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Diseases of Pleura. 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

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Diseases of Pleura

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Diseases of pleura

Diseases of Pleura


Department of Medicine

Manipal College of Medical Sciences

Pokhara, Nepal

Diseases of pleura

Negative intrapleural pressure: ~ 5mm



  • Disease process involving the pleura and giving rise to

    • pleuritic pain

    • evidence of pleural friction

      Common feature of

    • Pulmonary infection

    • Infarction

    • Malignancy

  • Primary pleural involvement – in T.B.

Clinical features

Clinical features

  • Characteristic symptom – Pleural pain

    On examination:

  • Rib movement restricted – reduced chest expansion

  • Pleural rub may be present

    • may only be heard in

      • deep inspiration

      • near pericardium - pleuro-pericardial rub

Diseases of pleura

  • Loss of the pleural rub and diminution in the chest pain indicate

    • Either recovery


    • development of a pleural effusion

  • 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

Diseases of pleura


Diseases of pleura

The accumulation within the pleural space of

  • Serous fluid -

  • Frank pus -

  • Blood -

pleural effusion



Diseases of pleura

Pleural fluid accumulates

increased hydrostatic

& decreased osmotic

pressure –


  • Increased microvascular pressure

  • due to disease of pleural surface or injury in the adjacent lung ‘Exudate’



  • Congestive heart failure

  • Cirrhosis (hepatic hydrothorax)

  • Hypoalbuminemia

  • Nephrotic syndrome

  • Myxedema

  • Constrictive pericarditis



Parapneumonic causes

Malignancy (carcinoma, lymphoma,mesothelioma)

Pulmonary embolism


Collagen-vascular conditions (rheumatoid arthritis, SLE)

Asbestos exposure  


Postcardiac injury(Dressler’s)syndrome

Esophageal perforation

Radiation pleuritis

Drug use  


Meigs syndrome


Yellow nail syndrome


Diseases of pleura

Clinical assessment

  • Symptoms and signs of pleurisy often precede the development of an effusion in patients with

    • Tuberculosis

    • underlying pneumonia

    • pulmonary infarction

    • connective tissue disease

Diseases of pleura

  • 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

Diseases of pleura

BREATHLESSNESS - only symptom related to effusion and its severity depends on the



of accumulation

Diseases of pleura

Clinical features

Diseases of pleura

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

Diseases of pleura

On palapation

  • Trachea & apex beat shifted to opposite side

  • Decreased tactile fremitus

Diseases of pleura

  • Displacement toward the side of the effusion is an important clue to obstruction of a lobar bronchus

Diseases of pleura


  • Dullness on percussion- stony dull

    • obliteration of tympanitic percussion note over Traube’s space in left sided effusion

  • Level of dullness goes up in axilla

  • Dullness over grocco’s triangle

Diseases of pleura

  • surface markings

    • left sixth rib

    • left midaxillary line

    • left costal margin

Traube's space

Diseases of pleura

Upper margin of fluid

Grocco’s triangle

XII th rib

Grocco s paravertebral triangle

Grocco's Paravertebral Triangle

  • 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

Diseases of pleura


  • Decreased or absent breath sounds

  • Pleural friction rub may be present ONLY WHEN EFFUSION IS SMALL

Diseases of pleura

zone of compensatory emphysema

compressed lung

Findings at the upper level of moderate effusion

Diseases of pleura

Increased VF, egophony & bronchial breath sounds

Skodaic resonance – percussion

Dull on percussion

Absent Br sound

Egophony: high-pitched nasal or bleating quality sound

Diseases of pleura

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

Diseases of pleura


Diseases of pleura

1.Chest X ray

  • 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

Diseases of pleura

200 ml fluid required to produce this shadow

60 ml in lateral view

10 ml in decubitus Xray

Diseases of pleura

X ray tube

X rays

Diseases of pleura

Some atypical pleural effusions

  • Localised effusions: previous scarring or adhesions in the pleural space

  • Subpulmonary effusion: Pleural fluid localised below the lower lobe simulates an elevated hemidiaphragm

