Dark Streaks and Yellow Exudates: Pleuroscopic Clues in Recurrent Post‐Traumatic Pleural Effusion

ABSTRACT

Thoracic splenosis is a well‐documented yet clinically elusive sequela of combined splenic rupture and diaphragmatic trauma, classically presenting years after initial injury as unexplained pleural effusions or dark hypervascular pleural nodules. This case illustrates a critical diagnostic pitfall: small superficial forceps biopsies of suspected ectopic splenomas routinely harvest only the reactive fibrous capsule, yielding non‐specific inflammatory histology that can obscure unconfirmed thoracic splenosis while requiring careful differentiation from tuberculous pleuritis and pleural malignancy.

We report the case of a 44‐year‐old male presenting 2 years after a road traffic accident, requiring emergency splenectomy, left diaphragmatic repair and tube thoracostomy, with a recurrent left‐sided hemorrhagic, exudative, lymphocytic pleural effusion. Diagnostic medical thoracoscopy (pleuroscopy) revealed dark purplish‐black streaks tracking along the diaphragm, yellow fibrinous exudate strands and a pleural nodule. Pleural biopsy demonstrated non‐specific fibrinopurulent exudates and active granulation tissue without atypia or granulomas, while fluid workup was negative for tuberculosis (normal adenosine deaminase (ADA), negative acid fast bacilli (AFB) smear, non‐detected GeneXpert MTB/RIF) and malignancy.

A 44‐year‐old male presented with progressive left‐sided pleuritic chest pain for 15 days. His surgical history was notable for high‐velocity blunt trauma from a road traffic accident (RTA) 2 years prior, which resulted in splenic rupture and left diaphragmatic tearing. He underwent emergency laparotomy with splenectomy, left diaphragmatic repair and chest tube insertion for a traumatic hemothorax. On examination, there was decreased air entry on the left side of the chest. Chest x‐ray showed left‐sided pleural effusion (Figure 1). Ultrasound‐guided pleural tap was attempted which was grossly hemorrhagic. Fluid chemistry met Light's criteria for an exudative effusion with a lymphocytic predominance. Pleural fluid (ADA) was normal, AFB smear was negative, GeneXpert MTB/RIF was not detected and cytology was negative for malignant cells. Coagulation profile was normal, viral serology was negative (Table 1). Echocardiography was normal while ultrasonographic evaluation of the abdomen and pelvis showed an absent spleen. Contrast enhanced computed tomography (CECT) chest showed left‐sided pleural effusion, pleural nodule and pleural thickening (Figure 2). Diagnostic medical thoracoscopy was performed under conscious sedation for direct pleural examination and targeted biopsy. Dark purple‐to‐black hemorrhagic streaks extending linearly along the diaphragmatic surface, hyperemic pleural mucosa intermingled with linear pale yellow strands and a discrete nodule were the findings on pleuroscopy (Figure 3). Pleural tissue biopsies showed fibrinopurulent exudate and granulation tissue and absence of any granulomas or mitotic activity (Figure 4). Immunohistochemistry (IHC) was positive for Cytokeratin (CK) in reactive mesothelial cells and negative for Synaptophysin, CK7 and TTF‐1.

FIGURE 1.

Chest x‐Ray PA view showing left‐sided pleural effusion.

TABLE 1.

Laboratory investigations, pleural fluid analysis and immunohistochemistry of tissue.

Investigation	Parameter	Reference range	Result
Complete blood picture	Haemoglobin	11.0–15.5 g/dL	11.47 g/dL
	Total leukocyte count	4.0–11.0 × 103/μL	6.82 × 10 3 /μL
	Platelet count	150–400 × 103/μL	211.5 × 10 3 /μL
Viral markers	HBsAg	Negative	Negative
	Anti‐HCV	Negative	Negative
	Anti‐HIV	Negative	Negative
Pleural fluid analysis	Appearance	—	Hemorrhagic, dark brown
	Protein	< 3.0 g/dL (transudate)/> 3.0 g/dL (exudate)	5.7
	LDH	< 200 U/L	3759
	Total WBC count	Count < 1000 cells/μL	1147
	Lymphocytes	< 50%	65%
	Neutrophils	< 25%	35%
	Adenosine deaminase (ADA)	< 30 U/L	21 U/L
	Ziehl–Neelsen (ZN) stain	Negative	Negative
	Fungal culture	No growth	No growth
	AFB smear	Negative	Negative
	GeneXpert MTB/RIF	Not detected	Not detected
	Cytology for malignant cells	Negative	Negative for malignant cells
Immunohistochemistry	Synaptophysin		Negative
	CK 7		Negative
	TTF‐1		Negative

Note: Bold entries indicate normal laboratory parameters that helped exclude alternative diagnoses (e.g., hematologic or infectious causes) rather than support the primary diagnosis.

FIGURE 2.

Contrast enhanced computed tomography chest showing left‐sided pleural thickening, pleural nodule and effusion.

FIGURE 3.

Diagnostic medical thoracoscopy (pleuroscopy). High‐definition thoracoscopic views showing (A) linear dark purplish‐black hemorrhagic streaks tracking along the diaphragmatic pleura, (B) hyperemic pleural membrane intermingled with pale yellow fibrinous exudate strands and (C) a discrete hyperemic pleural nodule with overlying fibrinous deposit.

FIGURE 4.

Histopathological features. Photomicrograph of pleural biopsy showing active granulation tissue with fibropurulent exudate. Note the complete absence of caseating granulomas or cellular atypia.

