TB pleural pathology

2021-02-06 12:00 AM

When the pleural fluid is low, the patient usually lies on his side to heal, when the fluid is more, the patient must lie on his side or lean against the wall to ease breathing difficulty.

Outline

It is a common clinical form of the disease. Number one in extrapulmonary tuberculosis.

Usually secondary to pulmonary tuberculosis.

According to the authors in the world and Vietnam, the rate of pleural tuberculosis in the extrapulmonary tuberculosis is 25-27%.

Meet at different ages, with teenagers and young people encounter more.

The most common clinical form of pleural tuberculosis is a lemon-yellow, free-flowing, serous effusion.

The prognosis is good, but still has serious complications such as: purulent pleuritis, effusion combined with pneumothorax, pleural thickening, pleural sediment drive if late diagnosis and incorrect value.

Outline

It is a common clinical form of the disease. Number one in extrapulmonary tuberculosis.

Usually secondary to pulmonary tuberculosis.

According to the authors in the world and Vietnam, the rate of pleural tuberculosis in the extrapulmonary tuberculosis is 25-27%.

Meet at different ages, with teenagers and young people encounter more.

The most common clinical form of pleural tuberculosis is a lemon-yellow, free-flowing, serous effusion.

The prognosis is good, but still has serious complications such as: purulent pleuritis, effusion combined with pneumothorax, pleural thickening, pleural sediment drive if late diagnosis and incorrect value.

Causes and mechanisms of pathogenesis

Reason

Commonly the human tuberculosis bacteria. Bovine tuberculosis and atypical tuberculosis bacteria are uncommon.

Mechanism of pathogenesis

Sugar spread of bacteria

Blood sugar and lymphatic blood are the main pathways of the spread of TB bacteria from primary damage to the pleura.

Access route: Tuberculosis lesions of the pulmonary parenchyma near the pleura. Progressively penetrates the pleura.

Good condition

Children are not vaccinated against BCG.

Children with primary tuberculosis infection but were detected late and not treated properly.

People in regular, direct contact with patients with pulmonary tuberculosis (direct sputum test: AFB positive).

Sudden cold infection.

Chest injury.

Systemic diseases causing immunodeficiency of the body: diabetes mellitus, gastric bypass, HIV infection, pregnant women and postpartum women ...

Pathology

General

First stage: pleural oedema, congestion, lemon yellow fluid appears. There may be pink, cloudy fluid.

The following stage: The pleura is thickened, rough, can see the tuberculosis particles, the tuberculosis lumps the bean pulp. Parenchyma of the pleura collapses.

Late stage: The pleural fluid decreases or goes away, the leaf wall, the viscera thickens, stick together or stick to the mediastinum, diaphragm. Fibrous bands can be seen dividing the pleural space into separate compartments.

Micro

The first stage: the pleural endothelial cell layer is destroyed, the fibrinolytic substance (fibrin) is deposited on the surface of the pleura, thickening the damaged pleura.

Later stage: Fibrous lesions appear.

End stage: The predominant fibrous organization in the pleura.

clinical

Typical form - tuberculosis pleural free effusion lemon yellow.

Onset stage

Acute developments: 

Approximately 50% of cases have an acute manifestation. 

Sudden, severe chest pain.

High fever 39 0 C - 40 0 C. 

Ho khan.

Shortness of breath.

Progress slowly: 

Approximately 30% of cases with signs: persistent chest pain, mild evening and evening fever, dry cough, increasing difficulty breathing.

Potential developments: 

Poor, discreet clinical signs. Often overlooked or found by accident on chest radiographs.

A small number of patients have very serious symptoms like typhoid disease.

Full-play stage

Body signs: 

Patient is pale, tired, thin, has constant fever, temperature fluctuates from 38oC to 400C, rapid pulse, low blood pressure, nausea, vomiting, and low urine output.

Mechanical signs:

Dry coughing bouts, coughing spells appear suddenly when changing positions. 

