Symptoms of tuberculous pleurisy

Distinguish pleurisy dry (fibrinous) and exudative.

Dry pleurisy in children and adolescents can be a manifestation of active, and most often primary or disseminated pulmonary tuberculosis as a result of lymphohematogenous spread of infection. The clinical picture of dry pleurisy is characterized by the appearance of pain in the chest, subfebrile or febrile body temperature, complaints of intoxication (general weakness, malaise, poor appetite, weight loss). If the symptoms of lung or intracardiac lymph nodes are at the forefront, then it is not always possible to recognize the beginning of pleurisy. Pain is the main symptom of dry pleurisy, intensified with deep breathing, coughing, sudden movements, are more often localized in the lower lateral sections of the thorax and can irradiate both upward (to the neck, shoulder) and downward (into the abdominal cavity), simulating the "sharp abdomen" . In order to distinguish pain from dry pleurisy from pain in intercostal neuralgia, the following symptom should be remembered: when the pleurisy is dry, the child tries to lie on the sore side, the pain intensifies when it tilts to the healthy side, and with intercostal neuralgia - into the patient. Percutaneously determine a certain limitation of mobility of the lower pulmonary margin on the side of the lesion. When auscultation in a restricted area, a characteristic noise of friction of the pleura is heard, which is usually determined in both phases of respiration. Radiologically dry pleurisy, as a rule, does not reveal, in fluoroscopy, the limitation of the mobility of the diaphragm can be noted. In the future, if the fibrinous layers were significant, spikes and infection of the rib-diaphragmatic sinus may appear. In the blood, changes are usually not noticed, the ESR may increase moderately. Tuberculin samples are positive or hyperergic. If specific changes in the lungs do not determine, then the history, the characteristic noise of friction of the pleura, the tuberculin sensitivity and the duration of the disease acquire decisive importance.

The clinical picture of exudative pleurisy largely depends on its localization. The effusion can be free or coagulated. Topography distinguishes apical pleurisy, costal, interlobar. Mediastinal, diaphragmatic panpleuritis. Clinical manifestations of exudative pleurisy are possible in the form of an acute onset with a rapid increase in body temperature, dyspnea, dry cough, chest pain (the most frequent variant) or asymptomatic course when pleurisy is detected accidentally during examination for upper respiratory tract infection and other diseases a rare variant of specific pleurisy is more common in adolescents). The clinical picture of apical, costal and diaphragmatic exudative pleurisy is characterized by pain on the corresponding side, high body temperature (38-39 ° C), weakness, constant coughing. With the accumulation of exudate pain can completely disappear, the patient is concerned only with the heaviness in the side. The amount of exudate can be from 300 ml to 2 liters and more. The child is pale, sluggish, dyspnea, cyanosis, quick breathing, quickening of the pulse, position forced - on the sore side. With bone-diaphragm pleurisy, severe pain in the hypochondrium may occur, and sometimes vomiting, difficulty swallowing, and symptom frenicus. This is due to the fact that the diaphragmatic pleura is provided with sensitive branches from two sources: the diaphragmatic nerve and the six lower intercostal nerves.

When examining the chest reveals the smoothness of the intercostal space on the side of the lesion, its lagging behind during breathing. During percussion, dullness (sometimes femoral stupidity) over the fluid, Ellis-Damois-Sokolov line, and auscultation-weakening or absence of respiratory noises are revealed. At the upper boundary of the fluid, the pleural friction noise can be heard. Above the level of fluid due to collapse of the lung sometimes listen to bronchial breathing, silent damp rales. An important sign of fluid accumulation in the pleural cavity is the weakening or absence of vocal tremor. When the liquid is entrapped, the physical data depend on the localization of the process. So, with inter-fronts. Mediated and mediastinal and diaphragmatic effusions, deviations from the norm may not be detected. In peripheral blood, the most constant sign is an increase in ESR, often significant. The number of leukocytes is moderately increased, a stab-shift shift of the leukocyte formula is possible. Absolute lymphocytopenia is characteristic. In the study of sputum (when the child identifies it), it is found to be of a mucous nature, the amount of white blood cells in the sputum is small. A Mantoux test with 2 TE is often hyperergic.

Exudate in tuberculous pleurisy macroscopically in most cases is a transparent serous fluid with various shades of yellow, relative density of exudate 1015 and higher, protein content is 30 g / l or more, the reaction of Rivalta is positive. Exudate is lymphocytic (90% of lymphocytes and more). Sometimes exudate happens to be eosinophilic (20% of eosinophils and more).

X-ray picture with free costal pleurisy is characterized by the fact that the pleural effusion has an arcuate upper border, its projection is from the lateral sections of the thoracic wall from top to bottom and medially. When the patient is in the vertical position, triangular uniform shading is defined in the lower anterior part of the pulmonary field with an oblique medial border. Mediastinum is displaced in the opposite direction, the diaphragm on the side of the effusion is located below the usual level. The degree of accumulation of fluid can be different, up to the total filling of the pleural cavity and complete shading of the lung.

Interdollar pleurisy in children is more often complicated by tuberculosis of the intrathoracic lymph nodes. If the clinical picture of these pleurisies is usually low-symptomatic and depends on the amount of effusion localization, then x-ray diagnosis is decisive and has features. In the anterior and lateral projections, along the course of the interlobar fissure, a lenticular, fusiform or ribbon-like shadow is visible, and in the lordotic position it retains an oval shape. This shadow of the imprisoned inter-pediatric pleurisy located in the lower segment of the interlobar gap differs from the shadow of the atelectasis of the middle lobe, which in the lordotic position acquires a typical triangular shape as the base to the mediastinum. With resorption of exudate in place of the interlobar slot, thin linear shadows of the compacted pleural sheets can be seen.

Mediastinal pleurisy usually occurs as a complication of the primary tuberculosis complex and lesions of tracheobronchial and bronchopulmonary lymph nodes. In this exudate accumulates between the pulmonary and mediastinal pleura. Most often it occurs as a complication of the primary tubercular complex or bronchoadenitis in young children. The course of pleurisy is prolonged, accompanied by pain behind the sternum, paroxysmal cough and symptoms of tuberculous intoxication. However, timely diagnosis and quality treatment lead to resorption of the exudate within 2-8 weeks. Doctors need to take into account that, despite rapid dynamics, it is possible to develop or a new outbreak of pulmonary tuberculosis, which dictates the need for long-term treatment and supervision of such children.