Evaluating a recurrent, hemorrhagic, lymphocytic exudative pleural effusion in a patient with a normal coagulation profile, negative tuberculosis workup and no cytological malignancy presents a diagnostic challenge. In the setting of remote thoracoabdominal trauma involving simultaneous splenic rupture and diaphragmatic disruption, the primary clinical suspicion is thoracic splenosis [1, 2]. Ectopic splenic tissue auto‐implants onto the parietal or diaphragmatic pleura through tears in the diaphragm, often presenting years later with pleuritic pain or recurrent bloody effusions due to local micro‐haemorrhage or mechanical friction [2, 3].

Consequently, the differential diagnosis in this case includes:

1. Tuberculous Pleuritis (TB Pleurisy): In TB‐endemic regions, a lymphocytic exudative effusion requires rigorous exclusion of tuberculosis. Although pleural fluid mycobacterial culture (BACTEC) was not performed due to its lower diagnostic sensitivity, TB pleurisy was confidently excluded based on the combined negative predictive value (98%) of normal pleural fluid ADA, negative Ziehl–Neelsen smear, non‐detected GeneXpert MTB/RIF and the complete absence of caseating or non‐caseating granulomas on thoracoscopic pleural biopsy [4].

2. Pleural Malignancy: A hemorrhagic, exudative effusion with nodular and hyperemic pleura is a classic presentation for pleural malignancy. While histopathology, fluid cytology and IHC were negative (Synaptophysin, CK‐7, TTF‐1) and ruled out malignancy.

3. Unconfirmed Thoracic Splenosis: Radiologically, it can present with numerous nodules of various sizes, most commonly in the left thorax. Biopsy of splenosis usually reveals distorted architecture with variable histology [1]. Rather than subjecting the patient to repeated invasive pleural procedures or surgical re‐exploration, functional nuclear imaging is the recommended diagnostic pathway [1, 2]. Technetium‐99m heat‐denatured red blood cell (99m‐Tc‐HDRBC) scintigraphy with SPECT/CT offers definitive confirmation by demonstrating selective radiotracer uptake within functional reticuloendothelial splenic tissue [5]. If positive, management remains conservative (symptomatic thoracentesis), avoiding unnecessary major surgery for a benign entity [1, 2]. Because superficial pleuroscopic forceps biopsies harvest only the overlying reactive fibrous pseudocapsule, histopathology in our case failed to capture the diagnostic deep tissue architecture of ectopic splenic parenchyma (red and white pulp); this directly mirrors documented diagnostic pitfalls where limited needle or superficial biopsies proved inconclusive and full‐thickness VATS biopsy was ultimately required to confirm benign thoracic splenosis [6].

Due to unavailability of video assisted thoracoscopy (VAT) and 99m‐Tc‐HDRBC scintigraphy with SPECT/CT in our setting, the patient was referred to the thoracic surgery and nuclear medicine departments for definite diagnosis. Comparison of our case with previously documented cases is shown in Table 2.

TABLE 2.

Comparison of our case with previously reported cases.

References	Age/Gender	Presenting complaints	Surgical history	CECT findings	Intervention done	Biopsy findings
Ahishek Maiti et Al. 2017 [7]	45 years/M	Pleuritic Chest Pain	Splenectomy after gunshot wound	Multiple pleural based nodules	Video assisted thoracoscopy (VAT)	Lymphoid follicles lined by endothelium
Lumbomir Tulinsky et Al. 2016 [6]	68 years/F	Dry Cough	Splenectomy after gunshot injury	Two homogeneous pleural nodules	CT‐guided Biopsy VAT	Inconclusive on CT‐guided biopsy Normal splenic tissue on VAT assisted biopsy
Albert H. et Al. 2013 [8]	62 years/F	Asymptomatic	Splenectomy, repair of lower lobe of left lung with chest tube placement After gunshot injury	Pleural based mass	VAT	Benign splenosis
Kyungeun Kim et Al. 2010 [9]	42 years/M	Asymptomatic	Splenectomy after iron bar piercing	Multinodular mass, pleural thickening	VAT	Trabeculae with abundant lymphoid tissue
Our case	44 years/M	Left‐sided pleuritic chest pain	Splenectomy, left‐sided diaphragmatic repair with chest tube placement after road traffic accident	Left‐sided pleural effusion with pleural nodule and thickening	Medical Thoracoscopy	Fibrinopurulent exudate with granulation tissue

Author Contributions

Ali Gohar: conceptualization, writing – original draft, writing – review and editing, visualization. Hafiz Muhammad Faisal Nadeem: investigation, validation, review. Rabbia Abbas and Romaisa Qamar: validation, review, writing original draft. Abida Bashir: validation and review. Muhammad Husnain Ahmad: methodology, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

IRB approval was not required for this article. The authors declare that this study was conducted according to the principles of the Declaration of Helsinki.

Consent

The authors declare that written informed consent was obtained from the patient for the publication of this manuscript writing and accompanying images and attest that the form used to obtain consent from the patient complies with the Journal requirements as outlined in the author guidelines. All imaging data included in this report have been anonymized to protect the patient's identity. No personal identifiers, such as names, dates of birth, or facial features, are included.

Conflicts of Interest

The authors declare no conflicts of interest.

Gohar A., Nadeem H. M. F., Abbas R., Qamar R., Bashir A., and Ahmad M. H., “Dark Streaks and Yellow Exudates: Pleuroscopic Clues in Recurrent Post‐Traumatic Pleural Effusion,” Respirology Case Reports 14, no. 10 (2026): e70759, 10.1002/rcr2.70759.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.