Chest pain: reduced compared to the onset.

Frequent breathing difficulty, both of which, gradually increases.

When the pleural fluid is low, the patient usually lies on his side to heal, when the fluid is more, the patient must lie on his side or lean against the wall to ease breathing difficulty.

Entity markers:

The most typical in the presence of effusion in the pleural space is syndrome 3 reduction:

Look: The side ribs are more fluid, the rib cage is reduced compared to the healthy side, the intercostal space is wide.

Touch: Sound vibration is reduced.

Typing: chisel, the upper limit of turbidity can be determined if the effusion is moderate, that is the Hyperbole curve with the lowest point close to the spine, the highest point in the armpit, also known as the Damoiseau curve.

Above the chiselled area, below the collarbone, when typing too much, it is called the peak of lung.

Multiple effusion: Typing half of the chest cavity. The fluid was much to the left, the heart was pushed to the right, the Traubel cavity was chiselled.

Listen:

Alveolar barrier is reduced or completely lost.

You can see pleural rubbing, pleural blowing sounds.

If crackles are heard, moist crack indicates damage to the lung parenchyma (usually pulmonary tuberculosis).

Some clinical forms are rare

Regional TB pleural effusion

The clinical signs are often discreet and difficult to diagnose; An effusion can be localized in:

Inter-lobe furrow. 

Armpit area.

Intermediate.

On the diaphragm.

Dry pleural tuberculosis

Hear pleural scrubbing.

Bleeding combined with pneumothorax due to tuberculosis

Examination of effusion syndrome and overflow syndrome at the top (loss of voice, loss of alveoli, echoes above).

Tuberculosis with pulmonary tuberculosis or tuberculosis of other organs

In addition to signs of pleural effusion there are also signs of lung parenchymal damage: moist ran, exploding, cavernous sound: patient coughs up sputum or coughs up blood.

Pleural tuberculosis in multilayer TB disease

Usually, pleural TB combined with TB in many other membranes: peritoneum, pericardium ... 

Subclinical

Diagnostic imaging tests

Technique of pleural ultrasound, X-ray is valid for determining pleural fluid. Usually chest x-ray (straight, inclined).

Less pleural effusion: Regular cloudiness in the basal area of ​​the lung, losing the diaphragm angle (volume of fluid about 0.5 litters).

Moderate effusion: Dark cloud, both occupy half or 2/3 of the lung field, volume of fluid about 1-2 litters, the mediastinum is pushed to the opposite side. The upper limit of the fuzzy region can be seen as an upward concave-face curve (Damoisseau).

Large effusion: Evenly blurred, the whole lung field, mediastinum is pushed to the opposite side, interstitial fissure widens, diaphragm is pushed down low, fluid quantity over 2 litters.

Localized effusion: Depending on the location of the effusion, there are corresponding fuzzy areas: 

Inter-lobe furrow effusion: The spindle-shaped fuzzy uniform corresponds to the inter-lobe groove.

Axillary pleural effusion: On the film straight see the cloudiness, clearly limited adjacent to the chest outside.

Median effusion: Asymmetrical wide medial ball.

Pneumothorax combined with pneumothorax: Below is a uniformly dark effusion, above is a homogeneous overflow area, the boundary between the two regions is a horizontal line.

Aspiration fluid and pleural fluid test

General properties

Lime, sticky, can coagulate after being sucked out of the pleural cavity (due to more albumin).

The fluid can be pink or cloudy.

Biochemical

Albumin: Over 30 g / litter.

Rivalta was positive. 

Fibrin above 6g / litter.

The enzyme LDH pleural fluid increases.

Glucose in the pleural fluid is lower than blood glucose.

Cell

Many lymphocytes, the rate of lymphocytes gradually increases, up to 90-100%.

You can see some polymorphonuclear leukocytes, erythrocytes, pleural endothelial cells.

Bacteria

It is difficult to see tuberculosis bacteria on direct examination.

