Differential diagnosis of exudate and transudate

Pleural effusion is the accumulation of pathological fluid in the pleural cavity with inflammatory processes in adjacent organs or pleural sheets or when the ratio between colloid osmotic pressure of the blood plasma and hydrostatic pressure in the capillaries is disturbed.

Pleural fluid of inflammatory origin is exudate. The fluid accumulated due to the disbalance between the colloid osmotic pressure of the blood plasma and the hydrostatic pressure in the capillaries is a transudate.

After receiving pleural fluid, it is necessary to determine, depending on the color, transparency, relative density, biochemical and cytological composition, whether the effusion is exudate or transudate.

Differential-diagnostic differences between pleural exudate and transudate

Symptoms	Exudate	Transudate
Onset of disease	Acute	Gradual
The presence of pain in the chest at the onset of the disease	Characteristically	Not typical
Increased body temperature	Characteristically	Not typical
The presence of common laboratory signs of inflammation (increased ESR, "biochemical inflammatory syndrome" *)	Characteristic and very pronounced	Not typical, sometimes the general laboratory signs of inflammation can be, but, as a rule, weakly expressed
Appearance of liquid	Muddy, not quite transparent, intense lemon yellow color (serous and serous-fibrinous exudate), often hemorrhagic, can be purulent, putrefactive with an unpleasant odor	Transparent, slightly yellowish, sometimes colorless liquid, odorless
Change in the appearance of pleural fluid after standing	Mutnets, more or less abundant flakes of fibrin fall out. Serous-purulent exudate is divided into two layers (upper - serous, lower - purulent). The effusion coagulates when standing	Remains transparent, the sediment is not formed or it is very gentle (in the form of a cloud), there is no inclination to coagulation
Protein content	> 30 g / l	<20 g / l
LDH	> 200 U / l or> 1.6 g / l	<200 U / l or <1.6 g / l
Pleural fluid protein / blood plasma protein	> 0.5	<0.5
LDH pleural fluid / LDH plasma blood	> 0.6	<0.6
The level of glucose	<3.33 mmol / l	> 3.33 mmol / l
The density of the pleural fluid	> 1.018 kg / l	<1.015 kg / l
Cholesterol / blood serum cholesterol	> 0.3	<0.3
Rivalta trial **	Positive	Negative
The number of leukocytes in the pleural fluid	> 1000 in 1 mm 3	<1000 in 1 mm 3
The number of erythrocytes in the pleural fluid	Variable	<5000 in 1 mm 3
Cytological examination of pleural fluid sediment	Neutrophilic leukocytosis predominates	A small amount of corrupted mesothelium

Notes:

* biochemical syndrome of inflammation - an increase in the blood serumucoid, fibrin, haptoglobin, sialic acids - non-specific indicators of the inflammatory process;

** Rivalta test - a test for determining the presence of protein in the pleural fluid: water in a glass cylinder is acidified with 2-3 drops of 80% acetic acid, then the test pleural fluid is dripped dropwise into the resulting solution. If it is exudate, then after each drop in the water a cloud in the form of cigarette smoke stretches, with transudate this trace does not.

After clarifying the nature of the effusion (exudate or transudate), it is advisable to take into account the most common causes of exudate and transudate, which to some extent facilitates the further differentiation of pleural effusions.

The nature of exudate is determined not only by the variety of causes, but also by the ratio of accumulation and resorption of effusion, the duration of its existence:

• moderate exudate and good resorption - fibrinous pleurisy;
• exudation exceeds suction of exudate - serous or serous-fibrinous pleurisy;
• infection of exudate with pyogenic microflora - purulent pleurisy (empyema of the pleura);
• the rate of resorption exceeds the rate of exudation - the formation of adhesions in resorption;
• carcinomatosis, pleural mesothelioma, lung infarction and trauma, pancreatitis, hemorrhagic diathesis, anticoagulant overdose - hemorrhagic effusion;
• prevalence of allergic processes - eosinophilic exudate;
• traumatization of the thoracic duct in case of tumor or tuberculous lesion - chyleous exudate;
• chronic perennial course of exudative pleurisy, in particular, with tuberculosis - cholesteric effusion.

