Exudative pleurisy - Diagnosis

Examination program for exudative pleurisy

1. General blood and urine analysis.
2. Biochemical blood test: determination of total protein, protein fractions, bilirubin, aminotransferases, cholesterol, glucose, lactate dehydrogenase, seromucoid, haptoglobin, fibrin, sialic acids, lupus cells, rheumatoid factor.
3. X-ray examination of the lungs and computed tomography of the lungs.
4. Ultrasound of the heart.
5. ECG.
6. Pleural puncture and examination of pleural fluid: assessment of physical and chemical properties (determination of protein, lactate dehydrogenase, lysozyme, glucose), cytological and bacteriological examination.
7. Phthisiatrician consultation.

Laboratory data

1. General blood analysis - characteristic neutrophilic leukocytosis with a shift in the leukocyte formula to the left, toxic granularity of leukocytes, a sharp increase in ESR. Many patients have moderately expressed anemia of the normochromic or hypochromic type.
2. General urine analysis - at the height of the disease, some patients are found to have slight proteinuria (usually less than 1), single fresh erythrocytes, and renal epithelial cells.
3. Biochemical blood analysis - the most characteristic are pronounced dysproteinemia (decreased albumin levels and increased a2- and gamma-globulins) and "biochemical inflammation syndrome" (increased levels of sialic acids, seromucoid, fibrin, haptoglobin, the appearance of C-reactive protein). Mild hyperbilirubinemia is often detected, and an increase in alanine and aspartic aminotransferases (as a manifestation of toxic effects on the liver) and lactate dehydrogenase is possible.

Instrumental studies in exudative pleurisy

X-ray examination of the lungs

X-ray examination of the lungs is the leading available method that allows for reliable diagnosis of the presence of effusion in the pleural cavity. However, it should be taken into account that the X-ray method reveals a fluid volume of at least 300-400 ml, and lateroscopy - at least 100 ml. Most often, with free effusion in the pleural cavity, an intense homogeneous darkening with an oblique upper border going downwards and inwards is detected, the mediastinum is shifted to the healthy side. Large effusions cause darkening of a large part of the lung field (2/3-3/4 and even almost the entire lung). With small effusions, the darkening may occupy only the costophrenic sinus, while a high position of the diaphragm dome is noted. Subsequently, as the amount of fluid in the pleural cavity increases, the diaphragm dome descends. Small amounts of fluid in the pleural cavity are detected using the method of lateroscopy, i.e. radiography performed in a horizontal position on the affected side. In the presence of free, non-capsulated fluid, a parietal band-like shadow is detected.

When pleural adhesions are formed, encapsulated effusions occur, which are easily recognized radiologically. Depending on the localization, encapsulated costophrenic, paracostal, apical, paramediastinal, supradiaphragmatic, and interlobar effusions are distinguished.

Encapsulated pleurisy should be differentiated from focal pneumonia, tumors of the lung and mediastinum, pleural adhesions, and, less commonly, echinococcal cysts.

X-ray examination of the lungs should be performed before and after evacuation of effusion from the pleural cavity, which allows us to determine the nature of the pathological process (tuberculosis, pneumonia, tumor) in the corresponding lung. For more accurate diagnosis, it is often necessary to perform computed tomography of the lungs after evacuation of fluid.

Computer tomography of the lungs is used to detect lung pathology in case of widespread pleural damage: pneumonia, lung abscess, bronchogenic cancer and other diseases. With the help of this research method, pleural compactions caused by mesothelioma are well recognized. Encapsulated pleurisy is also well detected.

Ultrasound examination

Free fluid in the pleural cavity is easily detected by ultrasound examination. The examination should be performed not only with the patient lying down, but also sitting and standing. The chest is scanned in longitudinal planes along the axillary, paravertebral, and parasternal lines. At the site of pleural fluid accumulation, the sensor is deployed along the intercostal space and a transverse scan of the area of interest is performed.

V. I. Repik (1997) recommends starting the chest examination from the basal sections with the patient standing. Under the action of gravity, the fluid will first occupy the space between the lungs and the diaphragm in the posterolateral sections. With the patient lying down, the posteroinferior sections of the pleural space should be examined through the liver, if the effusion is localized on the right, and the spleen, if the effusion is localized on the left. In case of encapsulated pleural effusion, a thorough scanning of the area of the suspected pathological process should be performed.

The echographic picture in the presence of pleural effusion depends on the amount of fluid. If the volume of effusion is small, it looks like wedge-shaped echo-negative areas. As the amount of fluid increases, the echo-negative space expands, maintaining a wedge-shaped shape. The pleural sheets are pushed apart by the accumulated fluid. The lung tissue, which looks like a homogeneous echogenic formation, shifts to the root (up and to the center of the chest).

Fibrin threads formed in the exudate are detected during ultrasound examination as echogenic lines of varying length and thickness.

When encapsulated fluid is localized in the interlobar spaces, ultrasound examination may sometimes be ineffective.

Pleural effusion examination

Pleural puncture is of great importance, as it allows not only to confirm the presence of effusion, but also to conduct differential diagnostics. Given this, pleural puncture should be considered a mandatory procedure in patients with exudative pleurisy. The physical and chemical properties of the obtained fluid are assessed, its cytological, biochemical, bacteriological examination is performed, and differential diagnostics are carried out (see below).

Thoracoscopy

The method allows to examine the pulmonary and parietal pleura after evacuation of fluid. The diagnostic value of the method lies, first of all, in the fact that it allows, on the one hand, to state the presence of an inflammatory process of the pleura, on the other hand, to establish the specific or non-specific nature of the lesion. Non-specific inflammatory process of the pleura is characterized by hyperemia, hemorrhages, pleural adhesions, fibrin deposits and, along with these signs, the preservation of airiness of the lung tissue. Specific changes in the form of grayish or yellowish tubercles allow to assume the presence of a tuberculous or tumor process, clarification is made using a biopsy and analysis of clinical and laboratory data.

Thoracoscopic biopsy can obtain a pleural biopsy from the most altered areas of the pleura, which allows, first of all, to make an accurate diagnosis of tuberculosis or a malignant tumor and thus distinguish these diseases from non-specific exudative pleurisy.

Thoracoscopic pleural biopsy is performed under general anesthesia with artificial ventilation.

Surgical pleural biopsy is performed when thoracoscopy is impossible (in the presence of pleural adhesions). Surgical pleural biopsy is performed from a small incision in the corresponding intercostal space.

Puncture biopsy of the pleura is an effective and fairly simple method of etiological diagnostics of pleural effusions. There are practically no contraindications to this method. Characteristic manifestations of non-specific exudative pleurisy are:

• pronounced lymphoid-histiocytic infiltration in the pleura and subpleural layer;
• fibrosis of the thickened pleura.

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