Pleurisy is an inflammation of the pleura

Pleura is composed of two close-fitting layers

with a lubricating fluid between them. If the
fluid content remains unchanged by the
disease, the pleurisy is said to be dry. If the
fluid increases abnormally, it is a pleurisy
with effusion. If the excess fluid of the
effusion becomes infected, with formation of
pus, the condition is known as purulent pleurisy
or empyema.
 Dry pleurisy (pleuritis sicca) - the inflamed pleurae
rub directly against each other.
Clinical presentation
Fever, dry cough
Respiration is superficial, deep breathing, coughing
intensify friction of the pleural membranes and cause pain.
Lying on the affected side reduces the pain.
Inspection of the patient can reveal unilateral thoracic
lagging during respiration.
Auscultation determines pleural friction sound (rub) over
the inflamed site.
 Pleural effusion –
•abnormal accumulation of fluid in the pleural space
•always abnormal, indicates the presence of an underlying
disease
•90 percent of all pleural effusions are the result of only 5
disease processes: congestive heart failure, pneumonia,
malignancy, pulmonary embolism, and viral infection.
Evaluation of a pleural effusion –
•detailed history and physical examination (diagnosis of
many pleural effusions is based on the clinical setting and
exclusion of other alternative causes);
•categorization as a transudate or exudate:
• - transudative pleural effusions result from systemic
diseases that do not directly involve the pleura but produce
an imbalance between the pressure within blood vessels and
the amount of protein in blood, resulting in movement of
fluid into the pleural space; most frequently - congestive
heart failure or cirrhosis.
- exudatative pleural effusions result from local or
systemic diseases that directly injure the pleural surface;
most frequently associated with infectious diseases,
autoimmune disorders, bleeding, malignancies…
 Is the pleural effusion a transudate or exudate?
Sign Transudate Exudate
comparative density <1,015-1,018 >1,018

Rivalt test Negative Positive

protein <30 g/l >30 g/l

Pleural fluid/serum protein ratio <0,5 >0,5
LDH <1,6 mMol/l >1,6 Mol/l
Pleural fluid LDG/serum LDG ratio <0,6 >0,6
erythrocytes <10*109/l >100*109/l
leucocytes <1*109/l >1*109/l
pH >7,3 <7,3
glucose 3,3-5,5 mMol/l <3,3 mMol/l
Transudative pleural effusion (plasma passing from vessels
into pleural space due to hydraulic or osmotic abnormalities)
•Congestive heart failure (most common transudative
effusion)
•Hepatic cirrhosis with and without ascites
•Nephrotic syndrome
•Pulmonary emboli (25%)
•Peritoneal dialisis
•Hypoproteinemia (eg, severe starvation)
•Glomerulonephritis
•Superior vena cava obstruction
•Urinothorax
Exudative pleural effusion (inflammatory effusion )
 Infectious diseases - Bacterial, fungal, parasitic, and viral infections;
 Malignant disorders - Metastatic disease to the pleura or lungs, primary lung
cancer, mesothelioma, lymphoma, leukemia
 GI diseases and conditions - Pancreatic disease (acute or chronic disease,
pseudocyst, pancreatic abscess), intraabdominal abscess, esophageal
perforation , abdominal surgery, diaphragmatic hernia
 Pulmonary emboli (75%)
 Collagen vascular diseases - Rheumatoid arthritis, systemic lupus
erythematosus, Churg-Strauss syndrome, Wegener granulomatosis
 Meigs syndrome - Benign solid ovarian neoplasm associated with ascites and
pleural effusion
 Drug-induced primary pleural disease - Nitrofurantoin, dantrolene,
methysergide, bromocriptine, amiodarone, procarbazine, methotrexate,
ergonovine, ergotamine, oxprenolol, maleate, practolol, minoxidil, bleomycin,
interleukin-2, propylthiouracil, isotretinoin, metronidazole, mitomycin
 Uremic pleuritis
 Ruptured ectopic pregnancy
 Electrical burns
Parapneumonic effusions –
the most common cause of exudative pleural effusions,
arise from an inflammatory process adjacent to the visceral
pleura.
The effusion derives from inflammatory fluid entering the
lung interstices, transversing the visceral pleura, and
accumulating in the pleural space. This is an uncomplicated
parapneumonic effusion - pleural drainage is frequently
unnecessary, and the pleural process can be resolves with
antibiotic therapy alone.
Once bacterial infection has involved the pleural space, the
effusion increases in size with a concomitant increase in the
number of polymorphonuclear leukocytes creating empyema
which strongly suggests the need for pleural space drainage.
 Pleurisy with effusion:
posterior view:

1— Damoiseau's curve
Percussion over the area of fluid
accumulation produces dullness, the upper
limit of dullness is usually the S-shaped
curve;
2—Garland's triangle;
3—Rauchfuss-Grocco
triangle.
Chest radiography is the primary
diagnostic tool because of its availability,
accuracy, and low cost. It may confirm the
presence of effusion and suggest the
underlying etiology
50 mL of fluid will cause blunting of the
posterior costophrenic angle on a lateral
upright film, whereas 200 mL are required to
cause blunting of the lateral costophrenic
angle on a posteroanterior (PA) film.

