Transcript Slide 1

ALOK SINHA
Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal
Negative intrapleural
pressure: ~ 5mm
PLEURISY

Disease process involving the pleura and
giving rise to
• pleuritic pain
• evidence of pleural friction
Common feature of
• Pulmonary infection
• Infarction
• Malignancy
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Primary pleural involvement – in T.B.
Clinical features
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Characteristic symptom – Pleural pain
On examination:
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Rib movement restricted – reduced chest
expansion
Pleural rub may be present
• may only be heard in
 deep inspiration
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near pericardium - pleuro-pericardial rub
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Loss of the pleural rub and diminution in
the chest pain indicate
• Either recovery
or
• development of a pleural effusion
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Normal X-ray does not exclude
pulmonary cause for pleurisy
• pulmonary infection which may not have
been severe enough
• may have resolved before the chest X-ray
was taken
The accumulation within the pleural
space of
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Serous fluid - pleural effusion
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Frank pus -
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Blood - haemothorax
empyema
Pleural fluid accumulates
increased hydrostatic
& decreased osmotic
pressure –
‘Transudate’
Increased microvascular pressure
due to disease of pleural surface
or injury in the adjacent lung
‘Exudate’
Common causes
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Tuberculosis
Pneumonia ('para-pneumonic effusion')
Cardiac failure
Pulmonary infarction
Malignant disease
Subdiaphragmatic disorders
- subphrenic abscess
- pancreatitis etc
 Hypoproteinaemia
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Nephrotic syndrome
Liver failure
Malnutrition
Uncommon causes
 Connective tissue diseases
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systemic lupus erythematosus
rheumatoid arthritis
Acute rheumatic fever
Post-myocardial infarction syndrome
Meigs' syndrome (ovarian tumour + pleural effusion)
Myxoedema
Uraemia
Asbestos-related benign pleural effusion
Transudate
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Congestive heart failure
Cirrhosis (hepatic hydrothorax)
Hypoalbuminemia
Nephrotic syndrome
Myxedema
Constrictive pericarditis
Exudate
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Tuberculous
 Postcardiac injury
Parapneumonic causes (Dressler’s) syndrome
Malignancy (carcinoma,  Esophageal perforation
lymphoma,mesothelioma)
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Radiation pleuritis
Drug use
Chylothorax
Meigs syndrome
Sarcoidosis
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Yellow nail syndrome
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Pulmonary embolism
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Pancreatitis
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Collagen-vascular conditions
(rheumatoid arthritis, SLE)
Asbestos exposure
Trauma
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Clinical assessment
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Symptoms and signs of pleurisy often
precede the development of an effusion
in patients with
• Tuberculosis
• underlying pneumonia
• pulmonary infarction
• connective tissue disease
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Particular attention should be paid to a
recent history of
• contact with tuberculosis
• respiratory infection
• presence of heart disease
• liver or renal disease
• occupation (e.g. exposure to asbestos)
• risk factors for thromboembolism
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BREATHLESSNESS - only symptom
related to effusion and its severity
depends on the
• size
• rate
of accumulation
Clinical features
Manifest when pleural effusions >300 mL
On inspection:
 Fullness of chest on affected side
 Reduced expansion of chest
 Tracheal shift with Trail’s sign - observed
with effusions of > 1000 mL
• Prominence of lower part of
sternocleidomastoid due to tracheal deviation
On palapation
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Trachea & apex beat shifted to
opposite side
Decreased tactile fremitus
• Displacement toward the side of the effusion is
an important clue to obstruction of a lobar
bronchus
Percussion:
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Dullness on percussion- stony dull
• obliteration of tympanitic percussion note
over Traube’s space in left sided effusion
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Level of dullness goes up in axilla
Dullness over grocco’s triangle
surface markings
•left sixth rib
•left midaxillary line
•left costal margin
Traube's space
Upper margin of fluid
Grocco’s triangle
XII th rib
