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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

ALOK SINHA

Department of Medicine

Manipal College of Medical Sciences

Pokhara, Nepal



Pleurisy
PLEURISY

  • 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


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

    • Either recovery

      or

    • 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



The accumulation within the pleural space of indicate

  • Serous fluid -

  • Frank pus -

  • Blood -

pleural effusion

empyema

haemothorax


Pleural fluid accumulates indicate

increased hydrostatic

& decreased osmotic

pressure –

‘Transudate’

  • Increased microvascular pressure

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


Transudate
Transudate indicate

  • Congestive heart failure

  • Cirrhosis (hepatic hydrothorax)

  • Hypoalbuminemia

  • Nephrotic syndrome

  • Myxedema

  • Constrictive pericarditis


Exudate

Tuberculous indicate

Parapneumonic causes

Malignancy (carcinoma, lymphoma,mesothelioma)

Pulmonary embolism

Pancreatitis

Collagen-vascular conditions (rheumatoid arthritis, SLE)

Asbestos exposure  

Trauma

Postcardiac injury(Dressler’s)syndrome

Esophageal perforation

Radiation pleuritis

Drug use  

Chylothorax

Meigs syndrome

Sarcoidosis

Yellow nail syndrome

Exudate


Clinical assessment indicate

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

    • Tuberculosis

    • underlying pneumonia

    • pulmonary infarction

    • connective tissue disease



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

size

rate

of accumulation


Clinical features severity depends on the


Manifest when pleural effusions >300 mL severity depends on the

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 severity depends on the

  • Trachea & apex beat shifted to opposite side

  • Decreased tactile fremitus



Percussion clue to obstruction of a lobar bronchus:

  • 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


  • surface markings clue to obstruction of a lobar bronchus

    • left sixth rib

    • left midaxillary line

    • left costal margin

Traube's space


Upper margin of fluid clue to obstruction of a lobar bronchus

Grocco’s triangle

XII th rib


Grocco s paravertebral triangle
Grocco's Paravertebral Triangle clue to obstruction of a lobar bronchus

  • 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 clue to obstruction of a lobar bronchus

  • Decreased or absent breath sounds

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


zone of compensatory emphysema clue to obstruction of a lobar bronchus

compressed lung

Findings at the upper level of moderate effusion


Increased VF, egophony & bronchial breath sounds clue to obstruction of a lobar bronchus

Skodaic resonance – percussion

Dull on percussion

Absent Br sound

Egophony: high-pitched nasal or bleating quality 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 moderate pleural effusion:


1.Chest X ray moderate pleural effusion:

  • 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 moderate pleural effusion:

60 ml in lateral view

10 ml in decubitus Xray


X ray tube moderate pleural effusion:

X rays


Some atypical pleural effusions moderate pleural effusion:

  • 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


Subpulmonic effusion - Rt moderate pleural effusion:


Phantom tumor moderate pleural effusion:

-Pleural effusion in

Interlobar fissure


2. Ultra sonography of thorax moderate pleural effusion:


2. USG of thorax: moderate pleural effusion:

  • 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 moderate pleural effusion:


1.Biochemical analysis moderate pleural effusion:

  • 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


6.pH moderate pleural effusion:

Low pH suggests

infection

rheumatoid arthritis

ruptured oesophagus

advanced malignancy


LIGHT'S CRITERIA moderate pleural effusion:


2. Microscopic examination moderate pleural effusion:

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


3.Gram stain moderate pleural effusion:

may suggest parapneumonic effusion

4.ELISA or

PCR

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)


4. Pleural biopsy moderate pleural effusion:

May be required if all fails

  • With all methods combined yield is close to 95%



Pleural aspiration and biopsy
Pleural aspiration and biopsy diagnostic yield

  • Abrams needle


If all of them unhelpful: diagnostic yield

5. Throcacoscopy

6. HRCT


THORACOSCOPY diagnostic yield


Summary of investigations
Summary of Investigations diagnostic yield

  • X ray

  • USG thorax

  • Pleural fluid examination

    • Biochemical

    • Microscopic

    • Gram staining

    • Culture

  • PCR or ELISA

  • Pleural biopsy

  • Thoracoscopy

  • HRCT


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


Hemorrhagic diagnostic yield

Chylous- thoracic duct obstruction

Transudate in CCF



Tuberculous pleural effusion diagnostic yield

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


Effusion may accompany diagnostic yield

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: diagnostic yield

    • 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 diagnostic yield

    Chest radiography:

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

    Parenchymal disease is seen in a third of cases


  • 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


  • Treatment diagnostic yield

    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


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

    Some cases of malignancy & connective tissue disorder


    Malignant Histoplasmosis

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


    Causes most malignant effusions are metastatic
    Causes HistoplasmosisMost malignant effusions are metastatic


    Investigations
    Investigations Histoplasmosis

    • 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 Histoplasmosis

    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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