Pleural fluid homogeneous scan low positive AFB rate, 5-10%.

Culture of pleural fluid to find TB bacteria: According to some Vietnamese authors, the positive rate is about 13%, according to foreign authors, the positive rate is about 25%.

New testing techniques

Find antibodies to TB in the pleural fluid by ELISA technique; PCR detection of tuberculosis may be indicated in difficult and where practice is available.

Mantoux reaction

Usually strongly positive.

Pleural biopsy 

Through pleural bronchoscopy or blind biopsy to take samples for pathological tests for specific TB lesions.

Blood tests

The number of leukocytes is normal or slightly increased, the rate of lymphocytes is high, the rate of blood sedimentation increases.

Some other tests

Reaction ELISA of pleural fluid, scan of the lung, pleura. . .

Diagnose

Diagnosis of TB pleural effusion

In most cases, attention should be paid to clinical features: patients with pleural effusion accompanied by chronic infection and toxicity. Especially appearing in people with pre-existing favourable conditions: having primary tuberculosis in other parts, having contact with the source of TB transmission ... Pleural fluid test with common properties: lemon yellow, elevated Albumin exudate, Rivalta (+), multiple lymphocytes, a strong Mantoux positive reaction ... Usually the factors accompanying the clinical decision of the diagnosis. Factors with high diagnostic value confirm: find anti-TB antibodies by ELISA technique, find TB bacteria by PCR technique in the pleural fluid, pleural microscopy and pleural biopsy, computed tomography... is practical and is usually preferred only for difficult cases.

Differential diagnosis

Pleural effusion caused by cancer

The patient's age is usually over 50 years old.

Pink and red fluid (blood fluid), rate of 90%.

The effusion may be lemon yellow at first, but later on to the haemorrhage.

The fluid recurs rapidly, the LDH enzyme in the pleural fluid increases over 500 units.

Found malignant cells in the pleural fluid: 40-60% positive rate.

Pleural biopsy.

After aspiration, pleural inflation X-ray. 

Ultrasound of the pleura.

Laparoscopy. 

Bacterial pleural effusion (purulent TDMP)

Acute infection syndrome.

Cloudy or purulent fluid.

Pleural fluid test: Many degenerative polymorphonuclear leukocytes (pus cells).

Fresh microscopy, culture of pleural fluid to find pathogenic bacteria.

Pleural effusion caused by virus

Usually little effusion. 

Translate in.

The fluid is rapidly absorbed.

Pleural fluid test: Multiple lymphocytes.

Pleural effusion is due to a number of other causes

In the lungs:

Acute pneumonia.

Lung infarction.

 B.B.S disease (Besnier- Boeck- Chaumann).

In addition to the lungs:

Heart failure.

Cirrhosis of the liver.

Nephrotic syndrome.

Demons Meigs syndrome: Ovarian cyst combined with free pleural effusion. If the cyst is removed, the pleural effusion goes away.

Developments 

Going well

Patients with simple TB pleural effusion, early detection, prompt treatment usually goes well, the pleural fluid gradually decreases and disappears after a few weeks of treatment.

Bad developments

The elderly, debilitated, immunocompromised, pleural tuberculosis combined with chronic pulmonary tuberculosis often have bad symptoms.

Pleural effusion combined with pneumothorax.

Superinfected TB pleural effusion becomes purulent pleural effusion. 

 Pleural sediment.

Pleural cavity to chest wall. 

Multilayer TB.

Treatment 

Treat the cause 

Taking anti-TB medicine is important. In mild cases in adults, formula 2SRHZ / 6HE is often used; Children take 2RHZ / 4RH. Severe cases: disease detected late, combined with tuberculosis elsewhere ... Adults use formula 2SRHZE / 1RHZE / 5R3H3E3. Children take 2RHZ (S / E) / 4RH. 