Causes of pleural effusion (SL Malanichev, GM Shilkin, 1998, modified)

Type of effusion	Main reasons	Less frequent causes
Transudate	Congestive heart failure	Nephrotic syndrome (glomerulonephritis, amyloidosis of the kidneys, etc.); cirrhosis of the liver; myxedema, peritoneal dialysis
Exudates inflammatory infectious	Parapneumonic effusion; tuberculosis; bacterial infections	Subdiaphragmatic abscess; Intrahepatic abscess; Viral infection; fungal lesions
Inflammatory non-infectious exudates	Pulmonary embolism	Systemic diseases of connective tissue; pancreatitis (enzymatic pleurisy); reaction to medicines; asbestosis; Post-infarction syndrome Dressler; syndrome of "yellow nails" *; uremia
Tumor exudates	Cancer metastases; leukemia	Mesothelioma; Meigs syndrome "
Hemotorax	Injury; metastasis of cancer; pleural carcinomatosis	Spontaneous (in connection with hemostasis disorders); rupture of the vessel in pleural spikes with spontaneous pneumothorax; aortic aneurysm rupture into the pleural cavity
Chilothorax	Lymphoma; traumas of the thoracic lymphatic duct; carcinoma	Lymphangioleiomyomatosis

Notes:

* Syndrome of "yellow nails" - congenital hypoplasia of the lymphatic system: characterized by thickened and curved nails of yellow color, primary lymphatic edema, less exudative pleurisy, bronchiectasis.

** Meigs syndrome - pleurisy and ascites in carcinoma of the ovaries.

Tuberculous pleurisy

Tuberculosis is a common cause of exudative pleurisy. Most tuberculous pleurisy develops against a background of any clinical form of pulmonary tuberculosis (disseminated, focal, infiltrative), bronchoadenitis, or primary tuberculosis complex. In rare cases, tuberculosis exudative pleurisy can be the only and primary form of pulmonary tuberculosis. According to AG Khomenko (1996), there are three main variants of tuberculous pleurisy: allergic, perifocal and tuberculosis of the pleura.

Allergic pleurisy

Is hyperergic. It is characterized by the following clinical features:

• acute onset with pain in the chest, high body temperature, rapid accumulation of exudate, pronounced dyspnea;
• rapid positive dynamics (exudate resolves within a month, rarely - longer);
• increased sensitivity to tuberculin, which causes a positive tuberculin test;
• eosinophilia in peripheral blood and a significant increase in ESR;
• exudate mainly serous (in the early stages may be serous-hemorrhagic), contains a large number of lymphocytes, sometimes - eosinophils;
• a frequent combination with other manifestations due to hyperergic reactivity - polyarthritis, erythema nodosum;
• absence of mycobacterium tuberculosis in pleural effusion.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Perifocal pleuritis

Inflammatory process in pleural sheets in the presence of pulmonary tuberculosis - focal, infiltrative, cavernous. Particularly easy perifocal pleurisy occurs with subpleural location of the pulmonary tuberculosis focus. Features of perifocal pleurisy are:

• prolonged, often relapsing course of exudative pleurisy;
• formation of a large number of pleural cleavage (adhesions) in the phase of resorption;
• serous nature of exudate with a large number of lymphocytes and high lysozyme content;
• absence of mycobacteria in exudate;
• presence of one of the forms of tuberculosis lesions of the lungs (focal, infiltrative, cavernous), which is diagnosed by X-ray examination after preliminary pleural puncture and evacuation of exudate;
• sharply positive tuberculin tests.

Tuberculosis of the pleura

Immediate defeat of the pleura by the tuberculosis process, may be the only manifestation of tuberculosis or be combined with other forms of pulmonary tuberculosis. Tuberculosis of the pleura is characterized by the appearance of multiple small foci on pleural sheets, but it is possible that there are large foci with caseous necrosis. In addition, the exudative inflammatory reaction of the pleura develops with the accumulation of effusion in the pleural cavity.

