Dry (fibrinous) pleurisy: diagnosis

Laboratory diagnosis of dry pleurisy

1. The general analysis of a blood: probably increase in an ESR, a leukocytosis and shift of the leukocytic formula to the left (not a constant sign).
2. General analysis of urine - without pathological changes.
3. Biochemical analysis of blood - it is possible to increase the content of seromucoid, fibrin, sialic acids, alpha2-globulin.

Instrumental diagnosis of dry pleurisy

X-ray examination of the lungs

With fibrinous pleurisy, the high standing of the dome of the diaphragm from the corresponding side can be determined, its lagging behind deep breathing, limitation of the mobility of the lower pulmonary margin and slight turbidity of the part of the pulmonary field. With significant deposits of fibrin, it is sometimes possible to determine an unclear, indistinct shadow along the outer edge of the lung (a rare sign).

Ultrasonography

Using ultrasound, intensive fibrin overlays can be detected on the parietal or visceral pleura. They look like a thickening of the pleura with an uneven, wavy contour, increased echogenicity, a homogeneous structure.

Differential diagnosis of dry (fibrinous) pleurisy

[1], [2]

Intercostal neuralgia

Differences between dry pleurisy and intercostal neuralgia (intercostal neuromyositis) are presented in the table.

Bornholm disease

Bornholm disease (epidemic myalgia) is caused by enteroviruses (most often Coxsackie B). Epidemic outbreaks of the disease are more often observed in the summer-autumn period, individual cases of the disease can develop at any time of the year. Children and young people are more often ill. The disease begins with fever, rhinitis, sore throat when swallowing. Characteristic pain in the chest or upper abdomen, they increase with breathing, movement and are accompanied by a significant tension of the intercostal muscles. Along with this, patients hear a pleural friction noise, which indicates the involvement of the pleura in the inflammatory process. Usually the disease proceeds favorably and ends with recovery after 7-10 days. In some cases, it is possible to damage the heart, the central nervous system.

Differential diagnostic differences between dry pleurisy, intercostal neuralgia, intercostal neuromyositis

Symptoms	Dry Pleurisy	Intercostal neuralgia, intercostal neuromyositis
Conditions of occurrence in the chest	Pain associated with breathing, coughing	The pain is associated with movements, torso torso, excessive physical exertion
Relation of pain to the torso	The pain is strengthened when the body tilts to a healthy side (due to the stretching of the inflamed pleura)	Pain increases when the torso is tilted to the sore side
Palpation of intercostal spaces	Causes mild pain in the listening zone of pleural friction noise	Causes acute intense pain, especially in places of the closest approach of the intercostal nerve and its branches to the surface of the chest: in the spine, at the level of the middle axillary line and at the sternum
Noise of friction of the pleura	Listens in the area corresponding to the deposition of fibrin on the pleural sheets	Absent
Increased ESR	It happens often	Not typical
Increased body temperature	It happens often	Not typical

Diagnosis of Bornholm disease is based on typical clinical manifestations, multiple cases in the summer-autumn season, isolation of the virus from the pharynx and high titers of antiviral antibodies in the blood serum. These same signs make it possible to distinguish Bornholm disease from dry pleurisy.

Differential and diagnostic differences in left-sided paramediastinal pleurisy and fibrinous pericarditis

Symptoms	Left-sided paramedian dry pleurisy	Fibrinous pericarditis
Localization of pain	Primarily on the left side of relative dullness of the heart	Primarily in the precordial region
Increased pain with breathing and coughing	Characteristically	Maybe, but less typical
Localization of the noise of friction	The noise of friction of the pleura or pleuropericardial noise is more clearly defined by the left margin of relative dullness of the heart	The noise of friction of the pericardium is heard in the region of absolute stupidity of the heart and is not carried out anywhere
Dependence of friction noise on the respiration phase	Pleuropericardial noise increases at the height of inspiration, decreases with exhalation and persists with respiratory arrest	The noise of friction of the pericardium is constantly heard regardless of the phases of breathing
Synchronicity of friction noise with the activity of the heart	The noise of friction of the pleura is not synchronous with the activity of the heart, pleuropericardial noise is synchronous with the activity of the heart	Constant synchronic connection of pericardial friction noise with cardiac activity

[3], [4], [5], [6]

Pericarditis

The presence of pain in the left half of the chest, often with irradiation into the precordial region, leads to differential diagnosis of left-sided paramediastinal dry pleurisy and fibrinous pericarditis.

