What Are the Different Types of Pleurisy Treatment?

Tuberculous pleurisy is a pleural inflammation caused by Mycobacterium tuberculosis and its autolysates and metabolites entering the pleural cavity of a hypersensitive body. It belongs to extrapulmonary tuberculosis, and was classified as the fourth type of tuberculosis by the new classification rule approved by the Ministry of Health in 2000.

Basic Information

English name

tuberculous pleuritis

Visiting department

Respiratory Medicine

Common locations

Pleural cavity

Common causes

Mycobacterium tuberculosis infection

Common symptoms

Fever, chills, sweating, fatigue, loss of appetite, etc.

Causes of tuberculous pleurisy

Tuberculous pleurisy is a disease caused by the first entry of Mycobacterium tuberculosis into the body. Most tuberculous pleurisy in China is caused by human-type tuberculosis. The causes of tuberculous pleurisy are: Bacteria of hilar lymph tuberculosis flow back to the pleura through the lymphatic vessels. Pulmonary tuberculosis lesions adjacent to the pleura rupture, allowing the products of tuberculosis or tuberculosis infection to enter the pleural cavity directly. Acute or subacute hematogenous disseminated tuberculosis causes pleurisy. The body is highly allergic, and the pleura responds highly to tuberculosis toxins and causes exudation. Thoracic spine tuberculosis and rib tuberculosis rupture to the pleural cavity. Because needle pleural biopsy or thoracoscopy biopsy has confirmed that 80% of tuberculous pleurisy parietal pleura has typical pathological changes of tuberculosis. Therefore, direct spread of Mycobacterium tuberculosis to the pleura is the main pathogenesis of tuberculous pleurisy.

Clinical manifestations of tuberculous pleurisy

Most tuberculous pleurisy is an acute disease. Its symptoms are mainly manifested by systemic poisoning symptoms of TB and local symptoms caused by pleural effusion. The symptoms of tuberculosis are mainly fever, chills, sweating, fatigue, loss of appetite, and night sweats. Local symptoms include chest pain, dry cough and dyspnea. Chest pain is mostly located below the front axillary or posterior axillary line with the largest range of thoracic breathing movements. As the pleural effusion gradually increased, chest pain gradually reduced or disappeared after a few days. The pleural irritation can cause reflex dry cough, which is more obvious when the body is turned. When the volume of fluid is small, there is only chest tightness and shortness of breath. If a large amount of fluid is used to force the lungs, heart and mediastinum, breathing difficulties may occur. The faster and more effusions are produced and accumulated, the more difficult it is to breathe, and there may even be sitting breathing and cyanosis.

Tuberculous pleurisy

Pleural biopsy

Acupuncture pleural biopsy is an important method to diagnose tuberculous pleurisy. In addition to the feasible pathological examination of biopsy pleural tissue, the culture of tuberculosis bacteria can also be performed.

2.X-ray inspection

When the pleural effusion is less than 300ml, there may be no positive findings in the posterior anterior X-ray chest radiograph. When a small amount of fluid accumulates, the costosacral angle becomes blunt, and the volume of fluid is more than 500ml. When viewed from the supine position, the liquid accumulated in the lower part of the thoracic cavity is diffused, and the sharp costosacral angle is seen again. It can also be taken on the affected side in a horizontal position, showing stripe shadows with increased density on the outside of the lung. The medium volume of effusion appears as a uniform density-increasing shadow in the lower part of the thoracic cavity, and the sacral shadow is covered. The effusion is a curved shadow that is high on the outside of the upper edge and low on the inside. When there is a large amount of pleural effusion, the large part of the lung field is uniformly densely shadowed, the diaphragm is covered, and the mediastinum is shifted to the healthy side.

3. Ultrasound inspection

Ultrasonic detection of pleural effusion has high sensitivity, accurate positioning, and can estimate the depth and volume of pleural effusion, indicating the puncture site. It can also be distinguished from pleural thickening.

Diagnosis of tuberculous pleurisy

Based on medical history and clinical manifestations, tuberculous pleurisy is generally diagnosed. The clinical manifestations are mainly moderate fever, relief from chest pain after first onset, and dyspnea. Physical examination, X-ray examination and ultrasound examination can make a diagnosis of pleural fluid. Diagnostic thoracentesis, routine examination of pleural fluid, biochemical examination, and bacterial culture are necessary measures for diagnosis. These measures can diagnose 75% of the causes of pleural fluid.

