tuberculous pleurisy
Introduction
Introduction to tuberculous pleurisy When the pulmonary tuberculosis inflammation involves the pleura, the pleural inflammation is called tuberculous pleurisy. In some cases, pleurisy is caused by blood infection, and some are related to the body's allergic reaction. There is often a small to moderate amount of fluid, due to high protein in tuberculous pleurisy exudate, easy to cause pleural adhesions and hypertrophy. basic knowledge The proportion of sickness: 0.01% Susceptible people: no special people Mode of infection: droplet spread Complications: pleurisy
Cause
Cause of tuberculous pleurisy
(1) Causes of the disease
Primary tuberculosis is a disease caused by Mycobacterium tuberculosis invading the body for the first time. There are 4 types of Mycobacterium tuberculosis: human, bovine, bird and mouse, while human pathogenic bacteria are human tuberculosis and tuberculosis. Most of the pediatric tuberculosis in China is caused by human tuberculosis. The tuberculosis has strong resistance. In addition to acid, alkali and alcohol resistance, it is strong for cold, heat, dryness, light and chemicals. Tolerance, damp heat has strong bactericidal power against tuberculosis, it can be killed at 65 ° C for 30 min, 70 ° C for 10 min, 80 ° C for 5 min to kill, dry heat sterilization is poor, dry heat 100 ° C takes more than 20 min to kill, Therefore, dry heat sterilization, the temperature needs to be high, the time needs to be long, the tuberculosis bacteria in the sputum is killed within 2 hours under direct sunlight, and the ultraviolet ray only takes 10 minutes, instead it can survive for several months in the dark, in the sputum If tuberculosis is disinfected with 5% carbolic acid (phenol) or 20% bleaching solution, it takes 24 hours to take effect.
(two) pathogenesis
The pathways leading to tuberculous pleurisy are:
1 The lymphatic tuberculosis bacteria flow back to the pleura through the lymphatic vessels;
2 tuberculosis lesions adjacent to the pleura rupture, so that the products of tuberculosis or tuberculosis infection directly into the pleural cavity;
3 acute or subacute hematogenous disseminated tuberculosis caused by pleurisy;
4 The body's allergicity is high, and the pleura is highly responsive to tuberculosis toxins;
5 Thoracic tuberculosis and rib tuberculosis to the pleural cavity. Previously, the opinion that tuberculous pleural effusion is allergic to tuberculosis toxin is one-sided, because needle pleural biopsy or thoracoscopic biopsy has confirmed 80% tuberculous pleurisy wall pleura There are typical pathological changes of tuberculosis. Therefore, the direct involvement of Mycobacterium tuberculosis in the pleura is the main pathogenesis of tuberculous pleurisy.
Early pleural congestion, leukocyte infiltration, followed by lymphocyte infiltration predominance, fibrinous exudation on the pleural surface, followed by serous exudation, due to a large amount of fibrin deposition in the pleura, can form a wrapped pleural effusion or extensive pleural thickening The pleura often has nodules formed.
Prevention
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 rational treatment of smear-positive tuberculosis patients is a fundamental measure to prevent tuberculosis. Infants and young children suffer from active tuberculosis, and their family members should be examined in detail (thoracic film, PPD). Etc.) Regular physical examinations of primary and child care institutions should be conducted to detect and isolate infection sources in a timely manner, which can effectively reduce the chance of tuberculosis infection.
2. Popularization of BCG vaccination
Practice has proved that vaccination with BCG is an effective measure to prevent tuberculosis in children. BCG was invented by French physicians Calmette and Guerin in 1921, so it is also called BCG. China has vaccinated BCG in the neonatal period and inoculated BCG in the upper left arm of the left upper arm. Intradermal injection, the dose is 0.05mg / time, the scratch method is rarely used, the Ministry of Health notified in 1997 to cancel the 7-year-old and 12-year-old BCG re-integration plan, but if necessary, the child with negative age test Multiple cropping can be given, and BCG vaccine can be injected in the same day as the hepatitis B vaccine.
Contraindications to vaccination with BCG: positive lignin response; patients with eczema or skin disease; recovery period of acute infectious disease (1 month); congenital thymic dysplasia or severe combined immunodeficiency disease.
3. Prophylactic chemotherapy
Mainly used for the following objects:
(1) Infants under the age of 3 have not been vaccinated with BCG and have a positive test.
(2) Close contact with patients with open tuberculosis (multiple family members).
(3) The sputum test has recently changed from negative to positive.