Angina pectoris

Left-sided fibrinous pleurisy should be differentiated with angina due to some similarity of pain syndrome, especially in the paramediac localization of dry pleurisy.

Differential and diagnostic differences in left-sided paramediastinal pleurisy and angina pectoris

Symptoms	Left-sided paramedian dry pleurisy	Angina pectoris
Localization of pain	Primarily on the left side of relative dullness of the heart	Frontal
Conditions of occurrence of pain	Pain intensifies with deep inspiration, coughing	Pain appears and intensifies with physical activity, walking, climbing stairs
Irradiation of pain	Not typical	Characteristic in the left arm, left shoulder, shoulder blade
Noise of friction of the pleura	Characteristic, often audible pleuropericardial noise	Not typical
The stopping effect of nitroglycerin	Absent	Very characteristic
ECG	Without significant changes	Ischemic changes

[7], [8], [9], [10], [11], [12]

Myocardial infarction

Differential and diagnostic differences between paramediastinal pleurisy and myocardial infarction are presented in the table.

Acute appendicitis

Diaphragmatic pleurisy manifests itself mainly in the upper parts of the right side of the abdomen, but pains often radiate to the right iliac region and "simulate" appendicitis. Appendicitis is characterized by the following symptoms:

• Symptom Schetkina-Blumberga (the appearance of pain with a jerky withdrawal of the hand, immersed in the abdominal cavity)
• The symptom of the roving (the appearance or strengthening of pain in the right iliac region with pressure or soft tremors with the palm in the left ileal region)
• Symptom Sitkovsky (increased pain in the right iliac region when the patient is on the left side, which is due to the tension of the mesentery of the inflamed caecum)
• Symptom Bartamier-Michelson (increased pain during palpation of the right iliac region in the patient's position on the left side)
• Symptom Obraztsova (pain intensification in the right iliac region, if slightly press down the abdominal wall and force the patient to lift the straightened right leg

[13], [14], [15]

Stomach ulcer and duodenal ulcer

Carrying out differential diagnostics of diaphragmatic pleurisy and peptic ulcer of stomach and duodenum, it should be taken into account that peptic ulcer disease is associated with the appearance of pain with food intake (0.5-1 hour after eating with stomach ulcer, 1.5-2 hours after eating and on an empty stomach - with an ulcer of 12 duodenum); heartburn; belching sour; vomiting that brings relief; a positive symptom of Mendel - local percussive soreness, respectively, localization of the ulcer. The diagnosis is easily verified with the help of fibrogastroscopy. For diaphragmatic pleurisy is not characteristic of the relationship of pain to food intake, there are no "hungry" pain.

Spontaneous pneumothorax

The need for differential diagnosis of these diseases is due to the fact that the characteristic sign of both diseases is intense pain in the chest.

Differential diagnostic differences between fibrinous pleurisy and spontaneous pneumothorax

Symptoms	Fibrinous pleurisy	Spontaneous pneumothorax
Circumstances preceding the development of the disease	Often, infectious-inflammatory diseases of the upper respiratory tract, pneumonia	Intensive physical activity, coughing, sudden movements
Characteristics of pain	Sudden intense pain in the chest, worse with breathing, coughing, sneezing. Irradiation of pain is not typical for paracostal pleurisy	A sudden acute pain in the chest with irradiation in the neck, arm, sometimes in the epigastric region. Increased pain with breathing is less common than with fibrinous pleurisy
Percussion of the lungs	Usually, there is no change in percussion sound (except for parapneumonic tuberculosis, tumoral pleurisy)	Tympanitis
Noise of friction of the pleura	Listens	Absent
Vesicular breathing	Weakened	Over the tympanite zone is not listened to
Characteristic radiographic signs	High diaphragm dome standing with Of the corresponding side, lagging behind it during breathing, restriction of mobility of the lower pulmonary margin	Complete or partial collapse of the lung, displacement of the mediastinum in the opposite direction, the presence of air in the pleural cavity

Diskopathy of the thoracic spine

The thoracic fossa (osteochondrosis of the intervertebral discs) is also manifested by pain in the chest, often similar to pain in fibrinous pleurisy. The characteristic features of pain in the discopathy of the thoracic spine are the sudden occurrence of pain with a sudden change in body position, sharp extension, slopes, bends of the trunk; a significant reduction in its prone position, in a relaxed state, as well as in the extension of the spine; often encircling the nature of pain; absence of pleural friction noise. Radiography of the thoracic spine reveals osteochondrosis of intervertebral discs.

[16], [17]