thoracis, air leak syndromes, broncho-pleural and co-morbidities so also the duration of stay and
fistula, empyema neccesitans, pleural thickening outcome the diagnostic approach and modalities of
and scoliosis.3,9,12 Yet, extensive researches among treatments.
paediatric cases with pleural effusion is only Inclusion criteria: All children, between the ages
available for the developed countries, with scarcity of 1 month – 15years admitted for pleural effusion
of data in developing countries like ours despite it (patients aged less than 1 month are admitted into
being one of the commonest pleural disorders with the special care baby unit while 15 years is upper
high morbidity.3 limit of patient’s age admitted into the paediatric
This study aimed to determine the prevalence, department in Usmanu Danfodiyo University
clinical presentations, aetiology, treatment Teaching Hospital (UDUTH), Sokoto).
modalities and outcome of pleural effusion among The diagnosis of pleural effusion definition in this
hospitalized paediatric patients in a Nigerian health study is the accumulation of fluid in the pleural
facility. cavity based on 1. Clinical features and chest
examination findings and 2.
Materials and Method Radiologic investigations: chest radiography,
Study design and site: This was a retrospective chest ultrasonography or chest computer
hospital-based study with data collected over a tomography.
period of five years (January 2017 to December Exclusion criteria: All children without radiologic
2022). The study was conducted in the Paediatrics confirmation of the pleural effusion.
Department of the Usmanu Danfodiyo University Data Analysis: The data was analyzed with

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Abubakar FI et al Pattern and outcome of paediatric pleural effusion...

Statistical Package for the Social Sciences, version During the study period, a total of 9,056 children
20 (SPSS Inc., Chicago, IL, USA). were admitted and of which 49 were diagnosed with
Median, and interquartile range (IQR) were pleural effusion, contributing to 0.54% of the total
calculated for non-normally distributed continuous admissions. Their ages ranged from 6 months to 15
variables. Categorical variables were summarized years with a median age of 9 years (IQR 6). Ages 0 –
using proportions and percentages. Descriptive 10 years accounted for nearly three-fourth of the
weighted prevalence was used to compute for the patients (73.5%). Males accounted for more than
prevalence of pleural effusion. A chi-square test was two-third of the study participants with male to
used to determine for association between the socio- female ratio of 2.5:1 there was also a significant
demography and outcome parameter. A p-value of difference in disease prevalence based on age and
less than 0.05 was considered significant. gender (p=0.007). (Table 1).
The ethical approval was obtained from the Usmanu Cough (100.0%), difficulty in breathing (100.0%),
Danfodiyo University Teaching Hospital (UDUTH) respiratory distress (100.0%), tachypnea (100.0%),
ethical review committee with UDUTH Health low oxygen saturation (98.0%) and stony dull
Research Ethics Committee assigned number: percussion note (93.9%) were the major clinical
UDUTH/HREC/2022/1195/V1. features among patients with pleural effusion.
(Table 2)
Results Over two-thirds of the patients (77.5%) had right
sided pleural effusion. All the malignant causes of
Table 1: Age and Sex distribution of the study pleural effusion presented with left sided pleural
participants
effusion (Figure 1).
Pneumonia was the major cause (53.1%) of pleural
effusion followed by tuberculosis (32.6%). Two
cases of lymphoma and metastatic
rhabdomyosarcoma accounted for the malignant
causes (6.1%) of pleural effusion. The cardiac
causes included dilated cardiomyopathy and
rheumatic valvular heart disease while acute
glomerulonephritis and nephrotic syndrome
Table 2: Spectrum of Clinical features of Patients
with Pleural effusion constituted the renal causes (Table 3).

Figure 1: Site of Accumulation of Pleural Effusion

Table 3: Aetiology of Pleural Effusion

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Abubakar FI et al Pattern and outcome of paediatric pleural effusion...

Table 4: Aetiology of Pleural Effusion by Age and Gender

Table 5: Modalities of Treatment in Patients with anti-failure agents (parenteral diuretics) as a form of
Pleural Effusion treatment modality, while a small proportion (6.1%)
which constituted the malignant causes of pleural
effusion had thoracocentesis, pleurodesis and
chemotherapy.
Median duration of hospitalization was 22 days
(IQR17). The majority (83.7%) of the pleural
effusion cases were managed and discharged. The
three malignant cases (two cases of metastatic
lymphoma and a case of metastatic
rhabdomyosarcoma) of pleural effusion died while
on admission, accounting for 37.5% of total
mortality rate.