Clinical features of pleural tuberculosis:

• long-term course of the disease with persistent accumulation of effusion;
• exudate can be serous with a large number of lymphocytes and lysozyme (with the development of pleurisy due to the colonization of the pleura and the formation of multiple foci) or neutrophils (with caseous necrosis of certain large foci). With widespread caseous lesions of the pleura, the exudate becomes serous-purulent or purulent (with a very extensive lesion) with a large number of neutrophils;
• in the pleural effusion, mycobacterium tuberculosis is detected, both in microscopy and in the sowing of exudate.

With the widespread caseous necrosis of the pleura, the disintegration of large tuberculosis foci on the pleura and blockade of the mechanisms of resorption of exudate, purulent tuberculous pleurisy (tuberculosis empyema) can develop. In this case, the clinical picture is dominated by a very pronounced intoxication syndrome: body temperature rises to 39 C and above; there is a pronounced sweating (especially characteristic of perspiring sweat at night); patients lose weight. Characteristic of shortness of breath, significant weakness, pain in the side, pronounced leukocytosis in peripheral blood, increased ESR, often lymphopenia. Pleural puncture reveals a purulent exudate.

Tuberculosis pleural empyema can be complicated by the formation of a bronchopleural or thoracic fistula.

When the diagnosis of tuberculous pleurisy is made, the history (presence of pulmonary tuberculosis or other localization in the patient or immediate relatives), detection of mycobacterium tuberculosis in exudate, detection of extrapleural forms of tuberculosis, specific results of pleural biopsy and thoracoscopy data are of great importance. Typical signs of tuberculosis of the pleura during thoracoscopy are the prozoidal tubercles on the parietal pleura, extensive areas of caseous disease, pronounced inclination to the formation of pleural adhesions.

Parapneumonic exudative pleurisy

Bacterial pneumonia is complicated by exudative pleurisy in 40% of patients, viral and mycoplasma - in 20% of cases. Particularly often complicated by the development of exudative pleurisy streptococcal and staphylococcal pneumonia.

The main characteristic features of parapneumonic exudative pleurisy are:

• acute onset with severe pain in the chest (before the appearance of effusion), high body temperature;
• prevalence of right sided effusions;
• authentically high frequency of bilateral effusions in comparison with tuberculous exudative pleurisy;
• the development of exudative pleurisy on the background of diagnosed pneumonia and the radiological-determined pneumonic focus in the lung parenchyma;
• high frequency of purulent exudates with a large number of neutrophils, however, with an early and adequate antibiotic therapy, the exudate may be predominantly lymphocytic. A number of patients may have hemorrhagic exudate, in isolated cases - eosinophilic or cholesteric effusion;
• significant leukocytosis in the peripheral blood and an increase in ESR over 50 mm h (more often than with other etiology of pleurisy);
• rapid onset of a positive effect under the influence of adequate antibiotic therapy;
• detection of the pathogen in the sweat (by sowing exudate on certain nutrient media), the mycoplasmal nature of exudative pleurisy is confirmed by the growth in the blood of antibody titers to mycoplasma antigens.

Exudative pleurisy of fungal etiology

Pleural effusions of fungal etiology account for about 1% of all effusions. Fungal exudative pleurisies develop mainly in individuals with significant impairment of the immunity system, as well as those receiving immunosuppressants, glucocorticoid drugs and in patients with diabetes mellitus.

Exudative pleurisy causes the following types of fungi: aspergillus, blastomycete, coccidoid, cryptococcus, histoplasm, actinomycetes.

Fungal exudative pleurisies downstream are similar to tuberculous. Usually pleural effusion is combined with a fungal lesion of the lung parenchyma in the form of focal pneumonia, infiltrative changes; abscesses and even cavities of decay.

Pleural effusion in fungal exudative pleurisy is usually serous (serous-fibrinous) with marked predominance of lymphocytes and eosinophils. When a breakthrough into the pleural cavity of the subcapsular abscess, the effusion becomes purulent.