(4) The sputum test is a strong positive responder.
(5) The positive test of the lignin requires a longer-term use of adrenocortical hormone or other immunosuppressive agents.
Complication
Tuberculous pleurisy complications Complications pleurisy
It can form interlobular pleurisy, mediastinal pleurisy, encapsulated effusion and lung fund.
Symptom
Tuberculous pleural inflammatory symptoms Common symptoms Pleural effusion Night sweats Chest pain Chest pain Breathing sounds weakened Chest tightness Appetite loss Dry cough fatigue Sit breath
Most tuberculous pleurisy is an acute onset. The symptoms are mainly systemic symptoms of tuberculosis and local symptoms caused by pleural effusion. The symptoms of tuberculosis are mainly fever, chills, sweating, fatigue, loss of appetite, night sweats. Local symptoms include chest pain, dry cough and difficulty in breathing. Chest pain is mostly located in the front of the sacral line or below the sacral line of the thoracic respiratory movement. It is sharp pain, which is aggravated by deep breathing or coughing. As the pleural effusion gradually increases, a few days later. Chest pain gradually reduced or disappeared, effusion stimulation of the pleura can cause reflex dry cough, more obvious when the body position is rotated, only chest tightness when the amount of fluid is small, shortness of breath, a large amount of hydraulic pressure forced lung, heart and mediastinum, can occur Difficulty breathing, the faster the effusion produces and accumulates, the more difficult it is to breathe, and even the sitting breathing and cyanosis.
The signs are related to the amount of fluid accumulation and accumulation. The chest volume of the effusion or the interpleural pleural effusion is not obvious, or the pleural friction sound can be heard early. The upper thoracic cavity is slightly convex and the intercostal space is full. Respiratory movement is restricted, trachea, mediastinum and heart shift to the healthy side, the affected side tremor is weakened or disappeared, percussion voiced or real sound, auscultation breath sounds weakened or disappeared, speech conduction weakened, due to the upper boundary of pleural effusion The lungs are compressed. When the auscultation is heard, the breath sounds are not weakened but increased. If there is pleural adhesion and pleural thickening, the affected side of the thorax is depressed, the intercostal space is narrowed, respiratory movement is limited, speech tremor is enhanced, and percussion is voiced. The breath sounds weakened.
Examine
Tuberculous pleurisy
In the early stage of tuberculous pleurisy, the total number of white blood cells in the blood can be increased or normal, neutrophils predominate, and then the white blood cell count is normal, and converted to lymphocytes, and the erythrocyte sedimentation rate increases.
Pleural examination
The appearance of pleural fluid is mostly grass yellow, transparent or slightly turbid, or frosted glass. A few pleural fluids can be yellow, dark yellow, serous blood and even blood. The specific gravity is above 1.018. The Rivalta test is positive, the pH is about 7.00~7.30, and there are nucleated cells. Number (0.1 ~ 2.0) × 109 / L, the acute phase is dominated by neutrophils, and then lymphocytes predominate, protein quantitation 30g / L or more, such as greater than 50g / L, more support for the diagnosis of tuberculous pleurisy, glucose Content <3.4mmol/L, lactate dehydrogenase (LDH)>200U/L, adenosine deaminase (ADA)>45U/L, interferon->3.7/ml, carcinoembryonic antigen (CEA)<20g /L, flow cytometry cells are polyploid, tuberculosis antigens and antibodies have been reported to measure pleural effusion, although the concentration of pleural effusion in tuberculous pleurisy is significantly higher than non-tuberculous, but the specificity is not High, limiting its clinical application, the positive rate of Mycobacterium tuberculosis in pleural effusion is less than 25%, such as smear after pleural effusion centrifugation, pleural effusion or pleural tissue culture, polymerase chain reaction (PCR), etc. Positive rate, pleural effusion mesothelial cell count <5%.
Pleural biopsy
Acupuncture pleural biopsy is an important method for the diagnosis of tuberculous pleurisy. In addition to feasible pathological examination, biopsy pleural tissue can also be cultured with tuberculosis. For example, changes in parietal pleural granuloma suggest the diagnosis of tuberculous pleurisy, although other diseases such as fungi. Sexual disease, sarcoidosis, tuaremia and rheumatic pleurisy can have granulomatous lesions, but more than 95% of pleural granulomatous lesions are tuberculous pleurisy, such as pleural biopsy failed to detect granulomatous lesions, biopsy Specimens should be stained with acid, because tuberculosis can be found in the specimen by accident. The first pleural biopsy can detect 60% of tuberculous granuloma changes, and biopsy 3 times is about 80%, such as biopsy specimen culture plus microscopy. The positive rate of tuberculosis diagnosis is 90%. The pleural biopsy can also be performed under thoracoscopic direct vision. The positive rate is higher.