Aspiration pleural fluid 

Fluid aspiration needs to be absorbed early and completely. In order to limit complications when aspirating fluid (shock, air spill, bleeding, superinfection ...), it is necessary to comply with the principle of aspirating closed pleural fluid, sterile and not too much, too fast.

Anti-thickening pleural stick 

Use corticosteroids at the beginning: time for 6-8 weeks, dose 0.6 - 0.8 mg / weight / 24 hours, reduce dose gradually before stopping treatment. 

Patient practices early breathing

When fluid has stopped using diaphragmatic breathing method ... 

Combined surgical treatment

When there are complications of pleural sedimentation; Superinfection causes pleural leakage ... In addition to active internal medicine, it should be combined with: Minimum pleural opening, maximum pleural opening; Pleural dissection surgery; Pleural lavage combined with topical antibiotic treatment.

Reason

Commonly the human tuberculosis bacteria. Bovine tuberculosis and atypical tuberculosis bacteria are uncommon.

Mechanism of pathogenesis

Sugar spread of bacteria

Blood sugar and lymphatic blood are the main pathways of the spread of TB bacteria from primary damage to the pleura.

Access route: Tuberculosis lesions of the pulmonary parenchyma near the pleura. Progressively penetrates the pleura.

Good condition

Children are not vaccinated against BCG.

Children with primary tuberculosis infection but were detected late and not treated properly.

People in regular, direct contact with patients with pulmonary tuberculosis (direct sputum test: AFB positive).

Sudden cold infection.

Chest injury.

Systemic diseases causing immunodeficiency of the body: diabetes mellitus, gastric bypass, HIV infection, pregnant women and postpartum women ...

Pathology

General

First stage: pleural oedema, congestion, lemon yellow fluid appears. There may be pink, cloudy fluid.

The following stage: The pleura is thickened, rough, can see the tuberculosis particles, the tuberculosis lumps the bean pulp. Parenchyma of the pleura collapses.

Late stage: The pleural fluid decreases or goes away, the leaf wall, the viscera thickens, stick together or stick to the mediastinum, diaphragm. Fibrous bands can be seen dividing the pleural space into separate compartments.

Micro

The first stage: the pleural endothelial cell layer is destroyed, the fibrinolytic substance (fibrin) is deposited on the surface of the pleura, thickening the damaged pleura.

Later stage: Fibrous lesions appear.

End stage: The predominant fibrous organization in the pleura.

clinical

Typical form - tuberculosis pleural free effusion lemon yellow.

Onset stage

Acute developments: 

Approximately 50% of cases have an acute manifestation. 

Sudden, severe chest pain.

High fever 39 0 C - 40 0 C. 

Ho khan.

Shortness of breath.

Progress slowly: 

Approximately 30% of cases with signs: persistent chest pain, mild evening and evening fever, dry cough, increasing difficulty breathing.

Potential developments: 

Poor, discreet clinical signs. Often overlooked or found by accident on chest radiographs.

A small number of patients have very serious symptoms like typhoid disease.

Full-play stage

Body signs: 

Patient is pale, tired, thin, has constant fever, temperature fluctuates from 38oC to 400C, rapid pulse, low blood pressure, nausea, vomiting, and low urine output.

Mechanical signs:

Dry coughing bouts, coughing spells appear suddenly when changing positions. 

Chest pain: reduced compared to the onset.

Frequent breathing difficulty, both of which, gradually increases.

When the pleural fluid is low, the patient usually lies on his side to heal, when the fluid is more, the patient must lie on his side or lean against the wall to ease breathing difficulty.

Entity markers:

The most typical in the presence of effusion in the pleural space is syndrome 3 reduction:

Look: The side ribs are more fluid, the rib cage is reduced compared to the healthy side, the intercostal space is wide.

Touch: Sound vibration is reduced.

Typing: chisel, the upper limit of turbidity can be determined if the effusion is moderate, that is the Hyperbole curve with the lowest point close to the spine, the highest point in the armpit, also known as the Damoiseau curve.

