Causes of Hemorrhagic Pleural Effusion and Ascites in Children
In pediatric patients presenting with hemorrhagic pleural effusion and ascites together, malignancy is the primary concern and must be excluded first, followed by trauma, infectious complications, and systemic conditions affecting both compartments.
Primary Diagnostic Considerations
Malignancy (Most Critical)
- Most malignant effusions in children are blood-stained, making hemorrhagic fluid a key indicator of potential malignancy 1.
- Hematologic malignancies (leukemia and lymphoma) are the predominant pediatric cancers causing this presentation 1.
- Congenital leukemia can present with jaundice, pleural effusion, and ascites, with hemorrhagic features developing as thrombocytopenia worsens 2.
- Cytological examination should be sent to the hematology laboratory first for cytospin analysis in pediatric cases, then forwarded to cytology if non-hematologic malignant cells are identified 1.
- Malignancy should be suspected when there is absence of acute fever or pneumonia, or evidence of mediastinal mass or lymphadenopathy 1.
Trauma and Post-Surgical Complications
- Trauma is a recognized cause of pleural effusion in children and can produce hemorrhagic fluid in both pleural and peritoneal spaces 1.
- Post-cardiothoracic surgery can result in hemorrhagic effusions and ascites 1.
- Avoid large volume aspiration and general anesthesia in suspected mediastinal obstruction, as this poses significant risk of sudden death; limit diagnostic taps to 5 ml 1.
Infectious Causes with Hemorrhagic Features
- While most parapneumonic effusions are not hemorrhagic, complicated infections can develop blood-stained fluid 1.
- Dengue hemorrhagic fever presents with ascites (100% of cases) and pleural effusion (90% of cases) along with thrombocytopenia, hemorrhagic manifestations, and hepatomegaly 3.
- Tuberculous effusions may be hemorrhagic and typically show lymphocytic predominance, though 10% are neutrophil-predominant 1.
Systematic Diagnostic Approach
Initial Fluid Analysis
- Send aspirated fluid for differential cell count immediately to distinguish between neutrophil-predominant (infection) versus lymphocyte-predominant (tuberculosis or malignancy) 1.
- Perform Gram stain and culture for aerobic/anaerobic organisms, including acid-fast bacilli staining and mycobacterial culture 1.
- A predominance of lymphocytes in hemorrhagic exudate mandates exclusion of tuberculosis and malignancy 1.
Imaging Evaluation
- CT chest scan should be performed when malignancy needs to be excluded, particularly to evaluate for lymphoma or mediastinal masses 1.
- Assess for bilateral versus unilateral effusions: bilateral effusions may indicate tuberculosis, parasitic infection, or systemic disease 1.
Underlying Systemic Conditions
- Children with known congenital heart disease, renal disease, or connective tissue disorders may develop hemorrhagic effusions and ascites 1.
- Immunodeficiencies predispose to complicated infections that can become hemorrhagic 1.
Critical Clinical Pitfalls
Avoid These Errors
- Do not perform large volume thoracentesis or use general anesthesia/sedation when superior mediastinal obstruction from malignancy is suspected, as this carries significant mortality risk 1.
- Do not assume all hemorrhagic effusions are traumatic; malignancy and infection must be systematically excluded 1.
- Do not rely solely on cytology, as cytological examination may not reveal malignant cells even in confirmed malignancy 1.
Special Populations
- In previously well children, consider acute bacterial pneumonia with complicated parapneumonic effusion that has become hemorrhagic 1.
- In endemic areas, dengue hemorrhagic fever should be considered when hemorrhagic effusions and ascites present with thrombocytopenia and hepatomegaly 3.
- Neonates presenting with this combination require evaluation for congenital leukemia, particularly if accompanied by jaundice and low albumin 2.