Pleuritis

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)



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



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

 Benign asbestos effusion

 Meigs syndrome - Benign solid ovarian neoplasm 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 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

Characteristic Significance

Highly viscous Malignant mesothelioma

(due to increased levels of hyaluronic acid)

long-standing pyothorax

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: 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

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

Clinical Manifestations



Generalized symptoms of toxicity of TB:

fever, sweats, fatigue, weight loss



Pleuritic pain, dyspnea, cough



Pleural fluid is exudative and usually

reveals lymphocytosis



Rarely pleural fluid is blood stained

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