Pleural syndrome Tuberculous pleurisy Etienne Leroy Terquem – Pierre L’Her SPI / ISP S outien P...
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Transcript of Pleural syndrome Tuberculous pleurisy Etienne Leroy Terquem – Pierre L’Her SPI / ISP S outien P...
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Pleural syndromeTuberculous pleurisy
Etienne Leroy Terquem – Pierre L’HerSPI / ISP
Soutien Pneumologique International / International Support for Pulmonology
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Pleural effusion: Findings of fluid between visceral and parietal membrane
Lung
Visceral serous membrane
Parietal serous membrane
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Effusion in the pleural cavity
- Dense opacity, homogeneous, declive (mobile to change position)
- No systematised (not bounded by a fissure)
- - No air bronchogram
Upper limit of the opacity concave upwards and inwards
“Damoiseau’s curve “
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Small abundance (500 to 700 cc)
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Medium abundance
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Abundant pleural effusion
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Very abundant pleural effusion, overlapping right lung.Mediastinum is pushed on the opposit side.
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Pleurisy
Left atelectasis
Retraction
Pushing back
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Pleural syndrome
- Overlap of all the hemi thorax
Abundant effusion
- The mediastinum is pushed back
- The diaphragm is thrown down
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Right pleurisy + right atelectasis (pleural effusion associated with pulmonary retraction)
Pleural effusion is not retractile, except if there is an associated atelectasis
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Middle lobe atelectasis well visible after fluid evacuation
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A pleurisy, even if the abundance is small, is likely to involve passive atelectasis
decubitus
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The decubitus position modify radiological picture of the pleurisy(same patient, same day)
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Do not confound pleurisy and Ascension of the diaphragm
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Do not confound pleurisy and Diaphragmatic hernia
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Do not confound pleurisy and Diaphragmatic hernia
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Pleural effusion in the fissures
Front view:
Effusion in the small and in the
big fissure
Profil:
opacities with shuttle of a loom
form
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Effusion in the small fissure
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Encysted pleurisy in small and big fissura,only visible on lateral view
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Effusion in fissure is frequent in cardiac failure
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Encysted pleurisy
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Woman, 71 y. old, worsening condition and dyspnea Puncture: Serofibrinous fluid. Biopsy: metastasis from adenocarcinoma
Encysted pleurisy
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Left axillar and posterior thikened pleural wall
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Pleural tuberculosis
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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 (1)
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• 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 (2)
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• 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 begins early. Evacuation of the fluid and physiotherapy influence the good evolution
The serofibrinous tuberculosis (3)
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Right pleurisy associated with apical infiltrate:
Association with a pulmonary TB in less than 50% of the cases. Association pleurisy - pulmonary TB is more frequent in case of AIDS
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Tubercular pleurisy in a patient of 28 y. old
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Long term sequelae are possible…
Man ,58 years old , past history of pleurisy, (probable pleural TB). Restricitive chronic respiratory failure
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Long terme sequelae are possible, if initial managment
was late or imcomplete. Consequency is restrictive chronic respiratory failure
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Calcified and retractile sequela of pleural TB
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© OFCP
M 20 y. old t° 38°C, cough, and right latero-thoracic paint, dyspnea
Tuberculin Skin test: 3 mmAFB negativePuncture: serofibrinous fluid
protide : 44 g lymphocyte : 96 %
Pleural biopsy :
Epithelioid and giant cell granuloma with caseum necrosis
Culture BK + in liquid and biopsies
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Courtesy Dr Van Den Homberg Tanzania
Right abundant pleural effusion Note the typical concave aspect of the opacity’s superior edge (yellow arrows)
Nodular infiltrate of the left upper lobe with cavity (red arrow).
AFB positive in sputum.
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The main differential diagnoses are:
• The neoplasic pleurisy, (mainly metastatic)• The para pneumonic pleurisy• More rare etiologies:
– Pancreatitis – pulmonary embolism– auto immun diseases…
• Transudative pleural effusion (Protein ratio : pleural / blood < 0.5) = cardiac failure, hepatic failure, nephrotic syndrome and renal failure
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Note the pleural effusion and the pleural irregular thickness in the left axillar and apex pleural area, suggesting malignancy:
• primary pleural cancer = mesothelioma (past history occupational exposure to asbestos)
• or metastatic process… TB pleurisy is also possible in such CXR.
If possible pleural biopsy could facilitate the diagnosis
Left pleurisy
It’s aMesothelioma
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On the right side, same patient after 1 year of evolution; the pleural tumor process has increased. Of course no improvment with TB treatment which has been instaured on the beginning of the evolution
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But tubercular pleurisy is not always serofibrinous:
• The effusion can be gaseous: pneumothorax
• The effusion can be purulent et gaseous: Pyopneumothorax
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TB left pneumothorax with excavated RUL infiltrate
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Bilateral TB under treatment :
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Bilateral TB under treatment :Par rupture dans la plèvre d ’un nodule excavéPar rupture dans la plèvre d ’un nodule excavé
© OFCP
Rupture of a small TB excavatedNodule in the under pleural area
Apparition of a Left pneumothorax
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Small pleural effusion Hydro-pneumothoraxWith fluid level
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M 28 y, cough, dyspnea + + +, astheniaBilateral TB + left pneumothorax
Settathirath hospital VientianeInfectious & TB ward
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Same patientD 20
Fluid level
Left lung Air
Left hydropneumothorax
Settathirath hospital VientianeInfectious & TB ward
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It’s sero fibrinous fluid
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© OFCP
TB pyo-pneumothorax, by rupture of a cavern in pleural cavityBecause infection, the fluid contains pus with polynuclear leukocytes.
AFB can be positive in the fluid
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TB pyopneumothorax is a very severe manifestaton of TB with bad pronostic
it is almost always very late patients coming for consultation
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Thoracoplasty is often necessary to treat these pyo-pneumothorax
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Pleural Drainage Documents Dr Hans Rieder Cdrom IUATLD
Evacuation of pleural pus
But efficiency is very relative without continous aspiration…
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Without continous aspiration, this drainage will always be unsuccessful in case of TB pyo-pneumothorax
KSF hospital Phnom PenhPulmonology ward
Young Vietnamese patientMDR TB
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08.07.2002
M 18 y July 2002Lymphocytic pleurisyNegative AFBsputum & pleural fluid
We must treat TB serofibrinous pleurisy with tb treatment.Pleural evacuation is, of course not sufficiant
Treatment only by punctures
Centre hospitalier LibrevilleGabon, Internal Medicine ward
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08.07.02 26.07.02
08.10.02
Declared “cured“ by doctors
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07.12.2005
Cough sputum weight loss
Cavern
Mediastinal lymph node TB in his brother
cavern3 years later …
Military hospitalier HIA OBO LibrevilleGabon, Internal Medicine ward
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Pericarditis
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TB pericarditis
TB pericarditis are frequent in countries with hight TB incidence
© OFCP
après ponction péricardiqueaprès ponction péricardique
© OFCP
After pericardic puncture
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TB pericarditis
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After surgical fluid drainage
Pneumo-pericardium
and pneumo-peritoneum
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Note as the pericardium (parietal) is thin
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Do not confuse pericarditis and cardiomegaly. The treatment is very different :-Look at the cardiac edge: they are sharp with beginning of symetry-look at the lungs : they are clear with no signs of pulmonary oedema
Pericarditis Cardiomegaly with left ventricle hypertrophy
IMPORTANT +++ FOR NTP DOCTORS