Classification:

Dry pleurisy (pleuritis sicca)

Pleurisy with effusion (pleuritis exudativa)
The character of the inflammatory effusion may be different:
serous, serofibrinous, purulent, and haemorrhagic.

Etiology and pathogenesis

Serous and serofibrinous pleurisy (tuberculosis in 70-

90 per cent of cases, pneumonia, certain infections,

and also rheumatism in 10-30 per cent of cases)
Purulent process (pneumococci, streptococci,
staphylococci, and other microbes)
Haemorrhagic pleurisy (tuberculosis of the pleura,
bronchogenic cancer of the lung with involvement of
the pleura, and also in injuries to the chest)

DRY PLEURISY

Clinical picture
pain in the chest (a characteristic symptom )which
becomes stronger during breathing and coughing.
cough (is usually dry)
subfebrile temperature
Respiration is superficial (deep breathing intensifies
friction of the pleural membranes to cause pain).
Lying on the affected side lessens the pain.
Inspection of the patient can reveal unilateral thoracic

lagging during respiration.

Percussion fails to detect any changes except decreased
mobility of the lung border on the affected side.
Auscultation determines pleural friction sound over the
inflamed site.

 Normal pleural fluid has the following characteristics:

clear ultrafiltrate of plasma,
pH 7.60-7.64,
protein content less than 2% (1-2 g/dL)
fewer than 1000 WBCs per cubic millimeter
glucose content similar to that of plasma
lactate dehydrogenase (LDH) level less than 50% of
plasma and sodium, and potassium and calcium
concentration similar to that of the interstitial fluid.

 Transudative pleural effusion

Congestive heart failure (most common transudative

effusion)
Hepatic cirrhosis with and without ascites
Nephrotic syndrome
Peritoneal dialysis/continuous ambulatory peritoneal
dialysis
Hypoproteinemia (eg, severe starvation)
Glomerulonephritis
Superior vena cava obstruction
Urinothorax

 Exudative pleural effusion

Malignant disorders - Metastatic disease to the pleura or lungs, primary

lung cancer, mesothelioma, Kaposi sarcoma, lymphoma, leukemia

Infectious diseases - Bacterial, fungal, parasitic, and viral infections;
infection with atypical organisms such as Mycoplasma, Rickettsiae,
Chlamydia, Legionella
GI diseases and conditions - Pancreatic disease (acute or chronic
disease, pseudocyst, pancreatic abscess), Whipple disease,
intraabdominal abscess (eg, subphrenic, intrasplenic, intrahepatic),
esophageal perforation (spontaneous/iatrogenic), abdominal surgery,
diaphragmatic hernia, endoscopic variceal sclerotherapy
Collagen vascular diseases - Rheumatoid arthritis, systemic lupus
erythematosus, drug-induced lupus syndrome (procainamide,
hydralazine, quinidine, isoniazid, phenytoin, tetracycline, penicillin,
chlorpromazine), immunoblastic lymphadenopathy
(angioimmunoblastic lymphadenopathy), Sjgren syndrome, familial
Mediterranean fever, Churg-Strauss syndrome, Wegener
granulomatosis

 Benign asbestos effusion

Meigs syndrome - Benign solid ovarian neoplasm

associated with ascites and pleural effusion

Drug-induced primary pleural disease - Nitrofurantoin,
dantrolene, methysergide, bromocriptine, amiodarone,
procarbazine, methotrexate, ergonovine, ergotamine,
oxprenolol, maleate, practolol, minoxidil, bleomycin,
interleukin-2, propylthiouracil, isotretinoin,
metronidazole, mitomycin
Injury after cardiac surgery (Dressler syndrome) - Injury
reported after cardiac surgery, pacemaker implantation,
myocardial infarction, blunt chest trauma, angioplasty
Uremic pleuritis
Yellow nail syndrome
Ruptured ectopic pregnancy
Electrical burns

