Tuberculous pleurisy is an inflammation of the pleura of tuberculous etiology, occurring both in dry form and with the accumulation of exudate in the pleural cavity. The main symptoms of tuberculous pleurisy are stabbing pain in the side, dry cough, shortness of breath, subfebrile or febrile body temperature, malaise. When making a diagnosis, the X-ray picture, the results of the Mantoux test, the detection of MBT in sputum or pleural exudate, and pleuroscopy data are taken into account. Treatment of tuberculous pleurisy is carried out with tuberculostatic drugs, corticosteroids, NSAIDs; with massive exudation, a series of pleural punctures for aspiration of effusion is indicated; in the resorption phase, physical therapy and physiotherapy are prescribed.
ICD 10
A15 Tuberculosis of the respiratory system, confirmed bacteriologically and histologically
Meaning
Tuberculous pleurisy is a specific reaction of pleural leaves caused by the effects of Mycobacterium tuberculosis. Tuberculous pleurisy can develop as an independent form of tuberculosis infection or accompany the course of other clinical variants of pulmonary tuberculosis. Sometimes the lesion of the pleura is a manifestation of polyserositis – inflammation of the serous membranes of tuberculous etiology. In the structure of tuberculosis of the respiratory system, tuberculous pleurisy is 8-14%. It is spread mainly among young people (up to 40 years old), men are slightly more likely to get sick. Pleurisy of tuberculous genesis accounts for almost half of all exudative pleurisy, which cannot but arouse the alertness of specialists in the field of phthisiology and pulmonology.
Causes of tuberculous pleurisy
In most cases, tuberculous pleurisy develops against the background of active pulmonary tuberculosis: focal, infiltrative, disseminated, primary tuberculosis complex, etc. Occasionally occurs as an independent clinical form in the absence of signs of tuberculous lesions of other organs. A patient with tuberculosis pleurisy may be complicated by spontaneous or artificial pneumothorax (collapse therapy).
Mycobacterium tuberculosis penetrates into the pleural cavity in one of three possible ways: by contact (from pulmonary foci of decay of subpleural localization), by lymphogenic pathway (when spread through the lymphatic pathways) and by hematogenic pathway (through the blood vessel system in the presence of bacteremia). The source of the spread of MBT into the pleura are intra-thoracic lymph nodes or reactivated foci of tuberculosis in the lung. A necessary condition for the development of tuberculous pleurisy is a specific sensitization of pleural leaflets.
The following factors favor the occurrence of the tuberculous process in the pleura:
- hypothermia
- of hypovitaminosis and malnutrition
- taking GCS and immunosuppressants
- concomitant diseases (oncopathology, diabetes mellitus)
- close contact with a tuberculosis patient.
Pathogenesis
In response to the introduction of MBT, inflammatory edema, hyperemia and thickening of pleural leaflets develop. Soon, multiple miliary tubercles appear on them, sometimes larger foci with caseous necrosis. These changes are accompanied by a pronounced exudative reaction – sweating and accumulation of fluid in the pleural cavity. The nature of the exudate (fibrinous, serous, bloody, purulent) depends on the pathomorphological changes in the pleura.
Classification
Depending on the presence/absence and nature of effusion, tuberculous pleurisy can be fibrinous (dry) and exudative (effusion). In the latter case, serous, hemorrhagic, cholesterol, purulent exudate may occur.
Fibrinous (dry) pleurisy proceeds with a minimum amount of exudate, in which the fibrin content is increased. The liquid part of the exudate resolves quickly, and fibrin is deposited on pleural leaves. Over time, fibrous strands form between the pleural leaves, the pleural cavity is partially or completely obliterated – dry pleurisy turns into adhesive (adhesive) pleurisy.
Exudative (effusion) pleurisy. The most common variant of tuberculous pleurisy is exudative. The amount of effusion is usually significant, the exudate quickly arrives again after aspiration during thoracocentesis. According to the predominant cellular composition, the following types of exudate are distinguished: lymphocytic, eosinophilic and neutrophilic. With a sharp increase in the permeability of the capillaries of the pleura and the output of a large number of red blood cells, the character of the exudate becomes serous-hemorrhagic or hemorrhagic. Cholesterol exudate has a thick consistency, yellow color, a large amount of cholesterol is determined in it. Serous-purulent and purulent exudate is usually formed with an extensive caseous-necrotic reaction of the pleura.
By localization, there are apical, interlobular, costal, supradiaphragmatic, paramediastinal tuberculous pleurisy. Usually the lesion is unilateral, bilateral pleurisy of tuberculous etiology rarely develops (1.5%). In clinical terms, the most significant isolation of the following types of tuberculous pleurisy: allergic, perifocal, pleural tuberculosis and purulent pleurisy. During tuberculous pleurisy, there are 3 periods:
- accumulation of exudate and an increase in clinical manifestations
- stabilization
- resorption of exudate and subsiding of clinical signs.
Symptoms of tuberculous pleurisy
Allergic pleurisy
An allergic form of pleurisy occurs in people with primary tuberculosis, who have hypersensitivity to tuberculin and are prone to a pronounced hyperergic reaction. The clinic is developing acutely: body temperature rises sharply, febrility persists for 10-14 days. Since at this time there is a rapid accumulation of serous effusion, there is shortness of breath, pain in the side, tachycardia. Resorption of exudate occurs within a month, however, with a large volume of effusion, this process can take a prolonged course. Simultaneously with pleurisy (sometimes before or after it), flictenes, nodular erythema, polyarthritis appear.
