Pleural effusion is a common clinical problem, and bedside imaging plays a central role in its timely evaluation and management. In our prior companion articles, we outlined the clinical approach to pleural disease and the role of pleural fluid analysis. In this article, we describe how thoracic ultrasound (TUS) is incorporated into routine pleural practice. The value of TUS extends well beyond procedural guidance. TUS is routinely used to characterize pleural effusion, identify pleural and parenchymal abnormalities, refine the differential diagnosis, and guide appropriate pleural procedures. We present a practical approach to image acquisition, interpretation, and clinical decision-making at the bedside. We also review common pitfalls, limitations, and safety considerations that are important to everyday practice. Our goal is to provide clinicians with a structured approach for using TUS in the assessment and management of pleural effusions.

Refractory Mycoplasma pneumoniae pneumonia (RMPP) in children is associated with stronger inflammatory responses, more complex management, and a higher risk of pulmonary complications. Early identification of high-risk children may support timely treatment adjustment. This retrospective study included 500 hospitalized children with Mycoplasma pneumoniae pneumonia from November 2022 to November 2023. The cohort was randomly divided into a training set (n = 375) and a validation set (n = 125). Univariable and multivariable logistic regression analyses identified six independent predictors of RMPP: fever duration before admission, peak body temperature, lactate dehydrogenase level, sputum plugs or pleural effusion, lung consolidation, and hypoxemia. A web-based dynamic nomogram was constructed using these variables. The model showed good discrimination, with an area under the receiver operating characteristic curve/C-index of 0.840 (95% CI, 0.785-0.892) in the training set and 0.831 (95% CI, 0.743-0.906) in the validation set. Calibration curves showed good agreement between predicted and observed risks, and decision curve analysis suggested clinical net benefit across most threshold probabilities. Children with prolonged fever, high peak temperature, elevated lactate dehydrogenase, hypoxemia, and CT evidence of lung consolidation or sputum plugs/pleural effusion should be considered at increased risk of RMPP and may require closer monitoring and timely treatment adjustment.

Herein, we report a rare case of refractory pleural effusion secondary to radiotherapy-induced fibrosing mediastinitis. A male patient in his early 60s with a history of thoracic radiotherapy presented with a massive right-sided transudative pleural effusion. Imaging studies revealed occlusion of the right pulmonary vein and stenosis of the pulmonary artery, leading to a diagnosis of pleural effusion secondary to radiation-induced fibrosing mediastinitis. After unsuccessful pulmonary vein balloon dilation, an innovative approach was adopted: coil embolization of the pulmonary artery branches on the affected side. This strategy aimed to reduce visceral pleural hydrostatic pressure, thereby decreasing pleural fluid filtration. Postoperatively, the patient's shortness of breath improved, and the rate of pleural fluid accumulation slowed, demonstrating favorable short-term efficacy. When pulmonary venous intervention is ineffective, this article provides a novel interventional strategy for managing fibrosing mediastinitis-associated refractory pleural effusion.

Spontaneous hemothorax, defined as bleeding into the pleural cavity without trauma or coagulopathy, is rare. Especially, it is uncommon in patients with primary epithelial lung cancer. We report a rare autopsy case of lung adenocarcinoma harboring both an anaplastic lymphoma kinase (ALK) rearrangement and a tumor protein p53 (TP53) mutation, in which hemothorax led to the formation of a giant pleural hematoma.A 75-year-old man with stage IVB lung adenocarcinoma presented with mediastinal and cervical lymph node metastases and right pleural effusion at diagnosis. Molecular testing revealed an ALK rearrangement and a TP53 mutation. He was treated sequentially with alectinib, lorlatinib, and brigatinib. After disease progression and treatment-related complications, he presented to the emergency department with acute dyspnea and a rapid decrease in hemoglobin level. Contrast-enhanced computed tomography showed encapsulated fluid retention with faint high attenuation in the right pleural cavity, and magnetic resonance imaging findings were consistent with a hematoma. Given his poor performance status and the absence of active bleeding on imaging, invasive intervention was not performed. Despite supportive management, he died one week after admission from respiratory failure and hemodynamic deterioration.Autopsy revealed a giant pleural hematoma above the diaphragm, surrounded by pleural metastases. Although no definite source vessel was identified, active bleeding from a metastatic pleural lesion was observed, suggesting persistent tumor-related hemorrhage as the cause of the hemothorax.This case represents an extremely rare presentation of ALK-rearranged lung adenocarcinoma complicated by spontaneous hemothorax. Neither ALK rearrangement nor TP53 mutation has been directly linked to hemothorax, but the aggressive biological behavior associated with this molecular profile may have contributed to the catastrophic pleural bleeding. In lung cancer patients, rapid pleural fluid accumulation with hyperdense imaging findings should raise suspicion for hemothorax.