The diagnosis of fungal exudative pleurisy is verified by the repeated detection of micelles of fungi in the pleural fluid, in sputum, also by repeated isolation of the fungus culture during the sowing of exudate, pleural biopsy, sputum, pus from the fistula. According to the data of KS Tyukhtin, SD Poletaeva exudate fungal culture with blastomycosis is isolated in 100% of patients, cryptococcosis - in 40-50%, coccidiomycosis - in 20% of patients, and when plaque biopsy is sown - almost in all cases.

In addition, great importance in the diagnosis of fungal exudative pleurisy have serological methods for the study of blood serum and exudate - high titers of antibodies in the complement fixation reaction, agglutination-precipitation with antigens of certain fungi. Antibodies can also be detected using immunofluorescence and radioimmunoassay methods. A definite diagnostic value can have positive skin tests with the introduction of allergens of the corresponding fungus.

[10], [11]

Aspergillus pleurisy

Aspergillus exudative pleurisy most often develops in patients with therapeutic artificial pneumothorax (especially in the case of bronchopleural fistula formation) and in patients who underwent resection of the lung. Pleural fluid may contain brown lumps in which aspergillus is found. Characteristic is also the presence in the sweat of calcium crystals of oxalate

The diagnosis is confirmed by the detection of aspergillus in a culture of pleural effusion when sowing on special media, the detection of antiaspergillas in pleural effusion using the radioimmunoassay method.

[12], [13]

Blastomycosis pleurisy

Blastomycosis exudative pleurisy in the clinical picture resembles tuberculous pleurisy. In the lung parenchyma, infiltrative changes are often observed. Exudate is dominated by lymphocytes. With the help of microscopic analysis, it is possible to detect typical yeast fungi Blastomyces dermatitidis, the culture of pleural fluid on blastomycosis is always positive. In biopsies of the pleura, unclear granulomas are detected.

[14]

Coccidioidosis pleurisy

Exudative pleurisy in coccidioidosis in 50% of cases is accompanied by infiltrative changes in the lungs, nodular or multiform erythema, eosinophilia in the peripheral blood. Pleural effusion is an exudate, it contains many small lymphocytes and a high level of glucose is detected, eosinophilia of effusion is not characteristic.

With pleural biopsy, caseous and noncaseating granulomas are found. Sowing pleural biopsies for coccidiosis gives a positive result in 100% of cases, and sowing of effusion - only in 20% of cases. All patients have a positive skin test on Coccidioides immitis. After 6 weeks from the onset of the disease, antibodies in a 1:32 titer are detected with the complement fixation reaction.

[15], [16]

Cryptococcus pleurisy

Cryptococcusneotormans is spread everywhere and lives in the soil, especially if it is contaminated with pigs' excrement. Exudative pleurisy of cryptococcal origin more often develops in patients suffering from hemoblastoses, and usually it is one-sided. In most patients, along with pleural effusions, lung parenchymal involvement is detected in the form of interstitial infiltration or nodal formation. Pleural effusion is an exudate and contains many small lymphocytes. High levels of cryptococcal antigens are found in the pleural fluid and serum. The cryptococcosis of pleurisy is confirmed by the positive result of pleural fluid and pleural biopsy of the pleura or lungs on cryptococci.

[17], [18], [19], [20]

Histoplasmic Pleurisy

Hystoplasma capsulatum is common throughout the soil, the formation of pleural effusion is rare. Usually exudative pleurisy due to histoplasm has a subacute course, at the same time changes in the lungs appear in the form of infiltrates or subpleural nodes.

Pleural effusion is an exudate and contains many lymphocytes. With pleural biopsy, a noncaseating granuloma is found. The diagnosis is verified by obtaining a histoplasmic culture by sowing pleural fluid, sputum, a pleural biopsy, and also with a biopsy material. There can be high titres of antibodies to histoplasm in the blood of patients, which is determined by the method of immuno-electrophoresis.

Actinomycotic pleurisy

Actinomycetes are anaerobic or microaerophilic Gram-positive bacteria, normally found in the oral cavity. Infection with actinomycetes occurs usually from infected gums, carious teeth, tonsils of the patient himself. Actinomycosis is characterized by the formation of abscesses, the transition of the inflammatory process to the chest wall with the formation of pleurotoral fistulas. Possible formation of peripheral cutaneous, subcutaneous and muscle abscesses.

