pleurisy - medsyllabus.org fileetiology and pathogenesis serous and serofibrinous pleurisy...

Pleurisy

Pleurisy is inflammation of the pleura. 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 PLEURISYClinical 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

Characteristic SignificanceBloody Most likely an indication of

malignancy in the absence of trauma; canalso 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 sauceor anchovy paste)

Rupture of amebic liver abscess into the pleural space (amebiasiswith a hepatopleural fistula)

Black Aspergillus involvement of pleuraYellow-green with debris Rheumatoid pleurisy

Characteristic SignificanceHighly viscous Malignant mesothelioma (due

to increased levels of hyaluronic acid)long-standing pyothorax

Putrid odor Anaerobic infection of pleural space

Ammonia odor UrinothoraxPurulent EmpyemaYellow and thick, with metallic(stainlike) sheen

Effusions rich in cholesterol (longstanding chyliform effusion, eg,tuberculous or rheumatoid pleuritis)

PLEURISY WITH EFFUSIONClinical picture

● Complains: fever, pain or the feeling of heaviness in the side, dyspnea (which develops due to respiratory insufficiency caused by com-pression 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.

Cyanosis in pleurisy with effusion due to respiratory insufficiency is caused by lung collapse and limitation

of its respiratory surface

● 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.

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.

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.

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

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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