Grocco's Paravertebral Triangle
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Triangular area of dullness at the back of chest
on the healthy side
Base – horizontally along the XII th rib
Apex – at the level of upper margin of fluid on
diseased side
Internally – vertebral line
Externally – line joining the apex and lateral
base
Ascultation
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Decreased or absent breath sounds
Pleural friction rub may be present ONLY
WHEN EFFUSION IS SMALL
Findings at the upper level of
moderate effusion
zone of compensatory emphysema
compressed lung
Skodaic resonance – percussion
Increased VF,
egophony &
bronchial breath
sounds
Dull on percussion
Egophony: high-pitched nasal or
bleating quality sound
Absent Br sound
Possible findings at the upper level
of dullness in case of moderate
pleural effusion:
1. lung is compressed
 Increased vocal fremitus & aegophony –
nasal quality of sounds transmitted
 Bronchial breath sound
2. there may be a zone of compensatory
emphysema above it
 Skodaic resonance on percussion
INVESTIGATIONS
1.Chest X ray
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P A view: minimum of 200cc of fluid
required to produce blunting of
costophregnic angles in
Lateral view: 60 ml
lateral decubitus Xray: 10 ml
200 ml fluid required to produce this shadow
60 ml in lateral view
10 ml in decubitus Xray
X ray tube
X rays
Some atypical pleural effusions
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Localised effusions: previous scarring or
adhesions in the pleural space
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Subpulmonary effusion: Pleural fluid
localised below the lower lobe simulates an
elevated hemidiaphragm
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Fluid localised within an oblique fissure
may produce a rounded opacity simulating
a tumour
Subpulmonic
effusion - Rt
Phantom tumor
-Pleural effusion in
Interlobar fissure
2. Ultra sonography of thorax
2. USG of thorax:
• Can detect even less than 10 ml
• Can differentiate between pleural thickening
& effusion
• USG guided needle aspiration in small effusion
3. Diagnostic aspiration of pleural fluid
1.Biochemical analysis
1. Protein
2. L.D.H.
Required for calculating LIGHT’S CRITERIA
3. Sugar – low in bacterial infections & Rh. arthritis
4. A.D.A – high (>42) in T.B. & some fungal
infections
5. Amylase –
high in pancreatitis, oesophageal
rupture, malignancy
6.pH
• Low pH suggests
infection
 rheumatoid arthritis
 ruptured oesophagus
 advanced malignancy
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(FOR DISTINGUISHING PLEURAL TRANSUDATE FROM EXUDATE)
Pleural fluid is an EXUDATE if one or more of the
Following criteria are met:
1. Pleural fluid protein:serum protein ratio > 0.5
2. Pleural fluid LDH: serum LDH ratio > 0.6
3. Pleural fluid LDH > two-thirds of the upper limit of
normal serum LDH
2. Microscopic examination
Predominant cell type
• provides useful information and cytological
examination is essential
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Polymorphs suggest bacterial infection
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Lymphocytes: tuberculous
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High ADA + Pl. fluid lymphocyte/neutrophil > 0.75
– Highly diagnostic of tuberculous pleural effusion
Malignant cells ma be seen in malignancy
3.Gram stain
• may suggest parapneumonic effusion
4.ELISA
PCR
(Enzyme-linked immunosorbent assay)
or
(Polymerase chain reaction)
• Helpful in diagnosing T.B. if acid-fast bacilli
are not seen
5. Cultures: positive in 30 to 70%
4. Pleural biopsy
May be required if all fails
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With all methods combined yield is close
to 95%
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Combining pleural aspiration with biopsy
increases the diagnostic yield
Ultrasound or CT guided biopsy with
Abrams needle is most frequently
employed
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Abrams needle
Pleural aspiration and biopsy
If all of them unhelpful:
5. Throcacoscopy
6. HRCT
THORACOSCOPY
Summary of Investigations
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X ray
USG thorax
Pleural fluid examination
• Biochemical
• Microscopic
• Gram staining
• Culture
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PCR or ELISA
Pleural biopsy
Thoracoscopy
HRCT
PLEURAL EFFUSION: MAIN CAUSES & FEATURES
Cause
Tuberculosis
Appear
ance of Type of
fluid
fluid
Serous,
Usually
Amber
coloured
Exudate
Other diagnostic
cells in fluid
features
Predominant
Lymphocytes
(occasionally
polymorphs)
+ tuberculin test
Isolation of M.
tuberculosis from
pleural fluid (20%)
Positive pleural biopsy
(80%)
Malignant
disease
Cardiac
failure*
Serous,
Often
Blood
stained
Exudate
Serous,
Straw
coloured
Transudate
Serosal cells &
Lymphocytes
Often clumps of
malignant cells
Positive pleural biopsy
Few serosal cells
Other evidence of left
ventricular failure.
