Prevalence of Pleural Effusion over Eight Years among Egyptian Children in the Delta region: A Single Center Cross-Section Study.

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Magdy Mohamed Ebrahim Zedan, Hossam ElTahan, Dina Salama Abd-Elmagid, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7447699/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Pleural effusion (PE) is a significant clinical condition characterized by the accumulation of excess fluid in the pleural space, leading to respiratory distress and morbidity. It frequently complicates various pulmonary and systemic disease, including infections, malignancies and cardiac condition. In children, PE is commonly associated with pneumonia and respiratory infections, which remain a leading cause of pediatric morbidity and hospital admission worldwide. Despite its clinical importance, data on the prevalence and etiological factors of PE among pediatric populations in the Egyptian delta region are limited. The current cross-sectional study is a trial to address this gap by evaluating the prevalence and clinical phenotyping of PE in children admitted to a tertiary care center in delta region over an eight-year period. Understanding the epidemiology and underlying factors of PE in this setting is crucial for improving diagnosis, management and outcomes among affected children. Methods A cross-sectional study was conducted at Mansoura University Children’s Hospital (MUCH), Egypt, from January 2016 to December 2023. All admissions aged 2 months to 18 years (n = 19,411) were reviewed to identify cases of PE, PPE, and pneumonia for prevalence and phenotype analysis. Results The prevalence of Pleural effusion was 0.82% within this cohort, with infectious causes accounting for 83.13%. Pneumonia prevalence was 3.4% and parapneumonic effusion occurred in 19.96% in pneumonia cases. Clinical phenotyping revealed that the most common age group was 2–6 years (44.4%), with a male predominance (63.7%). Fever was present in 92.5% of cases, while abdominal symptoms occurred in 6.3%. The most frequent complication was loculation, observed in 13.8%. Staphylococcus coagulase-positive species were the primary isolates, found in 15.8% of pleural cultures and 14.4% of blood cultures. Radiological findings showed lobar consolidation in 43.8% of cases. None of the studied cases had received pneumococcal vaccination. In conclusion: This study highlights regional epidemiological patterns that differ from Western cohorts, emphasizing the clinical significance of Staphylococcus and the morbidity burden associated with delayed care among children in Egypt’s Delta-region. These findings underscore the urgent need to strengthen pneumococcal vaccination programs, enhance diagnostic infrastructure, and develop context-appropriate antimicrobial guidelines for resource-limited settings. Pleural Effusion Parapneumonic Effusion Empyema Pneumonia Pediatrics Egypt Prevalence Cross-Sectional Studies Figures Figure 1 Figure 2 Figure 3 Background Pleural effusion is defined as the abnormal accumulation of fluid in the pleural space due to an imbalance between vascular hydrostatic and oncotic pressures, resulting from excessive filtration or impaired absorption [ 1 , 2 ]. The pleural cavity is a thin space between the visceral pleura covering the lungs and the parietal pleura lining the thoracic cage, normally containing a small amount of lubricating fluid regulated by Starling forces and lymphatic drainage [ 3 ]. In children, PE arises from diverse causes including infectious etiologies such as PPE and empyema, as well as noninfectious causes like malignancies, tuberculosis, collagen vascular diseases, trauma, and others [ 1 , 4 , 5 ]. The clinical presentation of PE in pediatrics varies according to the underlying cause and fluid volume. Infectious cases commonly present with fever, cough, tachypnea, and dyspnea, while malignant effusions may be asymptomatic or show nonspecific symptoms like weight loss and low-grade fever until advanced stages cause respiratory distress or mediastinal masses. Gastrointestinal symptoms such as abdominal pain and vomiting may also accompany PE, particularly in lower lobe involvement [ 5 ]. Differentiation of pleural fluid into transudate or exudate using Light’s criteria is essential for diagnosis and management, with exudates indicating increased capillary permeability or impaired lymphatic drainage and transudates reflecting systemic vascular pressure imbalances [ 1 , 4 ]. Management depends on etiology and severity: small transudative effusions often require conservative treatment, whereas purulent, large, or complicated effusions necessitate interventions such as drainage, fibrinolytics, or surgical approaches including video-assisted thoracoscopic surgery (VATS) [ 2 , 6 ]. PPE, the most common pediatric phenotype of PE, frequently respond well to intravenous antibiotics but may require tertiary care for advanced management. Aim of the study: Despite its clinical importance, the phenotypic spectrum and epidemiology of pediatric PE remain underexplored in Egypt. This study aimed to assess its prevalence and characterize PPE phenotypes among Egyptian children. Methods Study design and population This is a cross-sectional study was conducted between January 1, 2016 and December 1, 2023, at Mansoura University Children’s Hospital (MUCH), a tertiary care center in Mansoura, the largest city in Egypt’s Delta region with a population of approximately 7 million inhabitants. The primary aim of the study to estimate the prevalence of pneumonia, PPE and PE in general. In addition, we aimed to characterize the phenotypic patterns of PE within the cohort. Inclusion criteria: The study included all pediatric admissions (n = 19411) aged 2 months to 18 years over an 8-years period. Within this cohort, we investigated the prevalence of PE, PPE and pneumonia in general. Diagnosis was based on clinical features supported by radiological findings, chest ultrasonography, and/or ultrasound-guided thoracentesis (Fig. 1 ). Exclusion criteria: Patients younger than 1 month, those with an incorrect provisional diagnosis, and cases of PE following cardiothoracic surgery were excluded. Ethical Committee approval: The Mansoura Faculty of Medicine’s Ethical Committee granted approval for this study in April 2023, under code (MS.23.04.2381). Permission to access the encoding system for data collection was authorized. Patient consent was not required due to the retrospective nature the study. Data collection: Data were gathered for all admitted children with an initial hospital diagnosis coded using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), under (“Pleural effusion in conditions classified elsewhere”, “Pleural effusion, not elsewhere classified”). Each Case was assessed based on several factors, including demographic characteristics, medical history, clinical presentation, physical examination, complications, associated comorbidities and risk factors. Laboratory investigations (complete blood count, C-reactive protein, erythrocyte sedimentation rate, blood culture, pleural fluid analysis and culture) were evaluated alongside radiological findings. The final diagnosis and therapeutic interventions- including antibiotic therapy, chest tube drainage and surgical intervention- were analyzed. Long-term outcomes, including mortality, complications and re-admissions also retrieved. Data sources included the