Perifocal pleurisy
Perifocal tuberculous pleurisy begins subacute or gradually. Often, patients associate the appearance of symptoms with previous hypothermia or ARVI. Patients are concerned about dry cough, tingling in the chest, unstable subfebrility. Increased pain in the side is provoked by deep breathing, position on the sick side, pressure on the intercostal space. Pain syndrome is often mistaken for myositis, plexitis, intercostal neuralgia, angina, and when irradiated into the abdomen – for an attack of acute cholecystitis.
If perifocal pleurisy proceeds with the accumulation of serous exudate, the clinical picture becomes more pronounced: elevated body temperature is constantly determined, tachycardia, shortness of breath, sweating occurs. The course of perifocal tuberculous pleurisy is prolonged (4-6 weeks), often recurrent.
Tuberculous pleurisy
Pleural tuberculosis can occur in the form of a disseminated, focal process, a caseous-necrotic reaction. It may be accompanied by the accumulation of serous, serous-purulent or purulent effusion. The course of pleural tuberculosis is persistent and prolonged. The onset of the disease is subacute or low-symptomatic. Symptoms of intoxication and fever prevail.
A special kind of exudative tuberculous pleurisy is the empyema of the pleura. The clinical picture is characterized by severe intoxication: body temperature above 39 ° C, chills, night sweats, pronounced weakness. Dyspnea and tachycardia gradually increase, pulling pains in the side appear, body weight decreases. The formation of a bronchopleural fistula is possible, as evidenced by coughing up purulent exudate. A long-existing purulent pleurisy can be complicated by a phlegmon of the chest wall, the formation of a pleurothoracic fistula, amyloidosis of internal organs.
Diagnostics
Various forms of tuberculous pleurisy have their own characteristic physical, auscultative, radiological and laboratory data. Therefore, at the slightest suspicion of tuberculosis etiology of the disease, the patient should be consulted by a phthisiologist.
- The allergic nature of tuberculous pleurisy is indicated by pronounced eosinophilia in the blood and pleural exudate. During diagnostic pleural puncture, serous exudate is obtained, but MBT is usually not detected in it. When conducting a videothoracoscopy, hyperemia of pleural leaflets can be determined.
- With fibrinous pleurisy, the affected side of the chest lags behind when breathing, the pleural friction noise is heard, the shortening of the percussion sound is determined. During lung x-ray, pleural layers (mooring) are detected. According to ultrasound of the pleural cavity, exudate is not detected or is determined in a meager amount.
- A different picture is typical for exudative tuberculous pleurisy. Physical examination reveals smoothness (with a large volume of exudate – bulging) of the intercostal space, dulling of percussion sound over the area of exudate accumulation, displacement of mediastinal structures in a healthy direction. In the acute phase, changes in the hemogram are characterized by significant leukocytosis and acceleration of ESR, lympho- and eosinopenia. X-ray and ultrasound examination determines the free fluid in the pleural cavity. A detailed assessment of the condition of the lung tissue is possible only after evacuation of the exudate. The diagnosis of purulent pleurisy is confirmed upon receipt of purulent exudate during pleural puncture.
Pleurisy of tuberculous etiology requires differentiation with pleurisy accompanying pneumonia, pleural mesothelioma, lung cancer, PE, congestive heart failure, collagenosis. In doubtful cases, verification of the diagnosis is facilitated by:
- CT of the lungs
- pleuroscopy (thoracoscopy)
- Mantoux test
- fine needle pleural biopsy
- immunological investigations (T-SPOT.TB, QuantiFERON test)
Tuberculous pleurisy treatment
Inpatient treatment. During the period of exudation and fever, bed rest is prescribed. It is recommended to eat with a restriction of salt and liquid, a large amount of protein and vitamins. In any clinical variant of tuberculous pleurisy, therapy with 3-4 anti-tuberculosis drugs is prescribed for at least 9 months. With severe exudation and hyperergia, a course of treatment with corticosteroids is carried out – this allows to stop further accumulation of effusion.
In case of continued exudation, repeated pleural punctures are performed with the introduction of chemotherapy drugs into the pleural cavity. Drainage of the pleural cavity with the imposition of active vacuum aspiration helps to achieve the speedy expansion of the lung and obliteration of pleural leaflets. During the period of exudate resorption, NSAIDs, electrophoresis, respiratory gymnastics are used.
In the presence of a bronchopleural fistula, its surgical closure is required. With tuberculous empyema of the pleura, intrapleural thoracoplasty, pleurectomy with lung decortication can be performed.
Prognosis and prevention
With timely and full-fledged treatment of tuberculous pleurisy, the prognosis is favorable. Mortality from pleural tuberculosis (mainly from chronic pleural empyema) is 1-2%. Patients who have not received treatment, or who have not received it in full, may develop disseminated pulmonary tuberculosis in the next three years. Prevention of tuberculous pleurisy is the same as in other clinical forms of infection (vaccination and tuberculin diagnostics among children and adolescents, preventive fluorography among adults, exclusion of contacts with tuberculosis patients, etc.).
Literature
- Unusual radiographic abnormalities observed during treatment of tuberculous pleural effusion. Cooke NJ, Crompton GK, Horne NW. Tubercle. 1974 Dec;55(4):261-7. link
- On the after-treatment of exudative pleurisy. Eiter E. Wien Med Wochenschr. 1965 link
- Contralateral pleural effusion during chemotherapy for tuberculous pleurisy. Vilaseca J, Lopez-Vivancos J, Arnau J, Guardia J. Tubercle. 1984 Sep;65(3):209-10. link
- Pleural tuberculosis. Lazarus AA, McKay S, Gilbert R. Dis Mon. 2007 Jan;53(1):16-21. link
- Drug resistance in patients with tuberculous pleural effusions. Skouras VS, Kalomenidis I. Curr Opin Pulm Med. 2018 Jul;24(4):374-379. link