Above the chiselled area, below the collarbone, when typing too much, it is called the peak of lung.

Multiple effusion: Typing half of the chest cavity. The fluid was much to the left, the heart was pushed to the right, the Traubel cavity was chiselled.

Listen:

Alveolar barrier is reduced or completely lost.

You can see pleural rubbing, pleural blowing sounds.

If crackles are heard, moist crack indicates damage to the lung parenchyma (usually pulmonary tuberculosis).

Some clinical forms are rare

Regional TB pleural effusion

The clinical signs are often discreet and difficult to diagnose; An effusion can be localized in:

Inter-lobe furrow. 

Armpit area.

Intermediate.

On the diaphragm.

Dry pleural tuberculosis

Hear pleural scrubbing.

Bleeding combined with pneumothorax due to tuberculosis

Examination of effusion syndrome and overflow syndrome at the top (loss of voice, loss of alveoli, echoes above).

Tuberculosis with pulmonary tuberculosis or tuberculosis of other organs

In addition to signs of pleural effusion there are also signs of lung parenchymal damage: moist ran, exploding, cavernous sound: patient coughs up sputum or coughs up blood.

Pleural tuberculosis in multilayer TB disease

Usually, pleural TB combined with TB in many other membranes: peritoneum, pericardium ... 

Subclinical

Diagnostic imaging tests

Technique of pleural ultrasound, X-ray is valid for determining pleural fluid. Usually chest x-ray (straight, inclined).

Less pleural effusion: Regular cloudiness in the basal area of ​​the lung, losing the diaphragm angle (volume of fluid about 0.5 litters).

Moderate effusion: Dark cloud, both occupy half or 2/3 of the lung field, volume of fluid about 1-2 litters, the mediastinum is pushed to the opposite side. The upper limit of the fuzzy region can be seen as an upward concave-face curve (Damoisseau).

Large effusion: Evenly blurred, the whole lung field, mediastinum is pushed to the opposite side, interstitial fissure widens, diaphragm is pushed down low, fluid quantity over 2 litters.

Localized effusion: Depending on the location of the effusion, there are corresponding fuzzy areas: 

Inter-lobe furrow effusion: The spindle-shaped fuzzy uniform corresponds to the inter-lobe groove.

Axillary pleural effusion: On the film straight see the cloudiness, clearly limited adjacent to the chest outside.

Median effusion: Asymmetrical wide medial ball.

Pneumothorax combined with pneumothorax: Below is a uniformly dark effusion, above is a homogeneous overflow area, the boundary between the two regions is a horizontal line.

Aspiration fluid and pleural fluid test

General properties

Lime, sticky, can coagulate after being sucked out of the pleural cavity (due to more albumin).

The fluid can be pink or cloudy.

Biochemical

Albumin: Over 30 g / litter.

Rivalta was positive. 

Fibrin above 6g / litter.

The enzyme LDH pleural fluid increases.

Glucose in the pleural fluid is lower than blood glucose.

Cell

Many lymphocytes, the rate of lymphocytes gradually increases, up to 90-100%.

You can see some polymorphonuclear leukocytes, erythrocytes, pleural endothelial cells.

Bacteria

It is difficult to see tuberculosis bacteria on direct examination.

Pleural fluid homogeneous scan low positive AFB rate, 5-10%.

Culture of pleural fluid to find TB bacteria: According to some Vietnamese authors, the positive rate is about 13%, according to foreign authors, the positive rate is about 25%.

New testing techniques

Find antibodies to TB in the pleural fluid by ELISA technique; PCR detection of tuberculosis may be indicated in difficult and where practice is available.

Mantoux reaction

Usually strongly positive.

Pleural biopsy 

Through pleural bronchoscopy or blind biopsy to take samples for pathological tests for specific TB lesions.

Blood tests

The number of leukocytes is normal or slightly increased, the rate of lymphocytes is high, the rate of blood sedimentation increases.

