Use of carefully titrated ultra‐low doses of alteplase in infected haemothorax caused by initial alteplase use to drain loculated malignant pleural effusion

Alteplase as a fibrinolytic can be used to break up fibrin to encourage clot breakdown for clinical use. In the pleural space, it is used for symptomatic loculated malignant pleural effusions and pleural infections and can potentially avoid the need for surgical intervention. The optimal dose and dosing regimen of intrapleural fibrinolytics is still unknown. Although generally considered safe, bleeding is a serious potential complication and studies are ongoing to try and determine the lowest effective dose of alteplase to successfully treat pleural infections. This case highlighted the safe use of very low doses of alteplase ranging from 0.25 to 0.5 mg following pleural bleeding after the use of alteplase to treat a patient with symptomatic malignant loculated effusion. It demonstrates once pleural bleeding has stopped, there is a role for carefully titrated intrapleural alteplase use to avoid surgery.