A characteristic feature of pleural exudate in actinomycosis is the presence of sulfur granules with a diameter of 1-2 mm - these are lumps of fine strains of bacteria. The diagnosis of actinomycotic exudative pleurisy is established by the detection of Actinomyces Israeli when plaque fluid is sown to special media. It is also possible to stain smears of exudate by Gram and detect subtle gram-positive threads with long branches, which is characteristic of actinomycosis.

[21], [22]

Pleurisy of parasitic etiology

The most common exudative pleurisy is observed with amoebiasis, echinococcosis, paragonimosis.

Amoebic pleurisy

The causative agent of amebiasis is Entamoeba histolytica. Amoebic exudative pleurisy occurs, as a rule, with a breakthrough into the cavity of the pleura through the diaphragm of the amoebic liver abscess. Thus there is a sharp pain in the right hypochondrium and right half of the chest, shortness of breath, the body temperature rises significantly, which is accompanied by chills. The patient develops purulent pleurisy. Pleural effusion is exudate, has a characteristic form of "chocolate syrup" or "herring oil" and contains a large number of neutrophilic leukocytes, hepatocytes, as well as small solid insoluble particles of the hepatic parenchyma. In 10% of patients exudates show amoebas. With the help of immunoradiological methods, high titres of antibodies to amoebae can be detected. Ultrasound and computerized tomography of the liver can diagnose liver abscess.

[23], [24]

Echinococcal pleurisy

Echinococcal exudative pleurisy develops with the breakthrough of the echinococcal cyst of the liver, lung or spleen into the pleural cavity. Very rarely, the cyst develops primarily in the pleural cavity itself. At the time of the breakout, there is a very sharp pain in the corresponding half of the chest, severe dyspnea, anaphylactic shock may develop in response to the ingestion of echinococcal antigens. With a breakthrough into the pleural cavity of the festering echinococcal cyst, an empyema of the pleura is formed.

Pleural effusion is an exudate and contains a large number of eosinophils (with secondary infection of the fluid - neutrophils), as well as scolexes with hooks of echinococci, the shell of the echinococcal cyst. In the pleural biopsy specimens are also identified with hooks of the parasite.

A skin test with an echinococcal antigen (Katsoni test) is positive in 75% of cases. Antibodies to the echinococcal antigen in the blood are also detected with the help of the complement fixation test (Weinberg test).

[25], [26],

Paragonyptic pleurisy

Paragonimosis develops when the parotymus is infested with Parostimus westermani or miyazflkii. A person becomes infected by eating raw or undercooked crabs, crayfish containing parasitic larvae. The larvae enter the human intestine, then penetrate the abdominal cavity through the intestinal wall, then migrate to the diaphragm, through it enter the pleural cavity and then through the visceral pleura into the lungs. In the lungs, the larvae turn into adult pulmonary flukes, which for many years parasitize the lungs and produce about 10,000 eggs a day.

The development of exudative pleurisy is extremely characteristic of paragonimosis. At the same time, many patients have focal and infiltrative changes in the lungs. The characteristic features of paragonytic exudative pleurisy are:

• a prolonged course with the formation of pronounced pleural fusion;
• a low content of glucose in the pleural exudate and a high level of lactate dehydrogenase and IgE, the IgE content being even higher than in the blood;
• pronounced eosinophilia of the pleural fluid;
• detection in pleural fluid, sputum, feces of pulmonary flukes, coated with a membrane;
• positive skin test with pulmonary fluke antigen;
• high titers of antibodies in the blood.

Endemic foci of infection are located in the Far East.

Pleurisy of tumor etiology

Among all pleural effusions, tumor effusions are 15-20%. According to the data of Light (1983), 75% of malignant pleural effusions are due to lung cancer, breast cancer, lymphoma. In the first place among all tumors that cause the appearance of pleural effusion is lung cancer. According to NS Tyukhtin and SD Poletayev (1989), lung cancer (usually central) is diagnosed in 72% of patients with tumor pleurisy.