  • Fluid localised within an oblique fissure may produce a rounded opacity simulating a tumour

Diseases of pleura

Subpulmonic effusion - Rt

Diseases of pleura

Phantom tumor

-Pleural effusion in

Interlobar fissure

Diseases of pleura

2. Ultra sonography of thorax

Diseases of pleura

2. USG of thorax:

  • Can detect even less than 10 ml

  • Can differentiate between pleural thickening & effusion

  • USG guided needle aspiration in small effusion

Diseases of pleura

3. Diagnostic aspiration of pleural fluid

Diseases of pleura

1.Biochemical analysis

  • Protein

  • L.D.H.

    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

Required for calculating LIGHT’S CRITERIA

Diseases of pleura


Low pH suggests


rheumatoid arthritis

ruptured oesophagus

advanced malignancy

Diseases of pleura


Diseases of pleura

2. Microscopic examination

Predominant cell type

provides useful information and cytological examination is essential

Polymorphs suggest bacterial infection

Lymphocytes: tuberculous

High ADA + Pl. fluid lymphocyte/neutrophil > 0.75 – Highly diagnostic of tuberculous pleural effusion

Malignant cells ma be seen in malignancy

Diseases of pleura

3.Gram stain

may suggest parapneumonic effusion

4.ELISA or


Helpful in diagnosing T.B. if acid-fast bacilli are not seen

5. Cultures: positive in 30 to 70%

(Enzyme-linked immunosorbent assay)

(Polymerase chain reaction)

Diseases of pleura

4. Pleural biopsy

May be required if all fails

  • With all methods combined yield is close to 95%

Diseases of pleura

  • Combining pleural aspiration with biopsy increases the diagnostic yield

  • Ultrasound or CT guided biopsy with Abrams needle is most frequently employed

Pleural aspiration and biopsy

Pleural aspiration and biopsy

  • Abrams needle

Diseases of pleura

If all of them unhelpful:

5. Throcacoscopy


Diseases of pleura


Summary of investigations

Summary of Investigations

  • X ray

  • USG thorax

  • Pleural fluid examination

    • Biochemical

    • Microscopic

    • Gram staining

    • Culture

  • PCR or ELISA

  • Pleural biopsy

  • Thoracoscopy

  • HRCT

Diseases of pleura

Rheumatoid arthritis; rheumatoid factor in serum.Cholesterol in chronic effusion; very low glucose in pleural fluid

Diseases of pleura


Chylous- thoracic duct obstruction

Transudate in CCF

Diseases of pleura

  • Presence of blood is consistent with

    • Pulmonary infarction

    • Malignancy

    • Tuberculosis

    • Traumatic

    • Anticoagulation

    • Mesothelioma

Diseases of pleura

Tuberculous pleural effusion

Result from:

  • Hypersensitivity reaction to Mycobacterium

  • 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

Diseases of pleura

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

  • Diseases of pleura

    Diagnosed on the basis of:

    • 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

    Diseases of pleura

    Other investigation

    Chest radiography:

    shows a small to moderate effusion (only 4% are large)

    Parenchymal disease is seen in a third of cases

    Diseases of pleura

    • 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 acid-fast bacilli are not seen on smear

  • Cultures: positive in 30 to 70% - results take a long time

  • Diseases of pleura


    Fever resolves within 2 weeks of instituting category I ATT

    may persist for 6 or 8 weeks

    The effusion usually resolves by 6 weeks

    may persist for 3 to 4 months

    Very ill patients may be helped by short-term corticosteroid treatment

    Diseases of pleura

    ADA can be +in: Fungal infections like coccidomycosis & Histoplasmosis

    Some cases of malignancy & connective tissue disorder

    Diseases of pleura


    P l e u r a l e f f u s i o n

    Causes most malignant effusions are metastatic

    CausesMost malignant effusions are metastatic



    • Pleural fluid cytology

    • CT chest with pleural contrast

      • Nodular, mediastinal, or circumferential pleural thickening on CT-highly specific for malignant disease

    Treatment options

    Treatment options

    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

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