Symptoms of tuberculous pleurisy

A distinction is made between dry (fibrinous) and exudative pleurisy.

Dry pleurisy in children and adolescents may be a manifestation of active, 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 chest pain, subfebrile or febrile body temperature, complaints of an intoxication nature (general weakness, malaise, poor appetite, weight loss). If signs of lung or intrathoracic lymph node damage come to the fore, then it is not always possible to recognize the onset of pleurisy. Pain is the main symptom of dry pleurisy, intensifies with deep breathing, coughing, sudden movements, is often localized in the lower lateral parts of the chest and can radiate both upward (to the neck, shoulder) and downward (to the abdominal cavity), simulating an "acute abdomen". To distinguish pain in dry pleurisy from pain in intercostal neuralgia, remember the following sign: in dry pleurisy, the child tries to lie on the affected side, the pain intensifies when leaning towards the healthy side, and in intercostal neuralgia - towards the affected side. Percussion reveals some limitation of mobility of the lower pulmonary edge on the affected side. Auscultation reveals a characteristic pleural friction noise in a limited area, usually detected in both phases of respiration. Dry pleurisy is usually not detected by radiography, but fluoroscopy may reveal limited mobility of the diaphragm dome. Later, if the fibrinous deposits were significant, adhesions and overgrowth of the costophrenic sinus may appear. Blood changes are usually not observed, ESR may increase moderately. Tuberculin tests are positive or hyperergic. If specific changes in the lungs are not determined, then the anamnesis, characteristic pleural friction noise, tuberculin sensitivity and duration of the disease become of decisive importance.

The clinical picture of exudative pleurisy largely depends on its localization. The effusion may be free or encapsulated. Topographically, there are apical, costal, interlobar, mediastinal, and diaphragmatic panpleurisy. Clinical manifestations of exudative pleurisy may be acute onset with a rapid increase in body temperature, dyspnea, dry cough, chest pain (the most common variant) or asymptomatic course, when pleurisy is detected accidentally during examination for damage to the upper respiratory tract and other diseases (this rarer 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, and constant coughing. With the accumulation of exudate, the pain may disappear completely, the patient is only bothered by the heaviness in the side. The amount of exudate can be from 300 ml to 2 liters or more. The child is pale, lethargic, shortness of breath, cyanosis appear, breathing becomes more frequent, the pulse accelerates, the position is forced - on the painful side. With costophrenic pleurisy, severe pain in the hypochondrium may appear, sometimes - vomiting, difficulty swallowing, phrenicus symptom. This is due to the fact that the diaphragmatic pleura is supplied with sensitive branches from two sources: the phrenic nerve and the six lower intercostal nerves.

Examination of the chest reveals smoothing of the intercostal spaces on the affected side, and a lag in breathing. Percussion reveals dullness (sometimes femoral dullness) above the fluid, the Ellis-Damoiseau-Sokolov line, and auscultation reveals weakening or absence of respiratory sounds. Pleural friction noise may be heard along the upper boundary of the fluid. Bronchial breathing and silent moist rales are sometimes heard above the fluid level due to lung collapse. An important sign of fluid accumulation in the pleural cavity is weakening or absence of vocal fremitus. With encapsulation of fluid, physical data depend on the localization of the process. Thus, with interlobar, encapsulated mediastinal and diaphragmatic effusions, deviations from the norm may not be detected. In the peripheral blood, the most constant sign is an increase in ESR, often significant. The number of leukocytes is moderately increased, a band shift in the leukocyte formula is possible. Absolute lymphopenia is typical. When examining sputum (when the child secretes it), its mucous nature is detected, the number of leukocytes in the sputum is small. The Mantoux test with 2 TE is often hyperergic.

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

The X-ray picture of free costal pleurisy is characterized by the fact that the pleural effusion has an arcuate upper border, its projection goes from the lateral sections of the chest wall from top to bottom and medially. When the patient is in an upright position, a triangular homogeneous shadow is determined in the lower outer part of the lung field with an oblique medial border. The mediastinum is shifted to the opposite side, the diaphragm on the side of the effusion is located below the usual level. The degree of fluid accumulation can vary, up to total filling of the pleural cavity and complete shadowing of the lung.

Interlobar pleurisy in children often complicates tuberculosis of the intrathoracic lymph nodes. If the clinical picture of these pleurisies is usually asymptomatic and depends on the size of the effusion localization, then X-ray diagnostics can be decisive and has its own characteristics. In the anterior and lateral projections along the interlobar fissure, a lens-shaped, spindle-shaped or ribbon-shaped shadow is visible, and in the lordotic position it retains an oval shape. In this way, the shadow of encapsulated interlobar pleurisy located in the lower section of the interlobar fissure differs from the shadow of atelectasis of the middle lobe, which in the lordotic position acquires a typical triangular shape with the base to the mediastinum. When the exudate is absorbed, thin linear shadows of compacted pleural sheets can be seen at the site of the interlobar fissure.

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