hospital database, electronic medical records and imaging archives, which were manually reviewed. Statistical analysis Data were analyzed using SPSS (version 25, IBM). Descriptive statistics were used to summarize categorical variables as frequencies and percentages (N (%)), while continuous variables were expressed as mean ± SD for normally distributed data or as median and range for non-normally distributed data. Comparisons of categorical variables were performed using the chi-square test or Fisher’s exact tests as appropriate. For continuous variables, independent t-tests were applied to normally distributed data, while the Mann-Whitney U test was used for two group comparisons with non-normal distribution. For comparisons involving more than two groups One-way ANOVA was preformed, followed by Tukey’s post hoc analysis; alternatively, the Kruskal-Wallis test was used for non-normally distributed data. A p-value of 1 month to 18 years, admitted over eight years to Mansoura University Children’s Hospital (MUCH), Egypt with various pediatric diseases. The findings revealed a pneumonia prevalence of 3.43%.and a pleural effusion prevalence of 0.82% of which 83.1% were due to infectious causes. Parapneumonic effusion cases 133 patients that accounts for a prevalence of 19.96% (Fig. 1 ). Prevalence of pneumonia to admitted cases in MUCH across 8 years: Prevalence of pleural effusion = (No. of pneumonia cases admitted / No. of totally cases admitted at MUCH from 2016 to 2023) X 100 = (666/19411) X 100 = 3.43%. Prevalence of pleural effusion to admitted cases in MUCH across 8 years: Prevalence of pleural effusion = (No. of pleural effusion cases admitted / No. of totally cases admitted at MUCH from 2016 to 2023) X 100 = (160/19411) X 100 = 0.82%. Prevalence of parapneumonic effusion cases in MUCH across 8 years: Prevalence = No. of parapneumonic effusion cases admitted / No. of totally pneumonia cases admitted at MUCH, across eight years from 2016 to 2023) = (133/666) X 100 = 19.96%. Phenotyping of different cases within cohort: Out of the pleural effusion cases, 44.4% were aged between 2 years and 6 years. Among them, 63.7% were males, and 36.3% were females. The majority of these children (75.0%) came from rural areas (Fig. 2 ). The highest percentage of pleural effusion cases was recorded in December across the studied years (Fig. 3 ). Fever was present in 92.5% of cases, while 14.4% had abdominal pain and 6.3% experienced vomiting. Among the reported complications, loculation & septations were the most common (13.8%) compared with pneumothorax and septicemia (Table 1 ). RD degree: respiratory distress. Data are presented as n (%). B symptoms: fever, night sweating and weight loss. Several comorbidities were identified among children diagnosed with pleural effusion. Hematological or oncology disease were the most frequent 8.1% followed by cardiac disease 5.6%. Recurrent pneumonia was observed in 25% of the cohort, while 16.9% had a history of NICU admission with respiratory problems. Notably, none of the studies cases had received no pneumococcal vaccination (Table 2 ). Data are presented as n (%). NICU = neonatal intensive care unit. Diagnostic aids used (Laboratory investigations, culture results, and radiologic phenotyping) among the studied group: Complete blood count (CBC) of the studied cases revealed predominant neutrophilia and thrombocytosis associated with elevated CRP and ESR (Table 3 ). Pleural fluid analysis showed an exudative nature in 64% of cases, while plural fluid culture demonstrated positivity for Staphylococcus coagulase-positive organisms in 15.8% of children. Similarly, blood culture results indicated that 14.4% of children had the same organism (Table 4). Radiological phenotyping demonstrated lobar pneumonia in 43.8% and consolidation collapse in 40.6% of cases, with the majority showing Right sided involvement (51.9%) (Table 5 ). Hb = hemoglobin; WBC = white blood cell; PLT = platelet count; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate. Continuous data are expressed as mean ± SD and range. The majority of the case showed elevated neutrophil count (11.75 ± 8.70 ×10⁹/L), thrombocytosis (527.31 ± 277.06 ×10⁹/L), CRP (107.76 mg/L) with a range of 0.00 to 2122.00 mg/L, and ESR (76.49 mm/hr) , ranging from 10.00 to 160.00. MRSA = methicillin-resistant Staphylococcus aureus; N/A = not assessed. Continuous data are expressed as mean ± SD and range and categorical data are expressed as n (%). MRSA = methicillin-resistant Staphylococcus aureus; N/A = not assessed. Continuous data are expressed as mean ± SD and range and categorical data are expressed as n (%). Data are presented as n (%). GGO: ground glass opacity. VP shunt: ventricle-peritoneal shunt Treatment modalities: Antibiotics (Empirical, culture-based) and interventional treatment: Empirical treatment was most frequently administered with cephalosporins (64.4%) and ampicillin (60.0%). Additionally, 38.1% of the children received meropenem, while 20.6% were treated with vancomycin and linezolid. Clindamycin, macrolides and aminoglycosides were prescribed in 5.6%, 3.8%, and 2.5% of cases respectively (Table 6 ). Most children required chest tube insertion, accounting for 73.8% of cases. Furthermore, 6.9% of the children underwent surgical intervention. (Table 6 ). Data are presented as n (%). VATS: Video-Assisted Thoracoscopic Surgery. O2: oxygen. Discussion Pediatric pleural effusion (PE), particularly parapneumonic effusion (PPE), remains a significant cause of morbidity in children, often developing as a complication of bacterial pneumonia [ 7 ]. Despite its clinical importance, the phenotypic spectrum and epidemiological determinants of pediatric PE and PPE are not well characterized in Egypt, especially in the Delta region. Our study, conducted at MUCH the largest tertiary care center in the Delta-provides the first comprehensive assessment of the prevalence, clinical features, and microbiological landscape of pediatric PE and PPE in this geographic area. In the current research, the prevalence of PPE was (19.96%) among 666 pneumonia cases over the eight-year period. This broadly consistent with a study conducted over 11 years period at a referral center for pulmonary and pleural infections in children in Poland that reported prevalence (16.7%) [ 8 ]. In contrast to our results lower incidences have been reported in Spain [ 6 ] and United Kingdom [ 9 ]. The high prevalence observed in our study is likely the inclusion of hospitalized severe cases, with S. aureus infections predominating, as well as the use of sensitive diagnostic tools as chest ultrasonography, whereas the comparable prevalence in Polish study may be due to high Streptococcus pneumoniae infections reported. On the other hand, the lower incidence that was found in different countries was possibly due to differences in pathogen profile and earlier treatment with a well stablished vaccination program. Our recommendations with the high reported prevalence in our study (19.96%), first early chest ultrasonography should be routinely done in pneumonia cases that can help to detect even mild PPE. Second, early antibiotic administration (both empirical and targeted) along with supportive care, may reduce progression of PPE. Lastly, there is a need for further research as comparative multicenter studies to explore risk factors for PPE development across different populations. In this study, out of the 