The second most common cause of malignant exudative pleurisy is metastatic breast cancer, the third is malignant lymphoma, lymphogranulomatosis. In other cases, we are talking about pleural mesothelioma, ovarian and uterine cancer, cancer of various parts of the gastrointestinal tract and tumors of other localizations.

The main mechanisms for the formation of pleural effusion in malignant tumors are (Light, 1983):

• tumor metastasis to the pleura and a significant increase in the permeability of its vessels;
• obstruction of lymphatic metastases and a sharp decrease in fluid resorption from the pleural cavity;
• defeat of lymph nodes of the mediastinum and reduction of outflow of a lymph from a pleura;
• obstruction of the thoracic lymphatic duct (development of chylothorax);
• development of hypoproteinemia due to cancer intoxication and impaired protein-educational function of the liver.

Pleural effusion of tumor nature has quite distinctive features:

• gradual development of effusion and the rest of clinical symptoms (weakness, anorexia, weight loss, shortness of breath, cough with separation of sputum, often with an admixture of blood);
• detection of a sufficiently large amount of fluid in the cavity of the pleura and its rapid accumulation after the performed pleurocentesis;
• detection of signs of bronchogenic carcinoma, an increase in mediastinal lymph nodes, metastatic pulmonary disease with the help of computer tomography or radiography (after preliminary removal of exudate from the pleural cavity);
• hemorrhagic character of effusion; with malignant lymphoma - often there is chylothorax;
• compliance of pleural effusion with all exudate criteria and very often low glucose content (the lower the level of glucose in the exudate, the worse the prognosis for the patient);
• detection of pleural effusion of malignant cells; it is advisable to analyze several pleural fluid samples to obtain more reliable results;
• detection of pleural fluid cancer-embryonic antigen.

In the absence of malignant cells in pleural exudate and suspicion of a tumor process, thoracoscopy with pleural biopsy and subsequent histological examination should be performed.

Pleurisy with malignant mesothelioma

Malignant mesothelioma is formed from mesothelial cells lining the pleural cavity. The development of this tumor is particularly affected by persons who work long hours with asbestos. The period between tumor development and the time of onset of contact with asbestos is 20 to 40 years.

The age of patients varies from 40 to 70 years. The main clinical symptoms of malignant mesothelioma are:

• gradually increasing pain of a permanent character in the chest without a clear connection with the respiratory movements;
• paroxysmal dry cough, constantly increasing shortness of breath, weight loss;
• Pleural effusion is the most common and early emerging symptom of malignant mesothelioma;
• syndrome of compression of the superior vena cava with a growing tumor (edema of the neck and face, widening of the veins in the neck and upper chest, shortness of breath); the germination of the tumor in the pericardium and the walls of the heart cavities leads to the development of exudative pericarditis, heart failure, cardiac arrhythmias;
• characteristic data for computed tomography of the lungs - a thickening of the pleura with an uneven nodular internal border, especially at the base of the lung, in some cases, tumor nodes in the lungs are determined;
• features pleural fluid: yellowish or serous-bloody color; has all the signs of exudate; decrease in glucose and pH; a high content of hyaluronic acid and the associated high viscosity of the liquid; a large number of lymphocytes and mesothelial cells in the sediment of exudate; detection of malignant cells in multiple studies of exudate in 20-30% of patients.

For the final verification of the diagnosis, multiple biopsy of the parietal pleura, thoracoscopy with biopsy and even diagnostic thoracotomy should be performed.

Pleurisy with Meigs syndrome

Meigs' syndrome is ascites and pleural effusion in malignant tumors of the pelvic organs (ovarian cancer, uterus cancer). In tumors of this localization, a significant ascites develops due to peritoneal carcinomatosis and ascitic fluid seeps through the diaphragm into the pleural cavity. Most often, pleural effusion is observed on the right, but bilateral localization is possible. Pleural effusion can also be caused by tumor metastases to the pleura.

Pleural effusion in Meigs syndrome is an exudate, it can detect malignant cells.

