Differential diagnosis of tbc pleurisy.

Keywords : pleurisy, differential diagnosis, Tuberculosis, pleural effusion, exudative, transudative.

BY GROUP 607

INTRODUCTION

Pleurisy is inflammation of the pleura that typically results in characteristic pleuritic pain and has a variety of possible causes.

Pleurisy requires careful differential diagnosis that includes tuberculosis (TB) and metastatic cancers, which are often found to be the cause in a large number of patients .

In many areas of the world, Tuberculosis is the most common cause of exudative Pleural effusion.

PLEURISY IN TUBERCULOSIS This usually develops soon after initial infection. A

granuloma located at the edge of the lung ruptures into the pleural space, the space between the lungs and the chest wall. Once the bacteria invade the space, the amount of fluid increases dramatically and compresses the lung, causing shortness of breath (dyspnoea) and sharp chest pain that worsens with a deep breath

Chest X-ray : shows small to moderate unilateral pleural effusions without associated infiltrates.

Clinically: Mild- or low-grade fever commonly is present, pleural friction rub and pleuritic chest pain .Tuberculosis pleurisy generally resolves without treatment; however, two-thirds of patients with tuberculosis pleurisy develop active pulmonary TB within 5 years.

Diagnostic test results: Pleural fluid analysis shows exudative effusion with elevated adenosine deaminase levels (> 40 to 60 U per L [670 to 1,000 nkat per L]), Caseous granuloma on pleural biopsy, Culture positive for M. tuberculosis on induced sputum, pleural fluid culture, or pleural biopsy.

B. A teenage girl with a left-sided pleural effusion which extends up into the interlobar fissure

Other diseases with pleurisy

1.CARDIAC DISEASES: Post-cardiac injury syndrome, post-myocardial infarction syndrome (Dressler's syndrome), postpericardiotomy syndrome, congestive heart failure.

Chest X-ray: shows unilateral pleural effusion with pericardial effusion.

Clinically: Fever, dyspnoea, pleuropericardial pain, pleural and/or pericardial friction rub; decreased breath sounds.

Diagnostic test results: pleural fluid analysis shows exudative effusion, elevated ESR, leukocytosis, electrocardiographic abnormalities similar to pericarditis.

Other diseases with pleurisy2.LUNG CANCER: Pleurisy can develop in

people with lung cancer. When pleurisy occurs because of lung cancer, a bloody pleural effusion is common.

Chest x-ray: shows unilateral pleural effusions with homogenous opacity

Clinically: chest pain, cough, dyspnoea, decreased fremitus in affected area, decreased breath sounds, dullness to percussion,hemoptysis. The pleurisy in this case is chronic and recurrent.

Diagnostic Test Results: pleural fluid analysis shows exudative pleural fluid with decreased pleural fluid glucose and pH and increased pleural fluid erythrocytes,leucocytes,LDH, and proteins. Malignant cells are found in pleural fluid. sputum examination shows malignant cells and erythrocytes.Transudate pleural fluid is seen in congestive heart failure

Other diseases with pleurisy3. VIRAL PLEURISY :Viral pleurisy is

usually a diagnosis of exclusion. Causes of viral pleurisy are influenza, parainfluenza, coxsackieviruses, respiratory syncytial virus, mumps, cytomegalovirus, adenovirus, and Epstein-Barr virus.

Chest X-ray :could be normal or abnormal chest x-ray with infiltrations and pleural effusion.

Clinically: Anamnesis presenting a recent respiratory illness,fever,cough,rapid, shallow respirations; pleural friction rub, pleuritic chest pain, myalgias, malaise, rhinorrhoea, nasal congestion, sick contacts.

Diagnostic test results: leukocytosis with lymphocytic predominance, culture shows viral etiology.

Other diseases with pleurisy4.BACTERIA PNEUMONIA :Pleurisy can also be

seen in bacteria pneumonia due to streptococcus pneumonia ,staphylococcus aureus,hemophilius influenza,kliebsiella,pseudomonas aerogenosa or other gram negative bacteria

Chest x-ray : shows infiltrates and pleural effusion.Clinically: fever, cough, purulent sputum production,

rhinorrhoea reduced breath sounds on auscultation if effusion present; dullness to percussion; reduced vocal fremitus; rales may be evident in areas of effusion with nearby parenchyma consolidation; friction rub may be heard.

Diagnostic Test Results: Exudative pleural effusion, Elevated white blood cell count, blood cultures show positive growth of offending organism, sputum culture shows specific bacteria involved.

