Tubercular pleurisy

Description:

Pleurisy can be the first clinical display of tuberculosis,  especially at teenagers and persons of young age. Often it develops at primary tuberculosis. Pleurisy can be the only clinical display of a disease when it arises in the presence of the skrytoprotekayushchy fresh centers located in lungs subplevralno or the centers in lymph nodes.

Symptoms of Tubercular pleurisy:

Clinically pleurisy is divided on dry and exudative.
On clinical manifestations pleurisy is divided on acute, subacute and chronic.

On localization allocate the following pleurisy:
a) bone and phrenic;
b) phrenic;
c) kostalny;
d) interlobar;
e) paramediastinal;
e) apical.

More often the exudate is located in a pleural cavity freely, but maybe with sacculated.

Dry (fibrinous) pleurisy represents an inflammation of limited sites of a pleura with adjournment on its surface of fibrin. The main clinical manifestations are stethalgias, dry cough, disturbance of the general state and subfebrile temperature. Localization of pains depends on the place of defeat. Pains amplify at deep breath, cough and pressing on mezhreberye.

At a physical research of patients lag of the struck side of a thorax at breath, small obtusion of percussion tone comes to light.

Auskultativno:  the main diagnostic character is the pleural rub which amplifies when pressing by a stethoscope and does not disappear after cough.

Blood test at patients with pleurisy reveals a moderate leukocytosis, shift of neutrophils to the left and acceleration of SOE.

At X-ray inspection restriction of mobility of a dome of a diaphragm comes to light, contours of a diaphragm become uneven, transparency of the struck departments of lungs goes down.

Dry pleurisy proceeds favorably and comes to an end with treatment. Sometimes it gains recurrent character.

Antibacterial treatment is carried out according to standard schemes depending on resistance of MBT and tolerance of an organism to antitubercular drugs.

Exudative (serous) pleurisy is a common form of pleurisy of a tubercular etiology. It begins gradually with a febricula, weakness, periodic stethalgias, occasionally with cough, subfebrile temperature. Then temperature increases, the stethalgia amplifies, short wind develops. In process of exudate accumulation an asthma accrues at the expense of a collapse of a lung and pressure upon bodies of a mediastinum.

Rather seldom pleurisy begins in the period of full health with a fever, high fever, a stethalgia, dry painful cough.

The course of acute serous pleurisy of a tubercular etiology can be divided into three periods: exudations; process stabilization; exudate resorptions.

At a physical research of patients with pleurisy, in a phase of exudation restriction of a respiratory excursion of the struck party, a smoothness of mezhreberiya and even their protrusion are noted at large amounts of liquid. The dullness with the upper bound in the form of the slanting line of Ellis-Damuazo which goes from a backbone up, reaches an upper point on axillary lines and falls further in front on a front wall of a thorax is characteristic. Shift of bodies of a mediastinum in the healthy party is usually observed at accumulation of a large amount of liquid in a pleural cavity.

Phases of stabilization and rassasyvaniye of exudate are characterized by subsiding of symptoms of a disease, decrease in temperature, reduction of pain and asthma. Gradually objective pathological symptoms disappear, but the pleural rub can appear.

Changes of a gemogramma in an acute phase are characterized by existence of a leukocytosis (to 12 000-15 000), lympho-and eosinopenias, neutrophylic shift to the left and acceleration of SOE to 50-60 mm/h. At a process zatikhaniye indicators of blood are normalized.

At exudative pleurisy essential shifts in a proteinogramma are noted. In an acute phase the amount of albumine decreases and globulins accrue. At involution of process the normal content of globulins is recovered.

If liquid accumulates over a diaphragm, then at X-ray inspection of the patient in vertical position she is often not visible. In similar cases the research in a side position is necessary. At increase in an exudate homogeneous blackout in the field of an outside sine appears. The pulmonary drawing is differentiated badly. Free liquid can move depending on position of a body of the patient. Pleural liquid can accumulate in interlobar cracks, paramediastinalno and in the field of a diaphragm dome where blackout at polyposition X-ray inspection is defined.

Purulent tubercular pleurisy (pyothorax, pleura empyema)
Purulent pleurisy is characterized by accumulation in an interpleural crack of purulent exudate. Except tuberculosis, limfogematogenny spread of a pyogenic infection can be the cause of purulent pleurisy at the TB patient at various purulent and infectious diseases. Not tubercular empyema in these cases can keep the character before treatment or quickly pass in mixed as a result of an aggravation of tubercular process.

