الفهرس 
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Abstract
Pleural effusion is a common clinical problem. The volume of the pleural fluid can increase dramatically with most pathologic conditions affecting the pleura. By applying Light´s criteria we can separate pleural effusions into exudate and transudate. In most instances, the cause of effusion becomes apparent.However, in about 20% of cases, the effusions remain etiologically undiagnosed after the initial evaluation.
A major problem remains the differentiation between malignant and infectious effusions, due to their different outcome and management; thus, the need for markers that may help in this differentiation is imperative. Acute-phase proteins, such as C-reactive protein (CRP), have been implicated in various infectious inflammatory and advanced malignant states, and these proteins are regulated by proinflammatory cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α).
TNFα, which is synthesized by various activated phagocytic andnonphagocytic cells, plays a key role in inflammatory processes. It is produced during a wide variety of infections, malignancy and other inflammatory conditions.
The aim of the work was to assess the role of TNF-α in the differentiation between pleural effusions of malignant and non malignant origins.
The patients were classified according to their final diagnosis into four groups:
Group I: Included 15 cases (8 males and 7 females) with malignant pleural effusions.
Group II: Included 10 cases (7 males and 3 females) with Para-pneumonic effusion and empyema.
Group III: Included 10 cases (6 males and 4 females) with tuberculous pleural effusions .
Group IV: Included 10 cases (7 males and 3 females) with transudative pleural effusions.
The patients were subjected to the following:
• Thorough history taking.
• Full clinical examination.
• Laboratory investigation including CBC, LDH, ADA, glucose, protein levels and tuberculin skin test.
• Sputum examination for AFB by Ziehl- Neelsen stain.
• Radiological evaluation of the cases was done by CXR, chest CT, abdominal ultrasound according to the need.
• Thoracocentises and the obtained pleural fluid was subjected to physical, chemical, bacteriological and cytological examination.
• Tissue biopsy was obtained by thoracoscopic pleural biopsy.
• The levels of TNFα in PE and serum were measured by ELISA technique.
The results of this study revealed the following:
• It was found that pleural fluid TNFα levels were significantly higher in pleural exudates than in transudates.
• Pleural fluid TNFα levels were significantly higher than serum TNFα in exudative effusion.
• TNFα levels were significantly higher in nonmalignant versuse malignant effusions.
• The levels of TNFα were increased with a highest mean values in tuberculous pleural effusion than that of malignant and parapneumonic effusions which indicate that this is a sensitive marker of granuloma formation.
• It was found to be increased in malignant and parapneumonic effusion in a lesser extent.
• There were significant increases in pleural fluid TNFα level in parapneumonic effusions versus malignant effusion mean values.
• This is a sensitive marker to differentiate between transudative and exudative effusions and differentiation between the different types of exudative effusions.
• Using a cutoff point of 20 pg/ml pleural fluid TNFα can be used to differentiate exudative pleural effusions from transudative pleural effusions with sensitivity 91.2%, specificity 84.2%, PPV 100%, NPV 100%.
• Using a cutoff point of 78 pg/ml pleural fluid TNFα can be used to differentiate tuberculous pleural effusions from malignant pleural effusions with sensitivity 86.2%, specificity79.3%, PPV 88.3%, NPV 81.7%.