Pleurisy in systemic connective tissue diseases

The most common exudative pleurisy develops with systemic lupus erythematosus. Pleural damage in this disease is observed in 40-50% of patients. Exudative pleurisy is usually bilateral, exudate serous, contains a large number of lymphocytes, it reveals lupus cells, antinuclear antibodies. A characteristic feature of exudative pleurisy in systemic lupus erythematosus is the high efficiency of glucocorticoid therapy. With pleural biopsy, chronic inflammation and fibrosis is found.

With rheumatism, exudative pleurisy is observed in 2-3% of patients, effusion is serous exudate, contains many lymphocytes. Usually pleurisy develops on the background of other clinical manifestations of rheumatism, primarily rheumatic heart disease and is well treatable with nonsteroidal anti-inflammatory drugs. Puncture biopsy reveals a picture of chronic inflammation of the pleura and its fibrosis.

Exudative pleurisy in rheumatoid arthritis is characterized by chronic recurrent course, serous lymphocyte exudate, contains rheumatoid factor in high titers (<1: 320), low glucose, high LDH level, cholesterol crystals are detected.

Exudative pleurisy can develop and with other systemic diseases of connective tissue - scleroderma, dermatomyositis. To establish an etiological diagnosis of exudative pleurisy, diagnostic criteria for these diseases are used and other causes of pleural effusion are excluded.

Pleurisy with acute pancreatitis

Pleural effusion in acute pancreatitis or marked exacerbation of chronic pancreatitis is observed in 20-30% of cases. The pathogenesis of this effusion is the penetration of pancreatic enzymes into the pleural cavity through the lymphatic vessels through the diaphragm.

Pleural effusion corresponds to the signs of exudate, serous or serous-hemorrhagic, is rich in neutrophils and contains a large amount of amylase (more than in serum). Pancreatogenic effusion is more often localized on the left and has a tendency to chronic course.

Pleurisy with uremia

Exudative uremic pleurisy, as a rule, is combined with fibrinous or exudative pericarditis. Exudate serous-fibrinous, is hemorrhagic, contains few cells, usually monocytes. The level of creatinine in the pleural fluid is elevated, but it is lower than in the blood.

Medicinal pleurisy

Pleural effusion may occur with hydralazine, novocainamide, isoniazid, chlorpromazine, phenytoin, sometimes with bromocriptine. To the appearance of effusion leads to long-term treatment with these drugs. Usually there is also a medical lesion of the lungs.

Empyema of the pleura

Empyema of the pleura (purulent pleurisy) - accumulation of pus in the pleural cavity. Empyema of the pleura may complicate the course of pneumonia (especially streptococcal), spontaneous pneumothorax penetrating chest injuries, pulmonary tuberculosis, and may also develop due to the transition of purulent process from neighboring organs (in particular, in the breakthrough of lung abscess)

Empyema of the pleura is characterized by the following clinical and laboratory features:

• there are intense pains in the chest and shortness of breath;
• body temperature rises to 39-40 ° C, there are tremendous chills and profuse sweating;
• there is a swelling of the chest tissue on the side of the lesion;
• marked symptoms of intoxication, suitable pain, general weakness, anorexia, myalgia, arthralgia;
• the analysis of peripheral blood is characterized by significant leukocytosis, a shift of the leukocyte formula to the left, a sharp increase in ESR, toxic granularity of neutrophils;
• characteristic inclination to encapsulation;
• exudate purulent, the cellular composition is characterized by a large number of neutrophilic leukocytes (more than 85% of all cells, an absolute number of neutrophils> 100000 in 1 mm), low glucose (less than 1.6 mmol / l), no fibrinogen (clot is formed), high total LDH (more than 5.5 mmol / l / h), low - LDH1 (less than 20%) and high LDH5 (more than 30%); pH value <7.2;
• from exudate it is possible to allocate culture of a streptococcus, a pathogenic staphilococcus and other originators, especially often anaerobic bacteria.

[27], [28], [29], [30], [31]

Pleural effusions in pulmonary embolism

Pleural effusions are observed with PE in 30-50% of cases. Their appearance is due mainly to the increased permeability of the visceral pleura in the projection of the infarction of the lungs. In 20% of cases pleural effusion in PE is a transudate in other cases it is exudates, sometimes hemorrhagic.