Response to diuretics.
(40%)
Evidence of malignant
disease elsewhere
Pulmonary
infarction
Serous or Exudate
blood- (rarely
stained transudate
Red blood
Cells
Eosinophils
Evidence of
Pulmonary
Infarction.
Source of
Embolism.
Factors
predisposing
to venous
thrombosi
Rheumatoid
disease
Serous
Turbid if
chronic
Lymphocyte
(occasional
polymorphs)
Rheumatoid
arthritis;
rheumatoid
factor in serum.
Cholesterol in
chronic effusion;
very low glucose
in pleural fluid
Exudate
Systemic
Serous
Lupus
erythematosus
(SLE)
Exudate
Lymphocytes
and serosal
cells
• Other
Manifestations
of SLE
• Antinuclear
factor or Anti
DNA in Serum
(Ds DNA)
Acute
pancreatitis
Serous or
Blood
stained
Exudate
No cells
predominate
High amylase
in pleural fluid
(greater than
in serum)
Obstruction of
thoracic duc
Milky
Chyle
(Chylous
Effusion)
None
Chylomicrons
Hemorrhagic
Chylous- thoracic
duct obstruction
Transudate in CCF
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Presence of blood is consistent with
 Pulmonary
infarction
 Malignancy
 Tuberculosis
 Traumatic
 Anticoagulation
 Mesothelioma
Tuberculous pleural effusion
Result from:
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Hypersensitivity reaction to Mycobacterium
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Microbial invasion of the pleura (less common)
• acid-fast bacillus stains of pleural fluid are
rarely diagnostic (<10-20 % of cases)
• pleural fluid cultures grow Mycobacterium
tuberculosis in less than 65% of cases
Effusion may accompany
1.Primary T. B.
• commonly unilateral, and results from a
hypersensitivity phenomenon
• May recover without treatment, but in close to two
thirds active tuberculosis develops within 5 years
2. Post primary T. B.: Subpleural T B focus
ruptures into the pleural space
 Clinically presentation as
• acute
• subacute
• chronic form
With fever, nonproductive cough or chest pain
Diagnosed on the basis of:
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Microscopy + Adenosine deaminase
(ADA) activity
ADA > 43 U/mL in pleural fluid supports
the diagnosis of TB pleuritis. sensitivity - 78%
ADA + Pl. fluid lymphocyte/neutrophil >
0.75 – Highly diagnostic of tuberculous
pleural effusion
Other investigation
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Chest radiography:
• shows a small to moderate effusion
(only
4% are large)
• Parenchymal disease is seen in a third
of cases
• Enzyme-linked immunosorbent assay(ELISA)
• Polymerase Chain Reaction (PCR)
may be helpful diagnostically
 Provide a more rapid diagnosis in the
more than 90% of cases in which acidfast bacilli are not seen on smear
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Cultures: positive in 30 to 70% - results take
a long time
Treatment
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Fever resolves within 2 weeks of instituting
category I ATT
• may persist for 6 or 8 weeks
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The effusion usually resolves by 6 weeks
• may persist for 3 to 4 months
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Very ill patients may be helped by short-term
corticosteroid treatment
ADA can be +in: Fungal infections like coccidomycosis & Histoplasmosis
Some cases of malignancy & connective tissue disorder
M
a
l
i
g
n
a
n
t
Pleural effusion
Causes
Most malignant effusions are metastatic
Investigations
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Pleural fluid cytology
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CT chest with pleural contrast
• Nodular, mediastinal, or circumferential
pleural thickening on CT-highly specific for
malignant disease
Treatment options
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Therapeutic pleural aspiration
Intercostal chest drainage
pleurodesis - seal the visceral to the
parietal pleura to prevent pleural fluid
accumulating
commonly used agents are sterile talc,
tetracycline, and bleomycin
• Corticosteroids should be discontinued
beforehand