Discussion
This study reported 0.54% overall prevalence rate
of paediatric pleural effusion, the finding is
consistent to studies in Ilorin, North Central
Nigeria, Morocco and India which reported a
prevalence of 0.5%, 0.51%, 0.82% respectively.13-15
In contrast, a higher prevalence of 7.5% was
observed among paediatric oncology patients with
16
Wilms tumor. The variation could be explained by
the fact that these patients with pleural effusion and
Figure 3: Outcome of hospitalization in Patients Wilms tumor were more likely to present with
with Pleural Effusion advanced stage tumors, have their preoperative
tumor rupture and lacked standardized management
Pneumonia was the commonest cause of pleural protocol, thereby predisposing them more to pleural
16
effusion among preschool (20.4%) and school aged fluid collection compare to other population. Also,
(26.5%) children while tuberculosis (12.2%) in patients with Wilms tumour did not feature in this
adolescents. All the females presented with study.
parapneumonic effusion (pneumonia and The prevalence of pleural effusion was higher in
tuberculosis) while all the malignant causes were males (71.4%) than in females (28.4%) which
seen in males. There was no statistically significant commensurate with Nabila and Hasan’s report of
difference in disease prevalence based on the age 80.0% and 66.7% accordingly.17,18 Pleural cavity
and gender distribution (p = 0.174 and 0.329) infection is mostly due to pulmonary infection, and
respectively. (Table 4). this was reported to be the main cause of paediatric
19
Majority of the cases (93.9%) had CTTD in pleural effusion in 50-60% of cases. This was
combination with antibiotics, anti-tuberculous and consistent with the index study. Thus, a potential
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Abubakar FI et al Pattern and outcome of paediatric pleural effusion...

reason for the male preponderance for pleural left sided pleural effusion more common in their
17
effusion may be linked to the role of X-chromosome study.
in immunoglobulin production which is responsible Majority of the cases had CTTD (93.9%) in
20
for fighting infections. The male gender has only combination with antibiotic (53.1%), anti-
one X-chromosome compare to two X- tuberculous (32.6%) and anti-failure agents (8.2%)
chromosomes in females which offer more as a form of treatment modality. Late presentation
protection against infections, since infectious and massive pleural effusion compromising
(pneumonia and tuberculosis) are the major causes respiratory function requiring urgent relief of
of pleural effusions, hence the susceptibility of the symptoms were the commonest presentation in all
male gender to pleural effusion. The median age of the cases necessitating the need for CTTD
presentation was 9 years (IQR 7) with 6-10 years procedure, making it the mainstay of treatment in
age category accounting for nearly half of the cases paediatric pleural effusion. This result is
which is similar to reports in India and Pakistan., comparable to these studies, while a small
and this was also higher than reports from previous proportion (6.1%) which constitutes the malignant
18,21-23
studies. These discrepancies could be due to causes of pleural effusion had thoracocentesis,
differences in the sample method, study population pleurodesis and chemotherapy.13,15,23 However, in
and causes of pleural effusion in different places of other studies, treatment with antibiotic alone was
the world. the most frequent form of therapeutic measure.22,27
Infectious/parapneumonic effusion (pneumonia Most of the patients (83.7%) responded well to
and tuberculosis) was the major cause (85.7%) of treatment and were discharged with median
paediatric pleural pneumonia with pneumonia and duration of hospitalization of 22 days (IQR 17). This
tuberculosis accounting for more than half and one – was also reported these studies.13,23 The high number
third respectively. This finding was similar to of recovery and discharged could be explained by
majority of the studies reported all over the the fact that majority of the causes of paediatric
14,17,19,21,22
world. This observation could be attributed pleural effusion in this study was infection (85.7%),
to the global reflection of parapneumonic effusion which are often vaccine preventable and can be
occurring in as many as 50-70% of patients admitted cured with antibiotics, hence the good response and
with a complicated pneumonia.24 Malignancy was high rate of discharge. A total of 8 cases (16.3%)
the second most common cause of Pleural effusion died while on admission, out of which all the cases
with lymphoma responsible for two-third of the associated with malignancy died, accounting for
malignant causes which was in concordance with 37.5% of the total pleural effusion case mortality
14,17,25
these reports. Additionally, lymphoma was the recorded. This demonstrates the poor survival,
most common malignancy associated with pleural outcome and high mortality rate associated with
19,26 28,29
effusion as reported by these studies. In contrast, pleural effusion associated with malignancy.
other studies observed that congestive cardiac
19,22
failure was the second commonest cause. Limitation
The most common clinical manifestations were This was a retrospective study where the data was
cough, difficulty in breathing, fever, respiratory obtained from case notes. Pleural aspirate
distress, tachypnea, desaturation, stony dull biochemistry analysis was not done in the patients
percussion note, tachycardia, chest asymmetry which would have been useful in the diagnosis and
which is in keeping with previous findings.14,17,18,21,23,27 classification of pleural effusion.
Majority of the cases presented with right sided
pleural effusion which was in agreement with Conclusion
previous studies, and this may be due to the anatomy Paediatric pleural effusion is caused by a wide range
of the right bronchus being shorter, larger diameter of disorders, with pleural infections largely
and oriented more vertical than the left bronchus, contributing as a cause of the disease, hence
aspirated microorganisms and particles tend to find prevention, early presentation, prompt diagnosis
their way into it or its branches.13,15,19,23 However, and inter professional/health care team
Nabila et al reported a contrasting finding with the management approach of pleural effusion will

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Abubakar FI et al Pattern and outcome of paediatric pleural effusion...

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Hydrothorax, haemothorax and chylothorax.
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