Tuberculous pleurisy in children

In children and adolescents, pleurisy can occur as a complication of tuberculosis of the intrathoracic lymph nodes and the primary tuberculosis complex. And also as an independent disease.

If a clinical and radiological examination clearly reveals a tuberculosis picture, pleurisy is regarded as a complication. In the same cases, when the changes do not reveal, pleurisy is considered as an independent form of tuberculosis. In the pathogenesis of pleurisy of tuberculosis etiology in children and adolescents, the nature of the initial tuberculosis process, the path of penetration of the pathogen into pleural sheets, the specific and nonspecific reactivity of the patient are of primary importance. The spread of infection can occur contact, hematogenous and lymphogenous ways. In some cases, a breakthrough of the caseous contents of the lymph node into the pleural cavity is possible.

According to the pathogenesis, there are three types of pleurisy:

• perifocal;
• predominantly allergic;
• tuberculosis of the pleura.

Perifocal pleurisy develops due to the involvement of the pleura in inflammation in the presence of a subpleurally located tuberculous focus or affected bronchopulmonary lymph nodes. The amount of exudation with perifocal pleurisy is usually small. The spread of pathogens and toxins from the affected bronchopulmonary lymph nodes often occurs lymphogenically through the flow of tissue fluid, which creates conditions for the penetration of mycobacteria into the pleura. Hypersensitization of this area leads to the fact that both specific and nonspecific stimuli (trauma, hypothermia, hyperinsolation, etc.) cause hyperergic inflammation of the pleura, which provokes the accumulation of exudate (by the type of paraspecific inflammation). The defeat of the pleura can also be hematogenous. In these cases the tubercle changes of the pleura, that is, pleural tuberculosis, develop in different lengths. The amount of exudation can be different, such pleurisy often manifest as migrating, recurring. The disease proceeds wavy, has a tendency to a prolonged course.

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.

Symptoms of tuberculous pleurisy

Diagnosis of tuberculous pleurisy

Accumulation of exudate in the pleural cavity occurs with many diseases of the lungs, pleura and other organs, which complicates etiologic diagnosis. In adolescents pleurisy are more often tubercular (75%). From pleurisy of non-tubercular etiology, exudation should be noted for pneumonia of various nature, rheumatism, collagenoses, circulatory insufficiency, tumors, trauma, etc.

In the differential diagnosis of pleurisy, evidence from the anamnesis indicates a tubercular nature of pleurisy: contact with a tuberculosis patient, hyperergic reaction in a Mantoux test or a turn of a tuberculin test. If the exudative pleurisy appeared on the background of a bend, it is most likely a pleurisy of tuberculosis etiology, and the child needs urgent chemotherapy.

Diagnosis of pleurisy