Diagnosis of Diagnosis of tuberculous pleurisy tuberculous pleurisy

Clinical diagnosisClinical diagnosis

Acute onset on high Acute onset on high risk person (TB risk person (TB contact, radiological contact, radiological suggestive lesions)suggestive lesions)

Fever in young adults Fever in young adults (the elderly-without (the elderly-without fever)fever)

Chest pain (often Chest pain (often axillary)axillary)

Dry cough triggered by Dry cough triggered by changing of positionchanging of position

SometimesSometimesimportant dyspnea – important dyspnea – depending on the depending on the volume of pleural volume of pleural effusioneffusion

Physical signs:Physical signs: Dullness to percussion, Dullness to percussion,

and and decreased breath sounds and voice and voice vibrationsvibrations

The affected hemithorax The affected hemithorax - the respiratory - the respiratory movements are reducedmovements are reduced

Bulging of the affected Bulging of the affected

hemithorax - inhemithorax - in patients patients with large pleural with large pleural effusion 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 mL.

(opposed to the appearance of atelectasis)

Ascension of the hemidiaphragm on the Ascension of the hemidiaphragm on the affected sideaffected side

The diaphragmatic dome is located more The diaphragmatic dome is located more laterally than it should (the third side of the laterally than it should (the third side of the diaphragm and not its center)diaphragm and not its center)

Costo-diaphragmatic sinus is shorterCosto-diaphragmatic sinus is shorter On the left side is an opacity, triangular On the left side is an opacity, triangular

shaped given by the retro-cardiac and para-shaped given by the retro-cardiac and para-mediastinal accumulation of liquid mediastinal accumulation of liquid

On the profile radiography is described a net On the profile radiography is described a net opacification in the posterior costo-phrenic opacification in the posterior costo-phrenic sinus, even though the front side radiographs sinus, even though the front side radiographs appear normalappear normal

Radiological Radiological

changeschanges

Intradermal TB test Intradermal TB test (tuberculine skin test)(tuberculine skin test) It is mandatory for all patients with It is mandatory for all patients with

exudative pleurisyexudative pleurisy May be negative in the acute phase of May be negative in the acute phase of

fluid formationfluid formation If the patient is not allergic, the test will If the patient is not allergic, the test will

be positive in the next two monthsbe positive in the next two months Negative TST does not exclude TB Negative TST does not exclude TB

pleurisypleurisy A positive TST in case of exudative A positive TST in case of exudative

pleurisy, after a careful investigation, pleurisy, after a careful investigation, requires requires tuberculostatic treatment to be started tuberculostatic treatment to be started

Morphopathological Morphopathological examinationexamination

Macroscopic aspectsMacroscopic aspects - serous fluid – - serous fluid – milliary gray-white granulations - clamps milliary gray-white granulations - clamps and adherent - fibrin deposits - and adherent - fibrin deposits - inflammatory response - rarely inflammatory response - rarely hemorrhagic reaction - neo membraneshemorrhagic reaction - neo membranes

Microscopic aspectsMicroscopic aspects – bare pleura - – bare pleura - hyperemia under mesothelium layer - hyperemia under mesothelium layer - fibrin deposits – gigant epithelioid fibrin deposits – gigant epithelioid follicles ± center necrosis - caseting follicles ± center necrosis - caseting necrosis necrosis

Evolution Evolution - restitutio ad integrum - - restitutio ad integrum - granulation tissue + fibrin -> granulation tissue + fibrin -> pachipleuritis - adherent -> pleural pachipleuritis - adherent -> pleural fibrosis -> bronchiectasisfibrosis -> bronchiectasis

Pleural fluid Pleural fluid examination examination Appearance is most commonly Appearance is most commonly

serous serous > 90% of cases> 90% of cases Rarely hemorrhagicRarely hemorrhagic Very rarely purulent fluid (TB Very rarely purulent fluid (TB

pleural empyema)pleural empyema)

Colour? Protein?

Cells? Others?

Diagnostic approach to pleural effusions

Etiology unknown

Etiology probable

(e.g. cardiac/renal)

Persistencewith therapy

Improvementwith therapy

Positive finding of• malignant cells• bacteria, fungus etc.• other specific parameter, e.g. amylase (>serum)

THORACENTESIS

The initial diagnostic The initial diagnostic consideration is distinguishing consideration is distinguishing transudates from exudates. transudates from exudates.

Although a number of chemical Although a number of chemical tests have been proposed to tests have been proposed to differentiate pleural fluid differentiate pleural fluid transudates from exudates, the transudates from exudates, the tests first proposed by tests first proposed by Light Light et al et al have become the criterion have become the criterion standards.standards.

