Lung white out: haemothorax after intrapleural tPA and DNase administration

• Published in: BMJ case reports Vol. 13; no. 12; p. e240475
• Main Authors: Chong, Woon H, Saha, Biplab Kumar
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 22.12.2020; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Aged; Anticoagulants; Case reports; Catheters; Chest tubes; Drainage; Enzymes; Female; Hemoglobin; Hemothorax - diagnostic imaging; Hemothorax - etiology; Hemothorax - surgery; Humans; Images In; Infections; Ostomy; Patients; Pleural effusion; Pleural Effusion - diagnostic imaging; Pleural Effusion - drug therapy; pleural infection; Pneumonia; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - adverse effects; Tomography, X-Ray Computed; unwanted effects / adverse reactions; pleural infection; unwanted effects / adverse reactions
• ISSN: 1757-790X; 1757-790X
• DOI: 10.1136/bcr-2020-240475

The decision was made to medically treat her loculated effusion by starting intrapleural enzymes of tissue plasminogen activator (tPA) involving 10 mg alteplase, and 5 mg dornase alfa (DNase) two times per day for the next 3 days. Several observational studies have demonstrated that the risk of developing haemothorax is highly variable, ranging between 1.8% and 10% in patients receiving intrapleural tPA with/without DNase.2–4 However, the risk increases exponentially to 28%–33% with the concurrent administration of therapeutic anticoagulation or when a higher dose of intrapleural tPA (20 mg alteplase) was used, regardless of coagulation panel results.3 5 The risk of bleeding was not increased in patients receiving aspirin, clopidogrel or prophylactic subcutaneous heparin.5 Interestingly, there is a case report in which a patient experienced severe intrapleural bleeding with opacification of a hemithorax after receiving intrapleural tPA/DNase while fully anticoagulated.6 This suggests that bleeding risk may be increased using this combination. Learning points Intrapleural tissue plasminogen activator (tPA)/dornase alfa therapy, which is often used for the non-surgical treatment of loculated parapneumonic pleural effusions, may be associated with the development of haemothorax which may be severe with opacification of the treated hemithorax.