Pleural syndrome. Tubercular pleurisy

Transcription

1 Pleural syndrome. Tubercular pleurisy Dr Etienne Leroy-Terquem Centre hospitalier de Meulan les Mureaux. France French-cambodian association for pneumology (OFCP)

2 Pleurisy: Findings of fluid between visceral and parietal membrane lung viscéral serous membrane pariétal serous membrane

3 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

4 Small abundance (500 to 700 cc)

5 Medium abundance

6 Abundant pleural effusion

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8 Pleurisy Pushing back Left atelectasis Retraction

9 Pleural syndrome Abundant effusion - Overlap of all the hemi thorax - The médiastinum is pushed back - The diaphragm is thrown down

10 Left pleurisy + left atelectasis (pleural effusion associated with retraction) Pleural effusion is not retractile, except if there is an associated atelectasis

11 The decubitus position modify radiological picture of the pleurisy

12 A pleurisy, even if the abundance is small, is likely to involve decubitus passive atelectasis

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14 Do not confound pleurisy and ascension of the diaphragm

15 Do not confound pleurisy and diaphragmatic hernia

16 Do not confound pleurisy and diaphragmatic hernia

17 Effusion in fissura Front view: Effusion in the small and in the big fissura Profil: opacities with shuttle form

18 Effusion in the small fissura

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20 encysted pleurisy

21 Woman, 71 y. old, worsening condition and dyspnea Puncture: serofibrinous fluid. Biopsy: métastasis from adénocarcinoma.

22 Pleural tuberculosis

23 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

24 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.

25 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

26 Man 20 y. old! t 38 C, cough, and right latero-thoracic paint, dyspnea! OFCP 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!

27 Tubercular pleurisy in a patient of 28 y. old, HIV +

28 Evolution during 5 monthes of a TB pleurisy under treatment

29 AFB négative in sputums but positive cultures in sputums and pleural fluid. Small nodules in right axillar area.

30 Right pleurisy associated with apical infiltrate:

31 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

32 But tubercular pleurisy is not always serofibrinous: The effusion can be gaseous: pneumothorax The effusion can be purulent et gaseous: Pyopneumothorax

33 Bilatéral TB under treatment OFCP OFCP Rupture of a small TB cavity In the under pleural area

34 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.

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37 TB pyo-pneumothorax, with a thick pleural wall The treatment of these pyo-pneumothorax is difficult and often needs Thoracic surgery OFCP

38 Tthoracoplasty is necessary for treatment of these pyo-pneumopthorax

39 OFCP OFCP TB péricarditis after péricardic puncture Les péricardites TB pericarditis are frequent in countries with hight incidence

40 OFCP

41 After pericardic puncture OFCP

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43 Pneumo pericarditis, after drainage of the fluid

44 Péricarditis cardiomégaly with left ventricle hypertrophy OFCP