Diagnosis of tuberculous pleurisy Clinical diagnosis v v
Diagnosis of tuberculous pleurisy
Clinical diagnosis v v v Acute onset on high risk person (TB contact, radiological suggestive lesions) Fever in young adults (the elderly-without fever) Chest pain (often axillary) Dry cough triggered by changing of position Sometimes important dyspnea – depending on the volume of pleural effusion Physical signs: v Dullness to percussion, and decreased breath sounds and voice vibrations v The affected hemithorax - the respiratory movements are reduced n Bulging of the affected n n hemithorax - in patients with large pleural effusion Egophony (E-to-A change) Pleural friction rub
Paraclinical diagnosis – RADIOLOGICAL EXAMINATION - Typical image of right basal pleurisy – opacity with mild intensity, with upper limit superior concave, in meniscus
Meniscus opacity with concave superior limit - upwards and inwards in two thirds lower left hemithorax
MASIVE PLEURISY- homogeneous opacity in the right hemithorax; Mediastinal shift away from the effusion: This is observed with effusions of greater than 1000 m. L.
Radiologica l changes Ø Ø Ø Ascension of the hemidiaphragm on the affected side The diaphragmatic dome is located more laterally than it should (the third side of the diaphragm and not its center) Costo-diaphragmatic sinus is shorter On the left side is an opacity, triangular shaped given by the retro-cardiac and paramediastinal accumulation of liquid On the profile radiography is described a net opacification in the posterior costo-phrenic sinus, even though the front side radiographs appear normal
Intradermal TB test (tuberculine skin test) n n n It is mandatory for all patients with exudative pleurisy May be negative in the acute phase of fluid formation If the patient is not allergic, the test will be positive in the next two months Negative TST does not exclude TB pleurisy A positive TST in case of exudative pleurisy, after a careful investigation, requires tuberculostatic treatment to be started
Morphopathological examination n Macroscopic aspects - serous fluid – milliary gray-white granulations - clamps and adherent - fibrin deposits - inflammatory response rarely hemorrhagic reaction - neo membranes Microscopic aspects – bare pleura - hyperemia under mesothelium layer - fibrin deposits – gigant epithelioid follicles ± center necrosis caseting necrosis Evolution - restitutio ad integrum - granulation tissue + fibrin -> pachipleuritis - adherent -> pleural fibrosis -> bronchiectasis
Pleural fluid examination Appearance is most commonly serous > 90% of cases n Rarely hemorrhagic n Very rarely purulent fluid (TB pleural empyema) n
Diagnostic approach to pleural effusions Etiology unknown THORACENTESIS Colour? Cells? Protein? Others? Etiology probable (e. g. cardiac/renal) Persistence with therapy Improvement with therapy Positive finding of • malignant cells • bacteria, fungus etc. • other specific parameter, e. g. amylase (>serum)
The initial diagnostic consideration is distinguishing transudates from exudates. n Although a number of chemical tests have been proposed to differentiate pleural fluid transudates from exudates, the tests first proposed by Light et al have become the criterion standards. n
The fluid is considered an exudate if any of the following apply: n Ratio of pleural fluid to serum protein greater than 0. 5 n Ratio of pleural fluid to serum lactate dehydrogenase (LDH) greater than 0. 6 n Pleural fluid LDH greater than two thirds of the upper limits of normal serum value n
PARAMETER TRANSUDATE EXSUDATE Clinical context Heart disease, liver, kidney, cancer, cachexia, hypothyroidism, Inflammation, cancer, collagen diseases pulmonary infarction Fibrin Does not stick fingers Sticks fingers Density 1015 > 1016 Rivalta reaction Negative Positive Pleural LDH/Serum LDH < 0, 6 ≥ 0, 6 Pleural LDH < 200 UI/L ≥ 200 UI/L Albumin < 3 g% ≥ 3 g% Serum albumin /pleural albumin ≥ 1, 29 < 1, 29 PARAMETER TRANSUDATE EXSUDATE Pleural protein /serum protein < 0, 5 ≥ 0, 5 Viscosity 1, 1 -1, 3 > 1, 6 Cholesterol < 60 mg% > 60 mg % Pleural bilirubin /Serum bilirubin < 0, 6 > 0, 6 Cellularity < 1000 cells/mm 3 > 1000 cells/mm 3
TB pleurisy Biochemistry Ø Ø Pleural protein > 30 g/l (exudate) Pleural glucose < 0. 6 g/l ADA (adenosine desaminase)> 30 (45) UI/l Pleural lysozyme/serum lysozyme > 2 Cytology Ø Ø Ø Lymphocytes > 80% PMN increased in the early stages Repair lesions - increased eosinophils Pleural T lymphocytes > serum T lymphocites The absence or low number of mesothelial cells
Bacteriological examination Can provide etiological certainty n Microscopically and culture are positive in only a 5 -10% cases n Pleural biopsy associated with seeding of a fragment of tissue on specific media culture for BK - increases to 50 -80% the detection of TB pleurisy n
Diagnostic approach to pleural effusions Etiology unknown THORACENTESIS Colour? Cells? Protein? Others? Etiology unknown Etiology probable (e. g. cardiac/renal) Improvement with therapy Persistence with therapy Positive finding of • malignant cells CLOSED PLEURAL BIOPSY Etiology unknown MEDICAL THORACOSCOPY • bacteria, fungus etc. • other specific parameter, e. g. amylase (>serum) Histological finding of malignancy or tuberculosis Follow-up Etiology unknown (<10%) In single cases surgical biopsy
Positive diagnosis § § Positive diagnosis of tuberculous pleurisy is based primarily on bacteriological and histological confirmation, together able to provide diagnosis in over 85% of cases. Most important arguments for the etiology of TB can be summarized: - age under 35 -40 years; - serous fluid - lymphocyte predominant; - pleural fluid protein above 30 g/l and pleural glucose under 0. 60 g/l; - a positive TST or TST becomes positive after 4 -6 weeks of tuberculostatic treatment; - increased ADA in pleural fluid; - report of pleural lysozyme/serum lysozyme than 2; - healing with scars; - favorable evolution under tuberculostatics treatment
Diagnostic approach to pleural effusions thoracentesis etiology ? closed pleural biopsy etiology ? medical thoracoscopy etiology ? follow-up surgical biopsy
REFERENCES http: //webcache. googleusercontent. com/search? q=cache: T 22 sqis_Jw. AJ: emedi cine. medscape. com/article/299959 overview+light+criteria+to+pleuresy&cd=1&hl=ro&ct=clnk&gl=ro
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