160 PE cases, (83.13%) were infectious including PPE, empyema, hydropneumothorax and pyopneumothorax, while (16.87%) were non-infectious. A study from Bihar, India, analyzed 42 pediatric cases of PE and found a higher proportion of non-infectious cases due to renal diseases [ 10 ]. Similar finding with higher infectious percentage of PPE was reported by a study over 13 years between January 2007 to December 2019 at the Children’s Hospital of Chongqing Medical University estimated (78.9%) of cases were infectious [ 11 ]. This comparable predominance could be explained by high rates of S. aureus and S. pneumoniae. Thus, our study highlights that routine imaging and pleural fluid analysis are crucial to differentiate infectious vs. non-infectious effusions. In addition, public health focus on pneumonia prevention (including vaccination, early treatment) which is needed to reduce infectious effusion burden. In the current study, the most affected age group was 2–6 years (44.4%), with a male predominance (63.7%), and the majority of cases (75%) residing in rural areas. These findings align with both local data [ 15 ] and international studies [ 6 ]. The vulnerability of this age group is likely multifactorial, involving waning maternal antibodies and immature adaptive immunity. Notably, the absence of pneumococcal vaccination in our cohort stands in stark contrast to the improved outcomes reported in regions with widespread PCV13 coverage. The seasonal association with respiratory infections, particularly during the winter peaks in incidence, this seasonal surge is attributed to the effects of cold, dry air compromising mucosal barriers along with increased indoor crowding, both of which enhance viral transmission and predispose to secondary bacterial infections. In our study, pleural fluid samples were analyzed from 114 out of 160 cases. The most common bacterial pathogen identified was Staphylococcus coagulase-positive (15.8%), followed by S. pneumoniae (4.4%). The predominance of Staphylococcus coagulase-positive bacteria (likely S. aureus ) as a leading pathogen of PE has also been reported in several studies worldwide [ 12 , 13 ]. In agreement with our results both Nigerian and Egyptian studies reported that Staphylococcus aureus as the most frequently isolated organism in pleural aspirates [ 14 , 15 ]. Two different studies from central Europe one from Poland [ 16 ] and the other from Spain [ 6 ] reported higher percentage of S. pneumoniae in pleural fluid analysis in contrast to our results. The high pleural culture positivity rate for S. pneumoniae reported in developed countries with widespread PCV coverage may highlight S. pneumoniae as a significant but reduced cause. The relatively low pleural culture positive rate of S. pneumoniae (4.4%) observed in our study suggests limitations in Molecular diagnostics (PCR) and antigen detection. Thus, we recommend enhancing microbiological diagnostics (e.g., PCR) to improve S. pneumoniae detection, furthermore; we emphasize the importance of incorporating pneumococcal vaccination in national vaccination programs. In our research, the majority of children presented clinically with fever (92.5%), abdominal pain (14.4%) or vomiting (6.3%), symptoms that can complicate diagnosis, particularly in cases of lower lobe involvement. In addition, complications such as loculation and septation (13.8%) and pneumothorax (6.3%) were observed at rates comparable to those reported in previous studies [ 14 , 20 , 21 ]. The median hospital stay and chest tube duration were both 14 days, consistent with findings from Portugal [ 22 ] and reflecting the impact of delayed presentation and the need for prolonged drainage [ 15 , 22 , 23 ]. In our study, recurrent pneumonia (25%) and a history of neonatal intensive care unit (NICU) admission for respiratory problems (16.9%) emerged as prominent risk factors, consistent with literature linking early-life lung injury and chronic respiratory conditions to increased susceptibility to pleural complications [ 14 , 24 ]. Hematologic and oncologic disease accounted for the highest proportion (8.1%) followed by cardiac disease (5.6%). This pattern may reflect malignant infiltration or lymphatic obstruction in hematologic cases, while cardiac-related effusions are due to increased hydrostatic pressure. Laboratory markers in our cohort demonstrated pronounced neutrophilia, thrombocytosis, and elevated CRP and ESR levels, findings that parallel the inflammatory profiles reported in other pediatric cohorts [ 2 , 19 ]. Notably, CRP levels declined significantly with treatment, supporting its utility as a prognostic biomarker for monitoring disease progression and therapeutic response. Our study showed that, radiologically, lobar consolidation (43.8%) and right-sided predominance (51.9%) were the most frequent findings, consistent with established patterns in pediatric PPE [ 17 , 18 ]. This predominance of lobar consolidation and right-sided involvement aligns with typical pediatric PPE, likely attributable to the anatomical structure of the right bronchus, which is shorter and more vertical, making it more susceptible to infection and fluid accumulation. Empirical antibiotic regimens were broad, with high usage rates of cephalosporin, ampicillin, and meropenem, reflecting the need for coverage against both S. pneumoniae and S. aureus in severe cases. These findings underscore the importance of local epidemiological data in guiding empiric therapy and highlight the challenges posed by antimicrobial resistance and limited vaccine coverage [ 5 , 25 ]. Summary and Conclusions This study underscores the notable burden of pediatric pleural effusion, particularly parapneumonic effusion. The high prevalence of infectious cases, in the context of absent pneumococcal vaccination, highlights critical public health deficiencies. Staphylococcus aureus emerged as the predominant pathogen, reflecting regional microbial trends and guiding empiric antibiotic strategies. Clinically, fever was most common, with loculations frequently observed; gastrointestinal symptoms may also occur, complicating diagnosis. The radiological and laboratory profiles align with classic presentations, supporting their continued use in early diagnosis and monitoring. These results emphasize the need for enhanced vaccination programs, improved diagnostic infrastructure, and context-specific management protocols to reduce the burden of pediatric pleural disease in resource-limited settings. Abbreviations PE Pleural Effusion PPE Parapneumonic Effusion MUCH Mansoura University Children’s Hospital ICD-10 / ICD-10-CM International Classification of Diseases, 10th Revision / Clinical Modification NICU Neonatal Intensive Care Unit CBC Complete Blood Count CRP C-Reactive Protein ESR Erythrocyte Sedimentation Rate MRSA Methicillin-Resistant Staphylococcus aureus PCV / PCV13 Pneumococcal Conjugate Vaccine / 13-valent Pneumococcal Conjugate Vaccine VATS Video-Assisted Thoracoscopic Surgery SD Standard Deviation SPSS Statistical Package for the Social Sciences Declarations Acknowledgments: not applicable. Authors’ contributions All authors contributed to the study conception and design. Material preparation was done by Hossam ElTahan, Magdy Mohamed Ebrahim Zedan, Dina Salama Abd-Elmagid, Hosam Eldin Abdel Twab. Data collection and Statistical analysis were performed by Hossam ElTahan. The first draft of the manuscript was written by Hossam ElTahan and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding No financial support was received for this study. Data Availability The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The Mansoura Faculty of Medicine’s Ethical Committee granted approval for this study in April 2023, under code (MS.23.04.2381). Permission to access the encoding system for data collection was authorized. Consent for participation Patient consent was not required due to the retrospective nature the study. Consent for publication Not applicable (no identifying information about participants is available in the article). Competing interests: The authors declare that they have no competing interests. 