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Pleural syndrome. Tubercular pleurisy Dr Etienne Leroy-Terquem Centre hospitalier de Meulan les Mureaux. France French-cambodian association for pneumology (OFCP) Pleurisy: lung Findings of fluid between visceral and parietal membrane viscéral serous membrane pariétal serous membrane Effusion in pleural cavity The superior limit is curved with a superior concavity ascending from the mediastinum to the lateral thoracic wall - Non systematised opacity (not limited by a scissura) - No aeric bronchogram - Mobility if change of position Small abundance (500 to 700 cc) Medium abundance Abundant pleural effusion Pleurisy Pushing back Left atelectasis Retraction Pleural syndrome Abundant effusion - Overlap of all the hemi thorax - The médiastinum is pushed back - The diaphragm is thrown down Left pleurisy + left atelectasis (pleural effusion associated with retraction) Pleural effusion is not retractile, except if there is an associated atelectasis The decubitus position modify radiological picture of the pleurisy A pleurisy, even if the abundance is small, is likely to involve passive atelectasis decubitus Do not confound pleurisy and ascension of the diaphragm Do not confound pleurisy and diaphragmatic hernia Do not confound pleurisy and diaphragmatic hernia Effusion in fissura Front view: Profil: Effusion in the small and in the big fissura opacities with shuttle form Effusion in the small fissura encysted pleurisy Woman, 71 y. old, worsening condition and dyspnea Puncture: serofibrinous fluid. Biopsy: métastasis from adénocarcinoma. Pleural tuberculosis The serofibrinous tuberculosis (1) The tubercular pleurisy most often occurs just after the primary infection.That is why the tuberculine test is often negative (anergic phase). Sometimes pleurisy occurs after reactivation from pulmonary under pleural tubercular nodule Sometimes, less often, pleurisy occures in the same times than pulmonary TB The serofibrinous tuberculosis (2) • is the most often unilatéral • with lymphocytic predominance (possible prédominance of neutrophilic leucocyte in the beginning.) • is exsudative: protides pleural protid > 30g/l ( or pleural protid / sanguineous protid ratio superior to 0,5) • is associated with a pulmonary TB in less than 50% of the cases. The association between pleurisy and pulmonary TB is more frequent in case of AIDS. The serofibrinous tuberculosis (3) • AFB are nearly always negative in the pleural fluid • The culture of the liquid (if it is realised) is positive only in the half of the cases. • Positive diagnostic is made by pleural biopsy (most often by thoracic puncture or if possible by thoracoscopy). The samplings can show specific lesions (tubercular granuloma) • Cure without sequela is possible if the treatment is early. Evacuation of the fluid and physiotherapy influence the good evolution Man 20 y. old! t° 38°C, cough, and right latero-thoracic paint, dyspnea! Tub. Skin test: 3 mm! AFB négative! Poncture : sérofibrinous fluid ! protid : 44 g ! ! lympho : 96 % ! pleural biopsy : ! Epithélioïd & gigantocellular granuloma with caseum necrosis! Culture BK + in liquid and biopsies! © OFCP Tubercular pleurisy in a patient of 28 y. old, HIV + Evolution during 5 monthes of a TB pleurisy under treatment AFB négative in sputums but positive cultures in sputums and pleural fluid. Small nodules in right axillar area. Right pleurisy associated with apical infiltrate: The main differential diagnoses are: • The néoplasic pleurisy, (mainly métastatic) • The para pneumonic pleurisy, • More rare etiologies: pancréatitis, pulmonary embolism, auto immun illnesses… • Transudative pleural effusion (pleural protid/ sanguineous protid ratio < 0.5): cardiac failure, hepatic failure, nephrotic syndrome and renal failure But tubercular pleurisy is not always serofibrinous: • The effusion can be gaseous: pneumothorax • The effusion can be purulent et gaseous: Pyopneumothorax Bilatéral TB under treatment © OFCP © OFCP Rupture of a small TB cavity In the under pleural area Par rupture dans la plèvre d ’un nodule excavé © OFCP TB pyo-pneumothorax , by rupture of a cavity in pleural cavity. Because of the infection, the fluid contains pus with polynuclear leukocytes. AFB are positive in the fluid. TB pyo-pneumothorax , with a thick pleural wall The treatment of these pyo-pneumothorax is difficult and often needs Thoracic surgery © OFCP Tthoracoplasty is necessary for treatment of these pyo-pneumopthorax © OFCP © OFCP TB péricarditis après ponction péricardique after péricardic puncture Les péricardites TB pericarditis are frequent in countries with hight incidence © OFCP © OFCP After pericardic puncture Pneumo pericarditis , after drainage of the fluid Péricarditis cardiomégaly with left ventricle hypertrophy © OFCP