Differential diagnosis of tuberculous pleurisy

Bacterial pneumonia

In the acute phase of tuberculous pleurisy, fever, chest pain, cough, shortness of breath, increased white blood cell counts, and chest X-rays show high-density uniform shadows, which are easily misdiagnosed as pneumonia. However, when pneumonia cough is more sputum, often rusty sputum. The lungs are signs of consolidation, and sputum smears or cultures can often find pathogenic bacteria. Tuberculous pleurisy is dominated by dry cough and pleural effusion in the chest. PPD test can be positive.

2. Pneumonia-like pleural effusion

Occurs in patients with bacterial pneumonia, lung abscess, and bronchiectasis with pleural effusion. Patients often have a history of lung lesions, and the volume of fluid is not large. Pleural fluid white blood cell count increased significantly, mainly neutrophils, and pleural fluid culture may have pathogenic bacteria growth.

3. Malignant pleural effusion

Malignant tumors of the lung, breast cancer, lymphoma, direct invasion or metastasis of the pleura, pleural mesothelioma, etc. can produce pleural effusion, and the most common are lung tumors associated with pleural effusion. Tuberculous pleurisy is sometimes distinguished from those with systemic lupus erythematosus pleurisy, rheumatoid pleurisy, and others with pleural effusion. These diseases have their own clinical characteristics, and the identification is not difficult.

Tuberculous pleurisy treatment

The treatment of tuberculous pleurisy includes general treatment, pleural fluid extraction, anti-tuberculosis treatment, and traditional Chinese medicine treatment. The principle of chemotherapy is the same as that of chemotherapy and active tuberculosis.

General treatment

The body temperature can be rested in bed above 38 . Generally, patients can get up properly. The total rest time is about to return to normal body temperature, and it must continue for 2 to 3 months after the pleural fluid disappears.

2. Thoracentesis

Because tuberculous pleurisy has high levels of pleural protein and fibrin, it is easy to cause pleural adhesions. Therefore, in principle, the pleural effusion should be drawn as soon as possible, 2 to 3 times a week. Do not pump more than 600ml for the first time, and about 1000ml for each subsequent pump, and do not exceed 1500ml at most. If the fluid is drawn too much and too fast, pulmonary edema and circulatory failure can occur after re-expansion due to a sudden drop in pressure in the chest. In case of dizziness, sweating, pale complexion, weak pulse, chilled limbs, decreased blood pressure, etc., immediately stop pumping fluids, inject epinephrine subcutaneously, and inject dexamethasone intravenously, and retain the IV catheter until the symptoms disappear. If pulmonary edema occurs after lung recruitment, appropriate rescue should be performed. Thoracic aspiration has the following effects:

(1) Alleviate symptoms of poisoning and accelerate fever.

(2) Relieve the compression of the lungs and heart blood vessels, and improve breathing and circulation.

(3) Prevent pleural adhesion and hypertrophy caused by fibrin deposition. At present, some scholars have suggested that a large amount of early fluid extraction or thoracic intubation and drainage can reduce complications such as pleural thickening and pleural adhesion.

3. Antituberculosis drug treatment

Generally combined with streptomycin (SM), isoniazid (INH) and rifampicin (RFP) or streptomycin (SM) isoniazid (INH) ethambutol (EMB). Streptomycin (SM) was injected intramuscularly, isoniazid (INH), rifampicin, and ethambutol were taken daily. All the above oral medications were taken continuously for 9 to 12 months. The treatment process must pay attention to the side effects of antituberculosis drugs, such as changes in hearing, changes in vision and liver function, etc., should be reduced or discontinued according to the situation.

Tuberculous pleurisy does not advocate the routine use of glucocorticoids because of many side effects. Prednisone can be used when there is a large amount of pleural effusion, unsatisfactory absorption, or severe symptoms of tuberculosis, until the pleural fluid is significantly reduced or the symptoms of poisoning are reduced weekly. Decreasing the drug too quickly or taking it for too short a time can easily cause a rebound of pleural fluid or toxic symptoms. Intrathoracic injections of antituberculosis drugs or corticosteroids have no certain significance. The concentration of anti-tuberculosis drugs in the pleural fluid is sufficient, and the absorption of pleural fluid and the prevention of pleural thickening by intra-thoracic injection are not significantly different from those who do not take the drug.

Tuberculous pleurisy prevention

1. Control the source of infection and reduce the chance of infection

Tuberculosis smear-positive patients are the main source of tuberculosis. Early detection and reasonable treatment of smear-positive tuberculosis patients are the fundamental measures to prevent tuberculosis.

2. Popular BCG vaccination

Practice has proven that vaccination with BCG is an effective measure to prevent tuberculosis in children.