Short-course intrapleural alteplase and DNase in complex effusion with bleeding risk

Pleural infection is an important clinical problem with significant morbidity. In poorly draining complex pleural effusions, the current management favours a less invasive image-guided placement of smaller bore catheters and adjunctive intrapleural fibrinolysis therapy (IPFT). We describe our experience of using IPFT in three patients with different bleeding risks with complex pleural effusions. The first was a 30-year-old with transfusion-dependent β-thalassemia with haemoglobin of 7.8 g/dL; second was an 87-year-old on dabigatran with haemoglobin of 10 g/dL; and the third was an 80-year-old with diffuse large B-cell lymphoma with haemoglobin of 8.6 g/dL. All three patients received three doses of alteplase and deoxyribonuclease (DNase) without any adverse effects of bleeding and had resolution of the effusion. This case series is an addition to the current literature on the safety of IPFT and we highlight the use of IPFT in patients with low baseline haemoglobin and on anticoagulation therapy.