A pleural effusion is tapped. Pleural fluid analysis: protein 42 g/L (serum 68 g/L), LDH 380 U/L (serum 220 U/L), glucose 2.1 mmol/L, pH 7.1, WBC 25,000 (85% neutrophils). What is the next immediate management step?

• A Insert a chest drain; consider intrapleural fibrinolytics if septated ✓
• B Start IV antibiotics and repeat aspiration after 48 hours
• C VATS (video-assisted thoracoscopic surgery) immediately
• D Send pleural fluid for cytology and defer drainage

Explanation

This pleural fluid meets Light's criteria for exudate and shows features of a complicated parapneumonic effusion or empyema: pH < 7.2, glucose < 2.2 mmol/L, very high neutrophil-dominant WBC, and LDH > three times upper limit of normal in the pleural space. BTS 2023 guidelines mandate chest drain insertion (not just antibiotics and serial tapping) for pH < 7.2, glucose < 2.2, or frank pus. Intrapleural fibrinolytics (tPA + DNase — MIST2 trial) are added for septated or complicated loculations to improve drainage. VATS is reserved for failure of drain + fibrinolytics.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.