Characteristic

Significance

Bloody

Most likely an indication of

malignancy in the absence of
trauma; can
also indicate pulmonary embolism,
infection, pancreatitis,
tuberculosis, mesothelioma, or
spontaneous pneumothorax

Yellow or whitish,
turbid

Presence of chyle, cholesterol or

empyema

Brown (similar to chocolate sauce

or anchovy paste)

Rupture of amebic liver abscess

into the pleural space (amebiasis
with a hepatopleural fistula)

Black

Aspergillus involvement of pleura

Yellow-green with debris

Rheumatoid pleurisy

Characteristic

Significance

Highly viscous

Malignant mesothelioma
(due to increased levels of
hyaluronic acid)
long-standing pyothorax

Ammonia odor

Urinothorax

Purulent

Empyema

Yellow and thick, with

metallic
(stainlike) sheen

Effusions rich in cholesterol

(longstanding chyliform
effusion, eg,
tuberculous or rheumatoid
pleuritis)

PLEURISY WITH EFFUSION

Clinical picture
Complains: fever, pain or the feeling of heaviness in the
side, dyspnea (which develops due to respiratory
insufficiency caused by compression of the lung). Cough is
usually mild (or absent in some cases).
Objective examination: Inspection of the patient reveals
asymmetry of the chest due to enlargement of the side
where the effusion accumulated; the affected side of the
chest usually lags behind respiratory movements. Vocal
fremitus is not transmitted at the area fluid accumulation.

 Percussion over the area of fluid accumulation

produces dullness. The upper limit of dullness is

usually the S-shaped curve (Damoiseau's curve) whose
upper point is in the posterior axillary line. The
Damoiseau curve is formed because exudate pleurisy
with effusion more freely accumulates in the lateral
portions of the pleural cavity, mostly in the costaldiaphragmatic sinus.

In addition to the Damoiseau curve, two triangles can

be determined by percussion in pleurisy with effusion.
The Garland triangle is found on the affected side is
characterized by a dulled tympanic sound. It
corresponds to the lung pressed by the effusion, and is
located between the spine and the Damoiseau curve.
The Rauchfuss-Grocco triangle is found on the healthy
and is a kind of extension of dullness determined on the
affected side, sides of the triangle are formed by the
diaphragm and the spine, while the continued
Damoiseau curve is the hypotenuse.

Pleurisy with effusion:

posterior view:
1Damoiseau's curve;
2Garland's triangle;
3Rauchfuss-Grocco
triangle.

Treatment
Antibiotics (eg, for parapneumonic effusions) and

diuretics (eg, for effusions associated with CHF) are

commonly used in the initial management of pleural
effusions in the ED. The selection of drugs in each
class depends on the cause of the effusion and its
clinical presentation. Particular attention must be
given to potential drug interactions, adverse effects,
and preexisting conditions.

Tuberculous pleural effusion

TB remains the most common cause of
pleural effusion in young people
Etiology: tubercle bacillus
Pathogenesis: host hypersensitivity to
tubercular protein in pleural tubercles
Delayed hypersensitivity

Clinical Manifestations
Generalized symptoms of toxicity of TB:
fever, sweats, fatigue, weight loss ss, etc.
Pleuritic pain, dyspnea, coughlea, etc.
Pleural fluid is exudative and usually
reveals lymphocytosis
Rarely pleural fluid is blood stained
Tubercular tests usually positive

Empyema
Thick purulent fluid with more than 100,000
cells per cubic millimeter or fluid with PH
values less than or equal to 7. 20 should
be treated as a presumptive empyema
The general objectives of therapy of empyema
are the elimination of both the systemic and
local infection.

Treatment of acute and chronic empyema

1. Control of infection
systemic and local
2. Repeated thoracentesis or drainage of the empyema
3. Chronic empyema is primarily treated operatively
4. Operative therapy is also indicated in the empyema
with associated bronchopleural fistula or with the
ipsilateral ruined lung

Thanks for your attention!