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Supplementary Files table1.docx table2.docx table3.docx table4.docx table5.docx table6.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 02 Nov, 2025 Reviews received at journal 29 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviews received at journal 05 Oct, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers invited by journal 23 Sep, 2025 Submission checks completed at journal 19 Sep, 2025 First submitted to journal 18 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7447699","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":524909787,"identity":"f3ae45cc-2b52-4ce2-b533-327fca0f0060","order_by":0,"name":"Magdy Mohamed Ebrahim Zedan","email":"","orcid":"","institution":"Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Magdy","middleName":"Mohamed Ebrahim","lastName":"Zedan","suffix":""},{"id":524909788,"identity":"7f8571a6-3c58-48a0-bc61-6f74bea8feff","order_by":1,"name":"Hossam 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2","display":"","copyAsset":false,"role":"figure","size":141859,"visible":true,"origin":"","legend":"\u003cp\u003eAge distribution among the pleural effusion cases.\u003c/p\u003e","description":"","filename":"figuer2.png","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/fd2a652f06934723f2931a5a.png"},{"id":92845171,"identity":"7cd51a79-cbc8-4246-a926-2969f7b08eb6","added_by":"auto","created_at":"2025-10-06 09:25:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":101973,"visible":true,"origin":"","legend":"\u003cp\u003eMonthly distribution of pleural effusion cases.\u003c/p\u003e","description":"","filename":"figuer3.png","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/3bdaae39f739c62f9b77c5de.png"},{"id":92847277,"identity":"1aaeb2f3-383b-4d1a-b6d8-6f20ed495d63","added_by":"auto","created_at":"2025-10-06 09:49:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1216355,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/e232b47f-c58a-423a-b765-bd02d127ebd3.pdf"},{"id":92843240,"identity":"8cf237c2-178d-4623-afe9-7946ca2f455c","added_by":"auto","created_at":"2025-10-06 09:17:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17036,"visible":true,"origin":"","legend":"","description":"","filename":"table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/f1e481bc03af42441ff8d8aa.docx"},{"id":92845725,"identity":"5b9f3725-af1b-4c62-8fba-c5ae84a34ac2","added_by":"auto","created_at":"2025-10-06 09:33:56","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16094,"visible":true,"origin":"","legend":"","description":"","filename":"table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/977366a31f2a6f34e3849dd1.docx"},{"id":92845177,"identity":"0081638f-0d8d-4d02-ad39-81d428ea64c0","added_by":"auto","created_at":"2025-10-06 09:25:56","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16548,"visible":true,"origin":"","legend":"","description":"","filename":"table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/4e93d9f44c0675a36848f05a.docx"},{"id":92845729,"identity":"9165f715-9b2e-4d0d-b769-de2733514524","added_by":"auto","created_at":"2025-10-06 09:33:57","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":17640,"visible":true,"origin":"","legend":"","description":"","filename":"table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/2d52c712c4024f60dc1e0b6a.docx"},{"id":92843263,"identity":"2d4efda7-aa74-4492-828a-1ecfcc350526","added_by":"auto","created_at":"2025-10-06 09:17:57","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":16701,"visible":true,"origin":"","legend":"","description":"","filename":"table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/fb3a794a2de80a3fcd3eae88.docx"},{"id":92843256,"identity":"b03101c1-f91a-44a6-b2d6-4ee39ae6ba89","added_by":"auto","created_at":"2025-10-06 09:17:56","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":16202,"visible":true,"origin":"","legend":"","description":"","filename":"table6.docx","url":"https://assets-eu.researchsquare.com/files/rs-7447699/v1/ff4e96afe5fe452f342c88af.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePrevalence of Pleural Effusion over Eight Years among Egyptian Children in the Delta region: A Single Center Cross-Section Study.\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cb\u003ePleural effusion\u003c/b\u003e is defined as the abnormal accumulation of fluid in the pleural space due to an imbalance between vascular hydrostatic and oncotic pressures, resulting from excessive filtration or impaired absorption [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The pleural cavity is a thin space between the visceral pleura covering the lungs and the parietal pleura lining the thoracic cage, normally containing a small amount of lubricating fluid regulated by Starling forces and lymphatic drainage [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In children, PE arises from diverse causes including infectious etiologies such as PPE and empyema, as well as noninfectious causes like malignancies, tuberculosis, collagen vascular diseases, trauma, and others [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe clinical presentation of PE in pediatrics varies according to the underlying cause and fluid volume. Infectious cases commonly present with fever, cough, tachypnea, and dyspnea, while malignant effusions may be asymptomatic or show nonspecific symptoms like weight loss and low-grade fever until advanced stages cause respiratory distress or mediastinal masses. Gastrointestinal symptoms such as abdominal pain and vomiting may also accompany PE, particularly in lower lobe involvement [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Differentiation of pleural fluid into transudate or exudate using Light\u0026rsquo;s criteria is essential for diagnosis and management, with exudates indicating increased capillary permeability or impaired lymphatic drainage and transudates reflecting systemic vascular pressure imbalances [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eManagement depends on etiology and severity: small transudative effusions often require conservative treatment, whereas purulent, large, or complicated effusions necessitate interventions such as drainage, fibrinolytics, or surgical approaches including video-assisted thoracoscopic surgery (VATS) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. PPE, the most common pediatric phenotype of PE, frequently respond well to intravenous antibiotics but may require tertiary care for advanced management.\u003c/p\u003e\u003cp\u003eAim of the study: Despite its clinical importance, the phenotypic spectrum and epidemiology of pediatric PE remain underexplored in Egypt. This study aimed to assess its prevalence and characterize PPE phenotypes among Egyptian children.