Chilothorax

Chilothorax is a chyleous pleural effusion, i.e. Accumulation in the pleural cavity of lymph. The main causes of chylothorax are damage to the lymphatic duct (during operations on the esophagus, aorta and trauma), as well as blockade of the lymphatic system and veins of the mediastinum with a tumor (most often lymphosarcoma). The development of chylothorax is also extremely characteristic of lymphangioleiomyomatosis.

Quite often the cause of chylothorax can not be established. Such a chylothorax is called idiopathic. According to Light (1983), idiopathic chylothorax in adults is most often the result of minor trauma to the chest lymphatic duct (with coughing, hiccough) that occurs after eating fatty foods. In rare cases, chylothorax develops with cirrhosis of the liver, heart failure.

Clinical manifestations of chylothorax completely correspond to the symptomatology of pleural effusion: patients complain of progressive dyspnea and heaviness in the region of the corresponding half of the thorax. The acute onset of the disease is characteristic. Unlike pleural effusions of a different nature, chylothorax, as a rule, is not accompanied by pains in the chest and fever, since lymph does not irritate the pleura.

At objective research of the patient signs of a pleural effusion are found out, that is confirmed by roentgenological research.

The diagnosis of chylothorax is verified by pleural puncture. The following properties of pleural fluid are characteristic of chylothorax:

• the color is milky white, the liquid is not transparent, cloudy, has no smell;
• contains a large amount of neutral fat (triglycerides) and fatty acids, as well as chylomicrons. It is generally accepted that for chilothorax, the triglyceride content is higher than mg mg%. If the level of triglycerides is less than 50 mg%, then the patient does not have chylothorax. If the content of triglycerides is between 50 and 110 mg%, it is necessary to determine the pleural liquid of lipoproteins by disk-electrophoresis in a polyacrylamide gel. If at the same time in the pleural fluid are found chylomicrons, then this is chylothorax.

Chilothorax is also characterized by the determination of a large number of drops of neutral fat (triglycerides) in microscopy of smears of a chyle liquid after staining with Sudan.

With prolonged existence of chylothorax, especially when a large amount of lymph accumulates in the pleural cavity, one often has to perform pleural punctures due to compression of the lung and displacement of the mediastinum. This leads to the loss of a large amount of lymph and exhaustion of the patient. This is due to the fact that about 2500-2700 ml of liquid containing large amounts of protein, fats, electrolytes and lymphocytes enter the breast lymphatic duct daily. Naturally, frequent removal from the pleural cavity of the lymph leads to a drop in the body weight of the patient and a violation of the immunological status.

[32], [33], [34]

Pseudohileptic pleural effusion

Pseudohileptic pleural effusion (pseudochilothorax) is an accumulation in the pleural cavity of a turbid or milky color of a liquid containing a large amount of cholesterol, without damaging the breast lymphatic duct.

As a rule, patients with pseudochlorothorax have a thickening and often calcification of the pleura as a result of prolonged exposure to the pleural effusion in the pleural cavity. The duration of pleural effusion may range from 3 to 5 years, sometimes even longer. It is assumed that cholesterol is formed in the pleural fluid as a result of degenerative changes in erythrocytes and leukocytes. Pathological changes of the pleura itself disrupt the transport of cholesterol, which leads to its accumulation in the pleural fluid.

It is generally believed that a chile-like effusion in the pleura is observed in patients with a long-lasting pleural effusion. This is most often observed with tuberculosis and rheumatoid arthritis.

The clinical picture of pseudochlorothorax is characterized by the presence of the above described physical and radiological symptoms of pleural effusion. Finally, the diagnosis is established using a pleural puncture and an analysis of the pleural fluid obtained. It is necessary to carry out differential diagnostics between chyleic and pseudo-chyle exudate.

Example of the formulation of the diagnosis

Right-sided lower-lobe pneumonia, severe form. Right-sided pneumococcal serous-fibrinous pleurisy, acute course. Respiratory failure II st.

[35], [36], [37]