Selpercatinib is a selective RET inhibitor with established efficacy in RET-altered malignancies; however, data regarding its long-term safety and pharmacokinetic behavior remain limited. We report a case of fatal hepatic failure occurring during prolonged selpercatinib therapy and describe associated clinical and pharmacokinetic findings. A 78-year-old man with RET-mutant medullary thyroid carcinoma received selpercatinib (160 mg twice daily) as second-line therapy following disease progression during vandetanib treatment. After dose interruption and subsequent dose adjustments, the patient achieved a sustained partial response during long-term treatment. Approximately 27 months after selpercatinib initiation, he developed progressive dyspnea, pleural effusion, and severe hepatic dysfunction, ultimately resulting in death. Plasma selpercatinib concentrations were measured during stable disease and later during hepatic decompensation. Pharmacokinetic analysis indicated that drug exposure during the stable treatment period was within the anticipated range, suggesting that elevated drug concentrations observed at the time of hepatic decompensation represented a consequence of impaired clearance rather than a primary cause. These findings implicate circulatory compromise as a potential mediating mechanism and highlight the importance of cardiovascular as well as hepatic monitoring during prolonged selpercatinib therapy. This case highlights a potential indirect mechanism of severe hepatic failure during long-term selpercatinib therapy, in which circulatory compromise-potentially mediated by selpercatinib-associated cardiovascular effects-may have contributed to congestive hepatic decompensation rather than direct drug-induced hepatotoxicity. These findings underscore the importance of integrating cardiovascular surveillance with hepatic monitoring during prolonged selpercatinib treatment.

We report a case of pulmonary nocardiosis and pulmonary tuberculosis following steroid pulse therapy for presumed myelitis. A 74-year-old man with transthyretin amyloid cardiomyopathy, chronic heart failure, and type 2 diabetes mellitus received two courses of steroid pulse therapy for suspected inflammatory myelitis. One month later, he developed progressive dyspnea and was admitted to our hospital. Chest computed tomography revealed multifocal right-sided infiltrates and pleural effusion. Although empirical piperacillin/tazobactam was initiated for presumed bacterial pneumonia, sputum Gram and Kinyoun stains revealed thin, branching, partially acid-fast bacilli, and sequencing of the secA1 gene identified Nocardia exalbida. Polymerase chain reaction (PCR) analysis was positive for Mycobacterium tuberculosis. Pleural fluid culture yielded Nocardia species. The patient's condition improved following combined antituberculous and anti-nocardial therapy, along with optimized heart failure management. Coinfection with nocardiosis and tuberculosis should be considered in immunosuppressed patients following corticosteroid therapy.

Objective: To investigate the clinical outcomes and prognostic factors in children with Mycoplasma pneumoniae necrotizing pneumonia (MPNP) at 1 year after discharge. Methods: This prospective cohort study enrolled 60 children with MPNP treated at the Department of Respiratory Medicine, Children's Hospital of Fudan University, between August 2023 and December 2024. Clinical, laboratory, and radiological data were collected during hospitalization. All patients were followed up for one year post-discharge, with serial assessments of symptoms, chest CT, and pulmonary function. Based on final CT findings, patients were categorized into good and poor prognosis groups. Univariate analysis, Lasso regression, and multivariate Logistic regression were used to identify independent predictors and construct a prediction model. Results: Among the 60 children (28 males, 32 females; age at presentation 6.0 (5.0, 8.0) years), 38 cases had good prognosis and 22 cases had poor prognosis. Compared with the good prognosis group, the poor prognosis had significantly higher proportions of acute-phase respiratory failure, intensive care unit admission, poor distal ventilation on bronchoscopy, necrotic cavity diameter ≥2 cm on imaging, ≥2/3 single-lobe involvement, multilobar consolidation, and moderate-to-large pleural effusion, as well as greater numbers of involved lobes and total CT scores (all P<0.05). At the 1-year follow-up, atelectasis occurred in all 22 cases (100.0%) in the poor prognosis group, with pulmonary cavity formation in 3 cases (13.6%) and abnormal pulmonary function in 8 cases (36.4%). Multivariate analysis identified poor distal ventilation on bronchoscopy (OR=9.29, 95%CI 2.03-60.46, P=0.003) and elevated lactate dehydrogenase (LDH) level (per 100 U/L increase, OR=2.16, 95%CI 1.42-3.90, P<0.001) as independent predictors of poor prognosis. The combined predictive model based on these two factors achieved an area under the curve of 0.93 (95%CI 0.87-0.99, P<0.001). Conclusions: A substantial subset of MPNP children still exhibit radiological sequelae and functional impairment one year after discharge. Acute-phase poor distal ventilation on bronchoscopy and markedly elevated serum LDH are independent predictors of poor prognosis. The prediction model combining these two factors demonstrates good discriminative ability.