Other diseases with pleurisy5.CONNECTIVE TISSUES DISORDERS: Systemic lupus

erythematosus ,rheumatoid arthritis and other connective tissue disorders can cause inflammation of the pleura.

Chest X-ray: shows small to moderate unilateral or bilateral pleural effusion.

Clinically: Prior diagnosis of systemic lupus erythematosus, rheumatoid arthritis, or other connective tissue disorder should raise suspicion, but pleuritic chest pain may be initial presentation, fever, arthritis, arthralgias, joint deformities, rash, alopecia, dry eyes or mouth(sjogren’s disease), synovitis (rheumatoid arthritis).

Diagnostic Tests Results :pleural fluid analysis shows exudative, effusion (rheumatoid arthritis characterized by low glucose level [< 40 mg per dL (2.2 mmol per L)], elevated lactic dehydrogenase level [> 700 U per L], and low pH [< 7.2]),increased C –reactive protein and increased VSH.

Abnormal disease-specific serologic markers

Other diseases with pleurisy6. PULMONARY EMBOLISM- A pulmonary

embolism is a blood clot that has floated through the bloodstream and lodged in the lungs. In people with pulmonary embolism, symptoms of pleurisy tend to occur when the pulmonary embolism is fairly small and has lodged in a part of the lungs near the pleura.

Chest X-ray: shows an area of pulmonary parenchyma infarction and unilateral pleural effusion, pulmonary consolidations compatible with infarction.

Clinically: Anamnesis shows a history of Prior embolism or clot, cancer, immobilization, sudden onset of chest pain; history of prolonged immobility; prolonged travel by plane or automobile; hypercoagulable syndromes; recent leg trauma, Deep vein thrombosis, estrogens use, or recent surgery, dyspnoea, syncope, tachycardia, tachypnea, pleural rub,hemoptysis,pleuritic chest pain.

Diagnostic Tests Results: Pleural fluid analysis is Transudate, CT angiogram shows presence of luminal filling defect in pulmonary arteries.

OTHER DISEASES WITH PLEURISY7. DRUG-INDUCED PLEURISYDrugs known to cause pleural disease include amiodarone (Cordarone),

bleomycin , bromocriptine (Parlodel), cyclophosphamide , methotrexate, methysergide, minoxidil , mitomycin , oxyprenolol , hydralazine, procainamide, isoniazid, methyldopa or chlorpromazine (lupus pleuritis); use of minoxidil, beta blockers, nitrofurantoin, practolol and sclerotherapeutic agents. Drugs that may cause lupus pleuritis include hydralazine (Apresoline), procainamide (Pronestyl), and quinidine.

Chest X-ray: may be normal or demonstrate infiltrate, pleural effusion, or pleural thickening.

Clinically: A history of the use of drug known to cause drug-induced pleural disease or drug-induced lupus pleuritis,Possible decreased breath sounds, pleural friction rub, dullness to percussion over area of effusion, diminished breath sounds in the same distribution.

Diagnostic Test Results: Exudative effusion ,eosinophils constituting >10% of cells in pleural fluid can be found in drug reactions with valproic acid (62% to 84% of cases)

OTHER DISEASES WITH PLEURISYFAMILIAL MEDITERRANEAN FEVER: is a hereditary inflammatory

disorder that affects groups of people originating from around the Mediterranean sea.

Chest X-ray: shows unilateral pleural effusion during episodes.

Clinically: Recurrent episodes of fever (one to four days) associated with abdominal, chest, or joint pain or erysipelas-like skin disease,mediterranean descent, family history of familial Mediterranean fever. During episodes: temperature of 38 - 40° C and signs of serositis (e.g., peritoneal irritation, pleural and/or pericardial friction rub. Other possible findings are joint swelling, unilateral erythema over extensor surface of leg, ankle, or foot.

Diagnostic Tests Results: pleural fluid analysis is a lymphocytic exudative pleural fluid. Increased acute phase reactants (ESR, CRP, WBC, fibrinogen),Positive mutation analysis for MEFV gene

conclusion

There are many diseases that have similar features like tuberculous pleurisy ,but TB pleurisy is a common disease that may be easy to diagnose if proper methods of diagnosis are carefully applied.

Tuberculosis pleurisy generally resolves without treatment.

The final diagnosis of TB pleurisy is based on combining clinical judgment with radiologic findings, microbiologic tests, and the histopathologic findings.

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Qiu L, Teeter LD, Liu Z, Ma X, Musser JM, Graviss EA. Diagnostic associations between pleural and pulmonary tuberculosis. J Infect 2006;53:377-86.

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