The fluid is considered an The fluid is considered an exudate exudate if any of the following if any of the following apply: apply: 

Ratio of pleural fluid to serum Ratio of pleural fluid to serum proteinprotein greater than greater than 0.50.5

Ratio of pleural fluid to serum Ratio of pleural fluid to serum lactate dehydrogenase (lactate dehydrogenase (LDH)LDH) greater than greater than 0.60.6

Pleural fluid LDH greater than two Pleural fluid LDH greater than two thirds of the upper limits of thirds of the upper limits of normal serum valuenormal serum value

PARAMETERPARAMETER TRANSUDATETRANSUDATE EXSUDATEEXSUDATE

Clinical contextClinical context Heart disease, liver, Heart disease, liver, kidney, cancer, kidney, cancer, cachexia, cachexia, hypothyroidism, hypothyroidism, pulmonary pulmonary

infarctioninfarction

Inflammation, cancer, Inflammation, cancer,

collagencollagen diseasesdiseases

FibrinFibrin Does not stick fingersDoes not stick fingers Sticks fingersSticks fingers

DensityDensity 10151015 > 1016> 1016

Rivalta reactionRivalta reaction NegativeNegative PositivePositive

Pleural LDH/Serum LDHPleural LDH/Serum LDH < 0,6< 0,6 ≥ ≥ 0,60,6

Pleural LDHPleural LDH < 200 UI/L< 200 UI/L ≥ ≥ 200 UI/L200 UI/L

AlbuminAlbumin < 3 g%< 3 g% ≥ ≥ 3 g%3 g%

Serum albumin /pleural Serum albumin /pleural albuminalbumin

≥ ≥ 1,291,29 < 1,29< 1,29

PARAMETERPARAMETER TRANSUDATETRANSUDATE EXSUDATEEXSUDATE

Pleural protein /serum Pleural protein /serum proteinprotein

< 0,5< 0,5 ≥ ≥ 0,50,5

ViscosityViscosity 1,1-1,31,1-1,3 > 1,6> 1,6

CholesterolCholesterol < 60 mg%< 60 mg% > 60 mg %> 60 mg %

Pleural bilirubin /Serum Pleural bilirubin /Serum bilirubinbilirubin

< 0,6< 0,6 > 0,6> 0,6

CellularityCellularity < 1000 cells/mm3< 1000 cells/mm3 > 1000 cells/mm3> 1000 cells/mm3

TB pleurisyTB pleurisy

BiochemistryBiochemistry Pleural protein > 30 g/l Pleural protein > 30 g/l

(exudate)(exudate) Pleural glucose < 0.6 g/lPleural glucose < 0.6 g/l ADA (adenosine ADA (adenosine

desaminase)> 30 (45) UI/ldesaminase)> 30 (45) UI/l Pleural lysozyme/serum Pleural lysozyme/serum

lysozyme > 2lysozyme > 2

CytologyCytology Lymphocytes > 80%Lymphocytes > 80% PMN increased in the PMN increased in the

early stagesearly stages Repair lesions - Repair lesions -

increased eosinophilsincreased eosinophils Pleural T lymphocytes > Pleural T lymphocytes >

serum T lymphocitesserum T lymphocites The absence or low The absence or low

number of mesothelial number of mesothelial

cellscells

BacteriologicBacteriological al examinationexamination

Can provide etiological certainty Can provide etiological certainty Microscopically and culture are Microscopically and culture are

positive in only a 5-10% casespositive in only a 5-10% cases Pleural biopsy associated withPleural biopsy associated with

seeding of a fragment of tissue on seeding of a fragment of tissue on specific media culture for BK - specific media culture for BK - increases to 50-80% the increases to 50-80% the detection of TB pleurisydetection of TB pleurisy

Colour? Protein? Cells? Others?

Diagnostic approach to pleural effusions

Etiology unknownEtiology probable

(e.g. cardiac/renal)

Etiology unknown

CLOSEDPLEURAL BIOPSY

Etiology unknown

Etiology unknown (<10%)

Persistencewith therapy

Improvementwith therapy

Positive finding of

• malignant cells

• bacteria, fungus etc.• other specific parameter, e.g. amylase (>serum)

Histological finding of malignancy or

tuberculosis

Follow-up

In single cases surgical biopsy

THORACENTESIS

MEDICALTHORACOSCOPY

Positive diagnosisPositive diagnosis Positive diagnosis of tuberculous pleurisy is based Positive diagnosis of tuberculous pleurisy is based

primarily on primarily on bacteriological and histologicalbacteriological and histological confirmation, confirmation, together able to provide diagnosis in over 85% of cases.together able to provide diagnosis in over 85% of cases.

Most important arguments for the etiology Most important arguments for the etiology of TB can be summarized:of TB can be summarized:- age under 35-40 years;- age under 35-40 years;- serous fluid - lymphocyte predominant;- serous fluid - lymphocyte predominant;- pleural fluid protein above 30 g/l and pleural - pleural fluid protein above 30 g/l and pleural glucose under 0.60 g/l;glucose under 0.60 g/l;- a positive TST or TST becomes positive after 4-6 - a positive TST or TST becomes positive after 4-6 weeks of tuberculostatic treatment;weeks of tuberculostatic treatment;- increased ADA in pleural fluid;- increased ADA in pleural fluid;- report of pleural lysozyme/serum lysozyme than - report of pleural lysozyme/serum lysozyme than 2;2;- healing with scars;- healing with scars;- favorable evolution under tuberculostatics - favorable evolution under tuberculostatics treatmenttreatment

Diagnostic approach to pleural effusions

follow-up

closed pleural biopsy

thoracentesis

etiology ?

medical thoracoscopy

etiology ?

surgicalbiopsy

etiology ?

http://webcache.googleusercontent.com/search?q=cache:T22sqis_JwAJ:emedicine.medscape.com/article/299959-overview+light+criteria+to+pleuresy&cd=1&hl=ro&ct=clnk&gl=ro

REFERENCES

Thank you !Thank you !