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and population\u003c/h2\u003e\u003cp\u003e This is a cross-sectional study was conducted between January 1, 2016 and December 1, 2023, at Mansoura University Children\u0026rsquo;s Hospital (MUCH), a tertiary care center in Mansoura, the largest city in Egypt\u0026rsquo;s Delta region with a population of approximately 7\u0026nbsp;million inhabitants. The primary aim of the study to estimate the prevalence of pneumonia, PPE and PE in general. In addition, we aimed to characterize the phenotypic patterns of PE within the cohort.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInclusion criteria:\u003c/h3\u003e\n\u003cp\u003eThe study included all pediatric admissions (n\u0026thinsp;=\u0026thinsp;19411) aged 2 months to 18 years over an 8-years period. Within this cohort, we investigated the prevalence of PE, PPE and pneumonia in general. Diagnosis was based on clinical features supported by radiological findings, chest ultrasonography, and/or ultrasound-guided thoracentesis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eExclusion criteria:\u003c/h3\u003e\n\u003cp\u003ePatients younger than 1 month, those with an incorrect provisional diagnosis, and cases of PE following cardiothoracic surgery were excluded.\u003c/p\u003e\n\u003ch3\u003eEthical Committee approval:\u003c/h3\u003e\n\u003cp\u003e The Mansoura Faculty of Medicine\u0026rsquo;s Ethical Committee granted approval for this study in April 2023, under code (MS.23.04.2381). Permission to access the encoding system for data collection was authorized. Patient consent was not required due to the retrospective nature the study.\u003c/p\u003e\n\u003ch3\u003eData collection:\u003c/h3\u003e\n\u003cp\u003eData were gathered for all admitted children with an initial hospital diagnosis coded using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), under (\u0026ldquo;Pleural effusion in conditions classified elsewhere\u0026rdquo;, \u0026ldquo;Pleural effusion, not elsewhere classified\u0026rdquo;). Each Case was assessed based on several factors, including demographic characteristics, medical history, clinical presentation, physical examination, complications, associated comorbidities and risk factors. Laboratory investigations (complete blood count, C-reactive protein, erythrocyte sedimentation rate, blood culture, pleural fluid analysis and culture) were evaluated alongside radiological findings.\u003c/p\u003e\u003cp\u003eThe final diagnosis and therapeutic interventions- including antibiotic therapy, chest tube drainage and surgical intervention- were analyzed. Long-term outcomes, including mortality, complications and re-admissions also retrieved. Data sources included the hospital database, electronic medical records and imaging archives, which were manually reviewed.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS (version 25, IBM). Descriptive statistics were used to summarize categorical variables as frequencies and percentages (N (%)), while continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for normally distributed data or as median and range for non-normally distributed data.\u003c/p\u003e\u003cp\u003eComparisons of categorical variables were performed using the chi-square test or Fisher\u0026rsquo;s exact tests as appropriate. For continuous variables, independent t-tests were applied to normally distributed data, while the Mann-Whitney U test was used for two group comparisons with non-normal distribution. For comparisons involving more than two groups One-way ANOVA was preformed, followed by Tukey\u0026rsquo;s post hoc analysis; alternatively, the Kruskal-Wallis test was used for non-normally distributed data. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe snap shot of our cross-section study, included 19411 pediatric patients aged from \u0026gt;\u0026thinsp;1 month to 18 years, admitted over eight years to Mansoura University Children\u0026rsquo;s Hospital (MUCH), Egypt with various pediatric diseases. The findings revealed a pneumonia prevalence of 3.43%.and a pleural effusion prevalence of 0.82% of which 83.1% were due to infectious causes. Parapneumonic effusion cases 133 patients that accounts for a prevalence of 19.96% (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003ePrevalence of pneumonia to admitted cases in MUCH across 8 years:\u003c/h3\u003e\n\u003cp\u003ePrevalence of pleural effusion = (No. of pneumonia cases admitted / No. of totally cases admitted at MUCH from 2016 to 2023) X 100\u0026thinsp;=\u0026thinsp;(666/19411) X 100\u0026thinsp;=\u0026thinsp;\u003cstrong\u003e3.43%.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003ePrevalence of pleural effusion to admitted cases in MUCH across 8 years:\u003c/h2\u003e\n \u003cp\u003ePrevalence of pleural effusion = (No. of pleural effusion cases admitted / No. of totally cases admitted at MUCH from 2016 to 2023) X 100\u0026thinsp;=\u0026thinsp;(160/19411) X 100\u0026thinsp;=\u0026thinsp;\u003cstrong\u003e0.82%.\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ePrevalence of parapneumonic effusion cases in MUCH across 8 years:\u003c/h2\u003e\n \u003cp\u003ePrevalence\u0026thinsp;=\u0026thinsp;No. of parapneumonic effusion cases admitted / No. of totally pneumonia cases admitted at MUCH, across eight years from 2016 to 2023) = (133/666) X 100\u0026thinsp;=\u0026thinsp;\u003cstrong\u003e19.96%.\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003ePhenotyping of different cases within cohort:\u003c/h2\u003e\n \u003cp\u003eOut of the pleural effusion cases, 44.4% were aged between 2 years and 6 years. Among them, 63.7% were males, and 36.3% were females. The majority of these children (75.0%) came from rural areas (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The highest percentage of pleural effusion cases was recorded in December across the studied years (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eFever was present in 92.5% of cases, while 14.4% had abdominal pain and 6.3% experienced vomiting. Among the reported complications, loculation \u0026amp; septations were the most common (13.8%) compared with pneumothorax and septicemia (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eRD degree: respiratory distress.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eData are presented as n (%).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eB symptoms: fever, night sweating and weight loss.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eSeveral comorbidities were identified among children diagnosed with pleural effusion. Hematological or oncology disease were the most frequent 8.1% followed by cardiac disease 5.6%. Recurrent pneumonia was observed in 25% of the cohort, while 16.9% had a history of NICU admission with respiratory problems. Notably, none of the studies cases had received no pneumococcal vaccination (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eData are presented as n (%).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eNICU\u0026thinsp;=\u0026thinsp;neonatal intensive care unit.