Pleurisy

Prepared by Lykhatska T.V.

 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.
 Aetiology 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)
 general indisposition;
 the temperature (subfebrile)
 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
 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
Turbid Possible increased cellular content
or lipid content
Yellow or whitish, Presence of chyle, cholesterol or
turbid empyema
Brown (similar to chocolate sauce Rupture of amebic liver abscess
or anchovy paste) into the pleural space (amebiasis
with a hepatopleural fistula)
Black Aspergillus involvement of pleura
Yellow-green with debris Rheumatoid pleurisy
 Characteristic Significance
Highly viscous Malignant mesothelioma (due
to increased levels of
hyaluronic acid)
long-standing pyothorax
Putrid odor Anaerobic infection of pleural
space
Ammonia odor Urinothorax
Purulent Empyema
Yellow and thick, with Effusions rich in cholesterol
metallic (longstanding chyliform
(stainlike) sheen effusion, eg,
tuberculous or rheumatoid
pleuritis)
 PLEURISY WITH EFFUSION
 Clinical picture
 Complains
 fever, pain or the feeling of heaviness in the side, and
dyspnoea (which develops due to respiratory insufficiency
caused by com­pression 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.
 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.
Thank you for attention!