Some other tests

Reaction ELISA of pleural fluid, scan of the lung, pleura. . .

Diagnose

Diagnosis of TB pleural effusion

In most cases, attention should be paid to clinical features: patients with pleural effusion accompanied by chronic infection and toxicity. Especially appearing in people with pre-existing favourable conditions: having primary tuberculosis in other parts, having contact with the source of TB transmission ... Pleural fluid test with common properties: lemon yellow, elevated Albumin exudate, Rivalta (+), multiple lymphocytes, a strong Mantoux positive reaction ... Usually the factors accompanying the clinical decision of the diagnosis. Factors with high diagnostic value confirm: find anti-TB antibodies by ELISA technique, find TB bacteria by PCR technique in the pleural fluid, pleural microscopy and pleural biopsy, computed tomography... is practical and is usually preferred only for difficult cases.

Differential diagnosis

Pleural effusion caused by cancer

The patient's age is usually over 50 years old.

Pink and red fluid (blood fluid), rate of 90%.

The effusion may be lemon yellow at first, but later on to the haemorrhage.

The fluid recurs rapidly, the LDH enzyme in the pleural fluid increases over 500 units.

Found malignant cells in the pleural fluid: 40-60% positive rate.

Pleural biopsy.

After aspiration, pleural inflation X-ray. 

Ultrasound of the pleura.

Laparoscopy. 

Bacterial pleural effusion (purulent TDMP)

Acute infection syndrome.

Cloudy or purulent fluid.

Pleural fluid test: Many degenerative polymorphonuclear leukocytes (pus cells).

Fresh microscopy, culture of pleural fluid to find pathogenic bacteria.

Pleural effusion caused by virus

Usually little effusion. 

Translate in.

The fluid is rapidly absorbed.

Pleural fluid test: Multiple lymphocytes.

Pleural effusion is due to a number of other causes

In the lungs:

Acute pneumonia.

Lung infarction.

 B.B.S disease (Besnier- Boeck- Chaumann).

In addition to the lungs:

Heart failure.

Cirrhosis of the liver.

Nephrotic syndrome.

Demons Meigs syndrome: Ovarian cyst combined with free pleural effusion. If the cyst is removed, the pleural effusion goes away.

Developments 

Going well

Patients with simple TB pleural effusion, early detection, prompt treatment usually goes well, the pleural fluid gradually decreases and disappears after a few weeks of treatment.

Bad developments

The elderly, debilitated, immunocompromised, pleural tuberculosis combined with chronic pulmonary tuberculosis often have bad symptoms.

Pleural effusion combined with pneumothorax.

Superinfected TB pleural effusion becomes purulent pleural effusion. 

 Pleural sediment.

Pleural cavity to chest wall. 

Multilayer TB.

Treatment 

Treat the cause 

Taking anti-TB medicine is important. In mild cases in adults, formula 2SRHZ / 6HE is often used; Children take 2RHZ / 4RH. Severe cases: disease detected late, combined with tuberculosis elsewhere ... Adults use formula 2SRHZE / 1RHZE / 5R3H3E3. Children take 2RHZ (S / E) / 4RH. 

Aspiration pleural fluid 

Fluid aspiration needs to be absorbed early and completely. In order to limit complications when aspirating fluid (shock, air spill, bleeding, superinfection ...), it is necessary to comply with the principle of aspirating closed pleural fluid, sterile and not too much, too fast.

Anti-thickening pleural stick 

Use corticosteroids at the beginning: time for 6-8 weeks, dose 0.6 - 0.8 mg/weight / 24 hours, reduce dose gradually before stopping treatment. 

Patient practices early breathing

When fluid has stopped using diaphragmatic breathing method ... 

Combined surgical treatment

When there are complications of pleural sedimentation; Superinfection causes pleural leakage ... In addition to active internal medicine, it should be combined with: Minimum pleural opening, maximum pleural opening; Pleural dissection surgery; Pleural lavage combined with topical antibiotic treatment.