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eDiagnostic aids used (Laboratory investigations, culture results, and radiologic phenotyping) among the studied group:\u003c/h2\u003e\n \u003cp\u003eComplete blood count (CBC) of the studied cases revealed predominant neutrophilia and thrombocytosis associated with elevated CRP and ESR (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Pleural fluid analysis showed an exudative nature in 64% of cases, while plural fluid culture demonstrated positivity for Staphylococcus coagulase-positive organisms in 15.8% of children. Similarly, blood culture results indicated that 14.4% of children had the same organism (Table 4). Radiological phenotyping demonstrated lobar pneumonia in 43.8% and consolidation collapse in 40.6% of cases, with the majority showing Right sided involvement (51.9%) (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eHb\u0026thinsp;=\u0026thinsp;hemoglobin; WBC\u0026thinsp;=\u0026thinsp;white blood cell; PLT\u0026thinsp;=\u0026thinsp;platelet count; CRP\u0026thinsp;=\u0026thinsp;C-reactive protein; ESR\u0026thinsp;=\u0026thinsp;erythrocyte sedimentation rate.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eContinuous data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD and range.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe majority of the case showed elevated \u003cstrong\u003eneutrophil count (11.75\u0026thinsp;\u0026plusmn;\u0026thinsp;8.70 \u0026times;10⁹/L), thrombocytosis (527.31\u0026thinsp;\u0026plusmn;\u0026thinsp;277.06 \u0026times;10⁹/L), CRP (107.76 mg/L)\u003c/strong\u003e with a range of 0.00 to 2122.00 mg/L, \u003cstrong\u003eand ESR (76.49 mm/hr)\u003c/strong\u003e, ranging from 10.00 to 160.00.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMRSA\u0026thinsp;=\u0026thinsp;methicillin-resistant Staphylococcus aureus; N/A\u0026thinsp;=\u0026thinsp;not assessed.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eContinuous data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD and range and categorical data are expressed as n (%).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMRSA\u0026thinsp;=\u0026thinsp;methicillin-resistant Staphylococcus aureus; N/A\u0026thinsp;=\u0026thinsp;not assessed.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eContinuous data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD and range and categorical data are expressed as n (%).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eData are presented as n (%).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eGGO: ground glass opacity. VP shunt: ventricle-peritoneal shunt\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eTreatment modalities: Antibiotics (Empirical, culture-based) and interventional treatment:\u003c/h2\u003e\n \u003cp\u003eEmpirical treatment was most frequently administered with cephalosporins (64.4%) and ampicillin (60.0%). Additionally, 38.1% of the children received meropenem, while 20.6% were treated with vancomycin and linezolid. Clindamycin, macrolides and aminoglycosides were prescribed in 5.6%, 3.8%, and 2.5% of cases respectively (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eMost children required chest tube insertion, accounting for 73.8% of cases. Furthermore, 6.9% of the children underwent surgical intervention. (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eData are presented as n (%).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eVATS: Video-Assisted Thoracoscopic Surgery. O2: oxygen.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePediatric pleural effusion (PE), particularly parapneumonic effusion (PPE), remains a significant cause of morbidity in children, often developing as a complication of bacterial pneumonia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite its clinical importance, the phenotypic spectrum and epidemiological determinants of pediatric PE and PPE are not well characterized in Egypt, especially in the Delta region. Our study, conducted at MUCH the largest tertiary care center in the Delta-provides the first comprehensive assessment of the prevalence, clinical features, and microbiological landscape of pediatric PE and PPE in this geographic area.\u003c/p\u003e\u003cp\u003eIn the current research, the prevalence of PPE was (19.96%) among 666 pneumonia cases over the eight-year period. This broadly consistent with a study conducted over 11 years period at a referral center for pulmonary and pleural infections in children in Poland that reported prevalence (16.7%) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In contrast to our results lower incidences have been reported in Spain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and United Kingdom [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe high prevalence observed in our study is likely the inclusion of hospitalized severe cases, with \u003cem\u003eS. aureus\u003c/em\u003e infections predominating, as well as the use of sensitive diagnostic tools as chest ultrasonography, whereas the comparable prevalence in Polish study may be due to high \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e infections reported. On the other hand, the lower incidence that was found in different countries was possibly due to differences in pathogen profile and earlier treatment with a well stablished vaccination program. Our recommendations with the high reported prevalence in our study (19.96%), first early chest ultrasonography should be routinely done in pneumonia cases that can help to detect even mild PPE. Second, early antibiotic administration (both empirical and targeted) along with supportive care, may reduce progression of PPE. Lastly, there is a need for further research as comparative multicenter studies to explore risk factors for PPE development across different populations.\u003c/p\u003e\u003cp\u003eIn this study, out of the 160 PE cases, (83.13%) were infectious including PPE, empyema, hydropneumothorax and pyopneumothorax, while (16.87%) were non-infectious. A study from Bihar, India, analyzed 42 pediatric cases of PE and found a higher proportion of non-infectious cases due to renal diseases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Similar finding with higher infectious percentage of PPE was reported by a study over 13 years between January 2007 to December 2019 at the Children\u0026rsquo;s Hospital of Chongqing Medical University estimated (78.9%) of cases were infectious [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This comparable predominance could be explained by high rates of \u003cem\u003eS. aureus\u003c/em\u003e and \u003cem\u003eS. pneumoniae.\u003c/em\u003e Thus, our study highlights that routine imaging and pleural fluid analysis are crucial to differentiate infectious vs. non-infectious effusions. In addition, public health focus on pneumonia prevention (including vaccination, early treatment) which is needed to reduce infectious effusion burden.\u003c/p\u003e\u003cp\u003eIn the current study, the most affected age group was 2\u0026ndash;6 years (44.4%), with a male predominance (63.7%), and the majority of cases (75%) residing in rural areas. These findings align with both local data [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and international studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The vulnerability of this age group is likely multifactorial, involving waning maternal antibodies and immature adaptive immunity. Notably, the absence of pneumococcal vaccination in our cohort stands in stark contrast to the improved outcomes reported in regions with widespread PCV13 coverage. The seasonal association with respiratory infections, particularly during the winter peaks in incidence, this seasonal surge is attributed to the effects of cold, dry air compromising mucosal barriers along with increased indoor crowding, both of which enhance viral transmission and predispose to secondary bacterial infections.