Tubercular damage of a pleura with formation of purulent exudate develops at heavy progressing of serous and hemorrhagic pleurisy more often or arises at break of a cavity in a pleural cavity. The tubercular empyema can chronically proceed. At the same time the condition of the patient worsens, raises temperature, there are oznoba, night sweats, an asthma, weight loss.

Especially hard the empyema at primary caseous pleurisy and disturbance of an integrity of a cavity when bronchopleural fistulas are formed proceeds. At long accumulation of a large amount of pus in a pleural cavity also plevrotorakalny fistula can be formed.

The chronic empyema leads to development of an amyloidosis of internals. At purulent pleurisy there are expressed shifts from a leykogramma and a proteinogramma, hypochromia anemia develops. In 90% of cases find tuberculosis mycobacteria in purulent exudate.

Reasons of Tubercular pleurisy:

Causative agents of tuberculosis are mycobacteria - acid resisting bacteria of the sort Mycobacterium. In total 74 types of such mycobacteria are known. They are eurysynusic in the soil, water, among people and animals. However tuberculosis causes conditionally allocated M. tuberculosis complex including Mycobacterium tuberculosis (a human look), Mycobacterium bovis (a bull look), Mycobacterium africanum, Mycobacterium bovis BCG (BTsZh-strain), Mycobacterium microti, Mycobacterium canetti in the person. Recently Mycobacterium pinnipedii, Mycobacterium caprae phylogenetic concerning Mycobacterium microti and Mycobacterium bovis are carried to it. The main species character of a mycobacterium of tuberculosis (MBT) - pathogenicity which is shown in virulence. Virulence can significantly change depending on environmental factors and be shown differently depending on a condition of a macroorganism which is exposed to bacterial aggression.

Tuberculosis at people most often arises at infection human and bull types of the activator. Allocation of M. bovis is noted preferential at inhabitants of rural areas where a way of transfer generally alimentary. Also bird's tuberculosis which occurs preferential at immunodeficient carriers is noted.

MBT belong to prokariota (in their cytoplasm there are no high-organized organellas of the device of Golgi, lysosomes). There are no plasmids, also characteristic of a part of prokariot, providing for microorganisms dynamics of a genome.

Form - slightly curved or direct stick of 1-10 microns × 0,2-0,6 microns. The ends are rounded slightly off. Usually they long and thin, but activators of a bull look thicker and short.

MBT are not mobile, do not form a microdispute and capsules.
In a bacterial cell it is differentiated:
- the microcapsule - a wall from 3-4 layers 200-250 nanometers thick, is strongly connected with a cell wall, consists of polysaccharides, protects a mycobacterium from influence of external environment, has no antigenic properties, but shows serological activity;
- the cell wall - limits a mycobacterium outside, provides stability of the sizes and a form of a cell, mechanical, osmotic and chemical protection, includes virulence factors - lipids with which fosfatidny fraction connect virulence of mycobacteria;
- homogeneous bacterial cytoplasm;
- the cytoplasmic membrane - includes lipoprotein complexes, fermental systems, creates intra cytoplasmatic membrane system (mesocatfish);
- nuclear substance - includes chromosomes and plasmids.

Proteins (tuberkuloproteid) are the main carriers of the MBT antigenic properties and show specificity in hypersensitivity reactions of the slowed-down type. Tuberculine concerns to these squirrels. Detection of antibodies in blood serum of TB patients is connected with polysaccharides. Lipid fractions promote acids and alkalis resistance of mycobacteria.

Mycobacterium tuberculosis - an aerobe, Mycobacterium bovis and Mycobacterium africanum - aerofila.

In the bodies affected with tuberculosis (easy, lymph nodes, skin, bones, kidneys, intestines, etc.) the specific "cold" tubercular inflammation having preferential granulematozny character and leading to formation of multiple hillocks with tendency to disintegration develops.

Treatment of Tubercular pleurisy:

Antibacterial therapy of tubercular pleurisy - the main method of treatment. During the acute period of a disease the bed rest, good nutrition with restriction of carbohydrates are shown, to salt and liquid, food has to be protein-rich, fats and vitamins (especially vitamin C).

Efficiency of treatment increases at use of corticosteroid hormones in an initial phase of a disease during 3-4 weeks. In the period of a rassasyvaniye of pleurisy are appointed treatment an electrophoresis with drugs of calcium and respiratory gymnastics.

At purulent pleurisy systematic and frequent evacuations of pus with washing of a pleural cavity and introduction of antibiotics to a pleural cavity are necessary. Treatment of patients with the chronic tubercular or mixed empyema difficult. In the absence of effect of therapeutic methods, especially in the presence of bronchial fistula, reasonablly surgical treatment.