Transcript 17. Pleurisy

Andriy Lepyavko, MD, PhD
Department of Internal Medicine № 2
Classification:
Dry pleurisy (pleuritis sicca)
Pleurisy with effusion (pleuritis exudativa)
The character of the inflammatory effusion may be different:
serous, serofibrinous, purulent, and haemorrhagic.
Etiology and pathogenesis
 Serous and serofibrinous pleurisy (tuberculosis in 70-
90 per cent of cases, pneumonia, certain infections,
and also rheumatism in 10-30 per cent of cases)
 Purulent process (pneumococci, streptococci,
staphylococci, and other microbes)
 Haemorrhagic pleurisy (tuberculosis of the pleura,
bronchogenic cancer of the lung with involvement of
the pleura, and also in injuries to the chest)
DRY PLEURISY
Clinical picture
 pain in the chest (a characteristic symptom )which
becomes stronger during breathing and coughing.
 cough (is usually dry)
 general indisposition;
 subfebrile temperature
 Respiration is superficial (deep breathing
intensifies friction of the pleural membranes to
cause pain). Lying on the affected side lessens the
pain. Inspection of the patient can reveal unilateral
thoracic lagging during respiration. Percussion fails
to detect any changes except decreased mobility of
the lung border on the affected side. Auscultation
determines pleural friction sound over the inflamed
site.
 Normal pleural fluid has the following characteristics:
clear ultrafiltrate of plasma, pH 7.60-7.64, protein
content less than 2% (1-2 g/dL), fewer than 1000 WBCs
per cubic millimeter, glucose content similar to that of
plasma, lactate dehydrogenase (LDH) level less than
50% of plasma and sodium, and potassium and
calcium concentration similar to that of the interstitial
fluid.
 Transudative pleural effusion
 Congestive heart failure (most common transudative
effusion)
Hepatic cirrhosis with and without ascites
Nephrotic syndrome
Peritoneal dialysis/continuous ambulatory peritoneal
dialysis
Hypoproteinemia (eg, severe starvation)
Glomerulonephritis
Superior vena cava obstruction
Urinothorax
 Exudative pleural effusion
 Malignant disorders - Metastatic disease to the pleura or lungs, primary
lung cancer, mesothelioma, Kaposi sarcoma, lymphoma, leukemia
 Infectious diseases - Bacterial, fungal, parasitic, and viral infections;
infection with atypical organisms such as Mycoplasma, Rickettsiae,
Chlamydia, Legionella
 GI diseases and conditions - Pancreatic disease (acute or chronic
disease, pseudocyst, pancreatic abscess), Whipple disease,
intraabdominal abscess (eg, subphrenic, intrasplenic, intrahepatic),
esophageal perforation (spontaneous/iatrogenic), abdominal surgery,
diaphragmatic hernia, endoscopic variceal sclerotherapy
 Collagen vascular diseases - Rheumatoid arthritis, systemic lupus
erythematosus, drug-induced lupus syndrome (procainamide,
hydralazine, quinidine, isoniazid, phenytoin, tetracycline, penicillin,
chlorpromazine), immunoblastic lymphadenopathy
(angioimmunoblastic lymphadenopathy), Sjцgren syndrome, familial
Mediterranean fever, Churg-Strauss syndrome, Wegener
granulomatosis
 Benign asbestos effusion
 Meigs syndrome - Benign solid ovarian neoplasm
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associated with ascites and pleural effusion
Drug-induced primary pleural disease - Nitrofurantoin,
dantrolene, methysergide, bromocriptine, amiodarone,
procarbazine, methotrexate, ergonovine, ergotamine,
oxprenolol, maleate, practolol, minoxidil, bleomycin,
interleukin-2, propylthiouracil, isotretinoin,
metronidazole, mitomycin
Injury after cardiac surgery (Dressler syndrome) - Injury
reported after cardiac surgery, pacemaker implantation,
myocardial infarction, blunt chest trauma, angioplasty
Uremic pleuritis
Yellow nail syndrome
Ruptured ectopic pregnancy
Electrical burns
Characteristic
Significance
Bloody
Most likely an indication of
malignancy in the absence of
trauma; can
also indicate pulmonary embolism,
infection, pancreatitis,
tuberculosis, mesothelioma, or
spontaneous pneumothorax
Turbid
Possible increased cellular content
or lipid content
Yellow or whitish,
turbid
Presence of chyle, cholesterol or
empyema
Brown (similar to chocolate sauce
or anchovy paste)
Rupture of amebic liver abscess
into the pleural space (amebiasis
with a hepatopleural fistula)
Black
Aspergillus involvement of pleura
Yellow-green with debris
Rheumatoid pleurisy
Characteristic
Significance
Highly viscous
Malignant mesothelioma
(due to increased levels of
hyaluronic acid)
long-standing pyothorax
Putrid odor
Anaerobic infection of pleural
space
Ammonia odor
Urinothorax
Purulent
Empyema
Yellow and thick, with
metallic
(stainlike) sheen
Effusions rich in cholesterol
(longstanding chyliform
effusion, eg,
tuberculous or rheumatoid
pleuritis)
PLEURISY WITH EFFUSION
Clinical picture
 Complains: fever, pain or the feeling of heaviness in the
side, dyspnea (which develops due to respiratory
insufficiency caused by compression of the lung). Cough is
usually mild (or absent in some cases).