\u003c/p\u003e\u003cp\u003eIn our study, pleural fluid samples were analyzed from 114 out of 160 cases. The most common bacterial pathogen identified was Staphylococcus coagulase-positive (15.8%), followed by \u003cem\u003eS. pneumoniae\u003c/em\u003e (4.4%). The predominance of Staphylococcus coagulase-positive bacteria (likely \u003cem\u003eS. aureus\u003c/em\u003e) as a leading pathogen of PE has also been reported in several studies worldwide [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In agreement with our results both Nigerian and Egyptian studies reported that \u003cem\u003eStaphylococcus aureus\u003c/em\u003e as the most frequently isolated organism in pleural aspirates [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTwo different studies from central Europe one from Poland [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and the other from Spain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported higher percentage of \u003cem\u003eS. pneumoniae\u003c/em\u003e in pleural fluid analysis in contrast to our results. The high pleural culture positivity rate for \u003cem\u003eS. pneumoniae\u003c/em\u003e reported in developed countries with widespread PCV coverage may highlight \u003cem\u003eS. pneumoniae\u003c/em\u003e as a significant but reduced cause. The relatively low pleural culture positive rate of \u003cem\u003eS. pneumoniae\u003c/em\u003e (4.4%) observed in our study suggests limitations in Molecular diagnostics (PCR) and antigen detection. Thus, we recommend enhancing microbiological diagnostics (e.g., PCR) to improve \u003cem\u003eS. pneumoniae\u003c/em\u003e detection, furthermore; we emphasize the importance of incorporating pneumococcal vaccination in national vaccination programs.\u003c/p\u003e\u003cp\u003eIn our research, the majority of children presented clinically with fever (92.5%), abdominal pain (14.4%) or vomiting (6.3%), symptoms that can complicate diagnosis, particularly in cases of lower lobe involvement. In addition, complications such as loculation and septation (13.8%) and pneumothorax (6.3%) were observed at rates comparable to those reported in previous studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The median hospital stay and chest tube duration were both 14 days, consistent with findings from Portugal [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and reflecting the impact of delayed presentation and the need for prolonged drainage [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our study, recurrent pneumonia (25%) and a history of neonatal intensive care unit (NICU) admission for respiratory problems (16.9%) emerged as prominent risk factors, consistent with literature linking early-life lung injury and chronic respiratory conditions to increased susceptibility to pleural complications [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Hematologic and oncologic disease accounted for the highest proportion (8.1%) followed by cardiac disease (5.6%). This pattern may reflect malignant infiltration or lymphatic obstruction in hematologic cases, while cardiac-related effusions are due to increased hydrostatic pressure.\u003c/p\u003e\u003cp\u003eLaboratory markers in our cohort demonstrated pronounced neutrophilia, thrombocytosis, and elevated CRP and ESR levels, findings that parallel the inflammatory profiles reported in other pediatric cohorts [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Notably, CRP levels declined significantly with treatment, supporting its utility as a prognostic biomarker for monitoring disease progression and therapeutic response.\u003c/p\u003e\u003cp\u003eOur study showed that, radiologically, lobar consolidation (43.8%) and right-sided predominance (51.9%) were the most frequent findings, consistent with established patterns in pediatric PPE [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This predominance of lobar consolidation and right-sided involvement aligns with typical pediatric PPE, likely attributable to the anatomical structure of the right bronchus, which is shorter and more vertical, making it more susceptible to infection and fluid accumulation.\u003c/p\u003e\u003cp\u003eEmpirical antibiotic regimens were broad, with high usage rates of cephalosporin, ampicillin, and meropenem, reflecting the need for coverage against both \u003cem\u003eS. pneumoniae\u003c/em\u003e and \u003cem\u003eS. aureus\u003c/em\u003e in severe cases. These findings underscore the importance of local epidemiological data in guiding empiric therapy and highlight the challenges posed by antimicrobial resistance and limited vaccine coverage [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Summary and Conclusions","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003cp\u003eThis study underscores the notable burden of pediatric pleural effusion, particularly parapneumonic effusion. The high prevalence of infectious cases, in the context of absent pneumococcal vaccination, highlights critical public health deficiencies. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e emerged as the predominant pathogen, reflecting regional microbial trends and guiding empiric antibiotic strategies. Clinically, fever was most common, with loculations frequently observed; gastrointestinal symptoms may also occur, complicating diagnosis. The radiological and laboratory profiles align with classic presentations, supporting their continued use in early diagnosis and monitoring.\u003c/p\u003e\u003cp\u003eThese results emphasize the need for enhanced vaccination programs, improved diagnostic infrastructure, and context-specific management protocols to reduce the burden of pediatric pleural disease in resource-limited settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePE Pleural Effusion\u003c/p\u003e\u003cp\u003ePPE Parapneumonic Effusion\u003c/p\u003e\u003cp\u003eMUCH Mansoura University Children\u0026rsquo;s Hospital\u003c/p\u003e\u003cp\u003eICD-10 / ICD-10-CM International Classification of Diseases, 10th Revision / Clinical Modification\u003c/p\u003e\u003cp\u003eNICU Neonatal Intensive Care Unit\u003c/p\u003e\u003cp\u003eCBC Complete Blood Count\u003c/p\u003e\u003cp\u003eCRP C-Reactive Protein\u003c/p\u003e\u003cp\u003eESR Erythrocyte Sedimentation Rate\u003c/p\u003e\u003cp\u003eMRSA Methicillin-Resistant Staphylococcus aureus\u003c/p\u003e\u003cp\u003ePCV / PCV13 Pneumococcal Conjugate Vaccine / 13-valent Pneumococcal Conjugate Vaccine\u003c/p\u003e\u003cp\u003eVATS Video-Assisted Thoracoscopic Surgery\u003c/p\u003e\u003cp\u003eSD Standard Deviation\u003c/p\u003e\u003cp\u003eSPSS Statistical Package for the Social Sciences\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation was done by Hossam ElTahan, Magdy Mohamed Ebrahim Zedan, Dina Salama Abd-Elmagid, Hosam Eldin Abdel Twab.\u003csup\u003e\u0026nbsp;\u003c/sup\u003eData collection and Statistical analysis were performed by Hossam ElTahan. The first draft of the manuscript was written by Hossam ElTahan and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo financial support was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Mansoura Faculty of Medicine\u0026rsquo;s Ethical Committee granted approval for this study in April 2023, under code (MS.23.04.2381). Permission to access the encoding system for data collection was authorized.