Ultrasonography detects as little as 5-50

mL of pleural fluid and has a 100% sensitivity
for effusions greater than 100 mL.
opacity of involved cavity and blunting of
costophrenic angle, mediastinal shift.
 Elocated (limited) pleural effusion
In case of complicated parapneumonic effusion fibrin frequently is deposited in
the pleural space forming barriers that loculate the infected area and lead to
regional composition of pleural fluid - forming elocated effusion

apical

interlobar paracostal

above the diaphragm paramediastinal

Elocated pleural effusion
. Elocated pleural effusion
The character of the inflammatory effusion may be
different: serous, serofibrinous, purulent, and
haemorrhagic.
Serous and serofibrinous pleurisy (tuberculosis,
pneumonia, and also rheumatism in 10-30 % of cases)
Purulent process (pneumococci, streptococci,
staphylococci, and other microbes)
Haemorrhagic pleurisy (tuberculosis of the pleura,
bronchogenic cancer of the lung with involvement of
the pleura, and also in injuries to the chest)
 Characteristic Significance
Bloody Most likely an indication of
malignancy in the absence of
trauma;
Can also indicate pulmonary
embolism, infection, pancreatitis,
tuberculosis, mesothelioma, or
spontaneous pneumothorax
Turbid Possible increased cellular content
or lipid content
Yellow or whitish, Presence of chyle, cholesterol or
turbid empyema
Brown (similar to chocolate sauce Rupture of amebic liver abscess
or anchovy paste) into the pleural space (amebiasis
with a hepatopleural fistula)
Black Aspergillus involvement of pleura
Yellow-green with debris Rheumatoid pleurisy
 Characteristic Significance
Highly viscous Malignant mesothelioma (due
to increased levels of
hyaluronic acid)
long-standing pyothorax
Putrid odor Anaerobic infection of pleural
space
Ammonia odor Urinothorax
Purulent Empyema
Yellow and thick, with Effusions rich in cholesterol
metallic (longstanding chyliform
(stainlike) sheen effusion, eg,
tuberculous or rheumatoid
pleuritis)
 PLEURISY WITH EFFUSION
Clinical presentation
Complains: fever, pain or the feeling of heaviness in the
side, dyspnea (which develops due to respiratory
insufficiency caused by compression of the lung). Cough is
usually mild (or absent in some cases).
Objective examination: The patient's general condition is
grave, especially in purulent pleurisy, which is attended by
high temperature with pronounced circadian fluctuations,
chills, and signs of general toxicosis. Inspection of the
patient reveals asymmetry of the chest due to enlargement
of the side where the effusion accumulated; the affected
side of the chest usually lags behind respiratory
movements. Vocal fremitus is not transmitted at the area
of fluid accumulation.
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Treatment
Antibiotics (eg, for parapneumonic effusions) and
diuretics (eg, for effusions associated with CHF) are
commonly used in the initial management of pleural
effusions in the ED. The selection of drugs in each
class depends on the cause of the effusion and its
clinical presentation. Particular attention must be
given to potential drug interactions, adverse effects,
and preexisting conditions.
Tuberculous pleural effusion
TB remains the most common cause of
pleural effusion in young people
Etiology: tubercle bacillus
Pathogenesis: host hypersensitivity to
tubercular protein in pleural tubercles
Delayed hypersensitivity
Clinical Manifestations
Generalized symptoms of toxicity of TB:
fever, sweats, fatigue, weight loss ss, etc.
Pleuritic pain, dyspnea, coughlea, etc.
Pleural fluid is exudative and usually
reveals lymphocytosis
Rarely pleural fluid is blood stained
Tubercular tests usually positive
Empyema
Thick purulent fluid with more than 100,000
cells per cubic millimeter or fluid with PH
values less than or equal to 7. 20 should
be treated as a presumptive empyema
The general objectives of therapy of empyema
are the elimination of both the systemic and
local infection.
Treatment of acute and chronic empyema
1. Control of infection
systemic and local
2. Repeated thoracentesis or drainage of the
empyema

3. Chronic empyema is primarily treated operatively

4. Operative therapy is also indicated in the

empyema with associated bronchopleural fistula or
with the ipsilateral ruined lung