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 the
common cause of morbidity in cancer patients
management of multiloculated malignant
with advanced disease. Most patients present
pleural effusions and only two studies have
with progressive dyspnoea, cough or chest pain
shown its efficacy in this condition4, 5.
that compromises their quality of life 1 . The
drainage and control of malignant effusions There are few case reports of intrapleural
promptly 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. The
thoracostomy. However, these methods usually present report is the first one on the use of
fail in patients with multiloculated effusions intrapleural streptokinase in multiloculated
where fibrinous adhesions impede free fluid malignant pleural effusions from India.
drainage causing persistent effusion and
dyspnoea. Thoracoscopic procedures are CASE REPORT
usually required in such patients, but may not
be possible in all2. A 60-year-old male smoker presented with
Intrapleural administration of fibrinolytic dry cough, right-sided chest pain and
agents has been shown to be effective and safe progressively increasing breathlessness of four
for 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@ rediffmail.com>.

2. 60 Intrapleural Fibrinolytic Therapy in Multiloculated MPE Ramakant Dixit et al
patient was tachypnoeic and had pallor and
digital clubbing. Clinical examination of
respiratory system suggested right sided pleural
effusion. Chest radiograph revealed massive
right-sided pleural effusion with mediastinal
shift to the opposite side.
In view of massive pleural effusion and to
relieve respiratory distress, tube thoracostomy
was done under waterseal system and about
750 ml straw-coloured clear fluid was drained
immediately. 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 Gram's and Ziehl-Neelsen staining. Clamp was removed after two hours and
Cytological examination of pleural fluid showed drainage was subsequently collected and
poorly differentiated malignant cells forming measured. The same dose of streptokinase was
solid clumps or vague glandular spaces sugges- repeated after 12 hours. There was marked
tive of adenocarcinoma. On fiberoptic broncho- improvement in dyspnoea and total drainage
scopy, an endobronchial mass was seen in the rose to 2800 ml after two instillations. There was
superior segmental bronchus of the right lower no haemorrhage or allergic complications
lobe which on histopathological examination related to this treatment. The third dose was
revealed adenocarcinoma infiltrating the fibrous repeated after another 12 hours and this time
stroma. The tumour cells were large with the drainage was 800 millilitre. The therapy was
pleomorphic nuclei having prominent nucleoli continued 12 hourly and after fourth dose, the
and mitotic figures. A small amount of mucicar- drainage was 200 millilitre. A total of six doses
mine positive material was also seen in some were given after which the drainage was
cells. Thus, a final diagnosis of malignant decreased significantly (less than 50 ml/day)
pleural effusion due to underlying carcinoma and the patient reported marked improvement
lung 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 about
300 ml fluid over next two days, although the
chest tube was patent and well positioned. A
repeat chest radiograph showed persistent
pleural effusion. Ultrasonography (USG) of
pleural space at this stage revealed multi-
loculated effusion on right side (Figure 1).
In view of multiloculated pleural effusion
resulting in poor tube drainage and persistent
symptoms, intrapleural fibrinolytic therapy was
planned as there was no contraindication to
such therapy. Streptokinase, 250,00 IU was
dissolved in 100 ml of normal saline and was
instilled into pleural space through chest tube Figure 2. Ultrasonography of pleural space after
after clamping it distally. Position of the patient intrapleural streptokinase therapy showing
was changed frequently to allow even complete resolution.

3. 2004; Vol. 46 The Indian Journal of Chest Diseases & Allied Sciences 61
Patient received mitoxantrone pleurodesis Intrapleural fibrinolytic treatment does not
before removal of the chest tube. He remained appear to alter the systemic coagulation
asymptomatic thereafter and discharged after 14 parameter11 and has been claimed to be safe
days. 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 of
till 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 effusion
agents has been in use for more than 50 years; it reported so far, experienced systemic side effects
has, 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 of
published 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 applying
and haemothorax3. However, this approach has this therapy to ensure safe and successful
rarely been reported in the control of multilocu- results.
lated malignant pleural effusion and a recent We conclude with remark that intrapleural
editorial opinion has suggested that intrapleural fibrinolytic therapy may be considered in
fibrinolytic therapy should be avoided in multiloculated malignant pleural effusion also,
patients with malignant pleural effusion, who fail to drain adequately with chest tube
despite a lack of evidence in the literature to drainage so as to improve dyspnoea and quality
support this view 9. There are only two publi- of life in these terminally ill patients.
shed reports supporting use of intrapleural
fibrinolytic therapy in patients with multilo-
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