Download Pleural syndrome. Tubercular pleurisy

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