We report a 31-year-old woman with cirrhosis who developed bilateral pleural and pericardial effusions caused by Curvularia hawaiiensis. The patient developed worsening shock and multiorgan failure during hospitalization despite broad-spectrum antibacterial and antifungal therapy. Her course was complicated further by development of bilateral pleural effusions and pericardial effusion. Pericardiocentesis and thoracentesis were performed, with cultures initially demonstrating scant mold growth. Liposomal amphotericin B was subsequently initiated; however, the patient ultimately died following transition to comfort-focused care. Postmortem identification of both pleural and pericardial isolates revealed Curvularia hawaiiensis, a rare dematiaceous mold infrequently associated with invasive disease. This case highlights the profound immune dysfunction associated with acute-on-chronic liver failure and demonstrates the potential for rare molds to cause rapidly progressive invasive infection in cirrhotic patients. Additionally, it underscores the diagnostic and therapeutic challenges posed by delayed organism identification and limited susceptibility data for uncommon fungal pathogens. This is the first reported pericardial infection due to this human pathogen.

To evaluate the efficacy and safety of medical thoracoscopy (MT) compared with tube thoracostomy (TT) for complicated parapneumonic effusion (CPPE) and empyema. We retrospectively analyzed 79 adults with stage 5 CPPE or empyema treated from May 2018 to January 2024. Patients were non-blindly assigned to an MT group (n = 25) or TT group (n = 54) according to attending physician discretion, imaging findings, clinical status, procedural suitability, and physician expertise. Baseline characteristics, pleural fluid biochemistry, clinical improvement, treatment failure, in-hospital mortality, total pre-intervention and post-intervention hospitalization, pleural fluid drainage volume, and postoperative complications were compared. Clinical improvement required symptom resolution plus radiographic reduction without further invasive intervention; treatment failure included persistent sepsis, additional intervention, or pleural-infection-related death. Median total hospitalization was 17 days (inerquartile range [IQR], 13-22) in the TT group and 20 days (IQR, 16-25) in the MT group, without a significant difference (P > .05). The MT group had more loculation/septation (92.0% vs 68.5%, P = .023) and longer pre-intervention hospitalization (7 days, IQR 5-11 vs 2 days, IQR 1-3; P < .05), suggesting more complex disease and delayed escalation. Post-intervention hospitalization was shorter after MT (10 days, IQR 6-17) than TT (15 days, IQR 11-20) (P < .05). Pleural fluid drainage volume was greater after MT (1210 mL, IQR 475-2300) than TT (600 mL, IQR 245-1212) (P < .05). Clinical improvement, treatment failure, adverse reactions, and mortality did not differ significantly between groups (P > .05). The overall adverse reaction rate was 16.0% after MT and 3.6% after TT (P = .076). MT appears feasible and safe for selected patients with CPPE and empyema. It was associated with greater pleural drainage and shorter post-intervention hospitalization than TT, despite use in patients with more complex disease. However, because this retrospective study involved non-blinded treatment allocation, selection bias, baseline imbalance, and a small sample, the findings are hypothesis-generating rather than definitive. MT did not show a statistically significant effect on in-hospital mortality. Prospective randomized studies are needed to define its optimal timing and role in pleural infection management.