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient consent was not required due to the retrospective nature the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable (no identifying information about participants is available in the article).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdnan MA, Hossain MD, Haque MR, Islam T, Ahmed I, Datta UK (2024): Pleural effusion in a pediatric ward: clinical feature, etiology and outcome. 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Thorax 60(Suppl 1):i1\u0026ndash;i21..\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtanasiu DL, Mitrica M, Petrescu L, Falup-Pecurariu O, Bleotu L, Lixandru RI, et al (2025): Pediatric pleural effusion and pneumococcal vaccination trends in the pre- and post-COVID era: a single-centre retrospective study. Children 12:242. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/children12020242\u003c/span\u003e\u003cspan address=\"10.3390/children12020242\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoares P, Barreira J, Pissarra S, Nunes T, Azevedo I, Vaz L (2009): Pediatric parapneumonic pleural effusions: experience in a university central hospital. Rev Port Pneumol 15:241\u0026ndash;259. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2173-5115(09)70108-3\u003c/span\u003e\u003cspan address=\"10.1016/S2173-5115(09)70108-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiese J, Schoen C, van der Linden M, Lehmann L, Goettler D, Keller S, et al (2019): Changes in the incidence and bacterial aetiology of paediatric parapneumonic pleural effusions/empyema in Germany, 2010\u0026ndash;2017: a nationwide surveillance study. Clin Microbiol Infect 25:857\u0026ndash;864. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cmi.2018.10.020\u003c/span\u003e\u003cspan address=\"10.1016/j.cmi.2018.10.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreenough A, Alexander J, Boorman J, Chetcuti PAJ, Cliff I, Lenney W, Morgan C, Shaw NJ, Sylvester KP, Turner J (2011): Respiratory morbidity, healthcare utilisation and cost of care at school age related to home oxygen status. Eur J Pediatr 170:969\u0026ndash;975. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00431-010-1381-6\u003c/span\u003e\u003cspan address=\"10.1007/s00431-010-1381-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavies HE, Davies RJ, Davies CW (2010):Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax 65(Suppl 2):ii41\u0026ndash;ii53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/thx.2010.137000\u003c/span\u003e\u003cspan address=\"10.1136/thx.2010.137000\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-bronchology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Bronchology](https://ejb.springeropen.com/)","snPcode":"43168","submissionUrl":"https://submission.nature.com/new-submission/43168/3","title":"The Egyptian Journal of Bronchology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pleural Effusion, Parapneumonic Effusion, Empyema, Pneumonia, Pediatrics, Egypt, Prevalence, Cross-Sectional Studies","lastPublishedDoi":"10.21203/rs.3.rs-7447699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7447699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePleural effusion (PE) is a significant clinical condition characterized by the accumulation of excess fluid in the pleural space, leading to respiratory distress and morbidity. It frequently complicates various pulmonary and systemic disease, including infections, malignancies and cardiac condition. In children, PE is commonly associated with pneumonia and respiratory infections, which remain a leading cause of pediatric morbidity and hospital admission worldwide. Despite its clinical importance, data on the prevalence and etiological factors of PE among pediatric populations in the Egyptian delta region are limited. The current cross-sectional study is a trial to address this gap by evaluating the prevalence and clinical phenotyping of PE in children admitted to a tertiary care center in delta region over an eight-year period. Understanding the epidemiology and underlying factors of PE in this setting is crucial for improving diagnosis, management and outcomes among affected children.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted at Mansoura University Children\u0026rsquo;s Hospital (MUCH), Egypt, from January 2016 to December 2023. All admissions aged 2 months to 18 years (n\u0026thinsp;=\u0026thinsp;19,411) were reviewed to identify cases of PE, PPE, and pneumonia for prevalence and phenotype analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe prevalence of Pleural effusion was 0.82% within this cohort, with infectious causes accounting for 83.13%. Pneumonia prevalence was 3.4% and parapneumonic effusion occurred in 19.96% in pneumonia cases. Clinical phenotyping revealed that the most common age group was 2\u0026ndash;6 years (44.4%), with a male predominance (63.7%). Fever was present in 92.5% of cases, while abdominal symptoms occurred in 6.3%. The most frequent complication was loculation, observed in 13.8%. Staphylococcus coagulase-positive species were the primary isolates, found in 15.8% of pleural cultures and 14.4% of blood cultures. Radiological findings showed lobar consolidation in 43.8% of cases. None of the studied cases had received pneumococcal vaccination.\u003c/p\u003e\u003ch2\u003eIn conclusion:\u003c/h2\u003e\u003cp\u003e This study highlights regional epidemiological patterns that differ from Western cohorts, emphasizing the clinical significance of Staphylococcus and the morbidity burden associated with delayed care among children in Egypt\u0026rsquo;s Delta-region. These findings underscore the urgent need to strengthen pneumococcal vaccination programs, enhance diagnostic infrastructure, and develop context-appropriate antimicrobial guidelines for resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Prevalence of Pleural Effusion over Eight Years among Egyptian Children in the Delta region: A Single Center Cross-Section Study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-06 09:17:51","doi":"10.21203/rs.3.rs-7447699/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-02T13:10:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-29T05:20:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220680338747814381917986613544716959449","date":"2025-10-11T08:29:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T13:31:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278172632519441023360485340585335380847","date":"2025-09-23T09:55:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-23T09:18:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-19T05:38:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Bronchology","date":"2025-09-18T17:14:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-bronchology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Bronchology](https://ejb.springeropen.com/)","snPcode":"43168","submissionUrl":"https://submission.nature.com/new-submission/43168/3","title":"The Egyptian Journal of Bronchology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b2bdfe6-b365-4019-b91d-b7e12404017a","owner":[],"postedDate":"October 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-22T04:23:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-06 09:17:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7447699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7447699","identity":"rs-7447699","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}