 Objective examination: The patient's general condition is
grave, especially in purulent pleurisy, which is attended by
high temperature with pronounced circadian fluctuations,
chills, and signs of general toxicosis. Inspection of the
patient reveals asymmetry of the chest due to enlargement
of the side where the effusion accumulated; the affected
side of the chest usually lags behind respiratory
movements. Vocal fremitus is not transmitted at the area
fluid accumulation.
 Percussion over the area of fluid accumulation
produces dullness. The upper limit of dullness is
usually the S-shaped curve (Damoiseau's curve) whose
upper point is in the posterior axillary line. The
effusion thus occupies the area, which is a triangle
both anteriorly am posteriorly. The Damoiseau curve is
formed because exudate pleurisy with effusion more
freely accumulates in the lateral portions of the pleural
cavity, mostly in the costal-diaphragmatic sinus.
In addition to the Damoiseau curve, two triangles can
be determined by percussion in pleurisy with effusion.
The Garland triangle is found on the affected side is
characterized by a dulled tympanic sound. It
corresponds to the lung pressed by the effusion, and is
located between the spine and the Damoiseau curve.
The Rauchfuss-Grocco triangle is found on the healthy
and is a kind of extension of dullness determined on the
affected side, sides of the triangle are formed by the
diaphragm and the spine, while the continued
Damoiseau curve is the hypotenuse.
Pleurisy with effusion:
posterior view:
1—Damoiseau's curve;
2—Garland's triangle;
3—Rauchfuss-Grocco
triangle.
Treatment
 Antibiotics (eg, for parapneumonic effusions) and
diuretics (eg, for effusions associated with CHF) are
commonly used in the initial management of pleural
effusions in the ED. The selection of drugs in each
class depends on the cause of the effusion and its
clinical presentation. Particular attention must be
given to potential drug interactions, adverse effects,
and preexisting conditions.
Tuberculous pleural effusion
 TB remains the most common cause of
pleural effusion in young people
 Etiology: tubercle bacillus
 Pathogenesis: host hypersensitivity to
tubercular protein in pleural tubercles
 Delayed hypersensitivity
Clinical Manifestations
 Generalized symptoms of toxicity of TB:
fever, sweats, fatigue, weight loss ss, etc.
 Pleuritic pain, dyspnea, coughlea, etc.
 Pleural fluid is exudative and usually
reveals lymphocytosis
 Rarely pleural fluid is blood stained
 Tubercular tests usually positive
Empyema
 Thick purulent fluid with more than 100,000
cells per cubic millimeter or fluid with PH
values less than or equal to 7. 20 should
be treated as a presumptive empyema
 The general objectives of therapy of empyema
are the elimination of both the systemic and
local infection.
Treatment of acute and chronic empyema
1. Control of infection
systemic and local
2. Repeated thoracentesis or drainage of the empyema
3. Chronic empyema is primarily treated operatively
4. Operative therapy is also indicated in the empyema
with associated bronchopleural fistula or with the
ipsilateral ruined lung
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