X-ray examination
When the pleural effusion is below 300ml, there may be no positive findings in the posterior anterior X-ray film. When the effusion is small, the rib angle becomes dull, and the effusion volume is more than 500ml. The supine position is observed in perspective, due to the accumulation of liquid in the lower part of the chest cavity. Spreading, seeing sharp rib angles, can also suffer from lateral lie, showing a strip of shadow on the outside of the lungs. The medium effusion shows a uniform density increase in the lower part of the chest, and the shadow is covered. The liquid has a high outer side of the upper edge and a low arc shadow on the inner side. When a large amount of pleural effusion occurs, most of the lung field is evenly densely shadowed, the shadow is covered, and the mediastinum is displaced to the healthy side.
Some tuberculous pleural effusions can be expressed as special types. Common ones are: 1 inter-leaf effusion: the fluid accumulates in one or more interlobular spaces, showing sharp-edged fusiform shadows or round shadows on the lateral chest. On the film, the position of the effusion is related to the leaf space. 2 The effusion under the lungs: the liquid mainly accumulates between the lung base and the diaphragm, often coexisting with the pleural pleural effusion. In the upright position, the sputum is increased, and the apex is increased. From the normal inner 1/3 to the outer 1/3, the middle is relatively flat, the left lung bottom effusion shows the distance between the shadow and the stomach bubble increases, the affected side rib angle becomes dull, as doubt Under the lungs, the patient underwent chest embolism or chest X-ray examination for 20 minutes. At this time, the liquid was scattered, and the outer edge of the affected lung showed a band-like shadow, and the diaphragm was formed. The thicker the band shadow, the thicker the product. The more fluid, 3 encapsulated effusion: the localized pleural effusion formed by pleural adhesion, the pleural pleural effusion often occurs in the lower posterior lateral wall, a few can occur in the anterior chest wall, X-ray signs upright or When properly tilted, the bottom edge is attached to the chest wall, and the inner edge protrudes toward the lung field. Sharp, uniform density fusiform or elliptical shadow, shadow edge and obstructed angle of chest wall, 4 mediastinal effusion: effusion of mediastinal pleural cavity, anterior mediastinal effusion showing shadow along the edge of heart and large blood vessels, right anterior superior mediastinum The effusion shadow is quite similar to the thymus shadow or the right upper lung without the shadow. Take the right lateral position, and the left front oblique 30° position for 20-30 minutes, take the posterior anterior chest radiograph of the position, showing that the upper mediastinum shadow is obviously widened. The mediastinal effusion must be differentiated from the heart's increased shadow or pericardial effusion, which appears as a triangular or banded shadow along the spine.
Ultrasound examination
Ultrasound detection of pleural effusion is highly sensitive, accurate positioning, and can estimate the depth of pleural effusion and the amount of fluid accumulation, suggesting that the puncture site can also be differentiated from pleural thickening.
Diagnosis
Diagnosis and diagnosis of tuberculous pleurisy
According to the medical history and clinical manifestations, tuberculous pleurisy can be diagnosed, the clinical manifestations are mainly moderate fever, relieved after initial chest pain, dyspnea, physical examination, X-ray examination and ultrasound examination can make diagnosis of pleural effusion, diagnostic thoracic puncture Routine examination of pleural fluid, biochemical examination and bacterial culture are necessary measures for diagnosis, and these measures can diagnose 75% of the cause of pleural fluid.
Differential diagnosis
Bacterial pneumonia
In the acute phase of tuberculous pleurisy, there is often fever, chest pain, cough, shortness of breath, leukocytosis, chest X-ray showing high-density uniform shadow, easy to be misdiagnosed as pneumonia, but coughing often has phlegm, often rust-colored sputum, The lungs are solid signs, pathogenic bacteria can often be found in sputum smear or culture, tuberculous pleurisy is mainly dry cough, the chest is a fluid sign, and the PPD test can be positive.
2. Pneumonia-like pleural effusion
Occurred in bacterial pneumonia, lung abscess and bronchiectasis with pleural effusion, the patient has a history of lung lesions, the amount of fluid is not much, found in the ipsilateral side of the lesion, the number of white blood cells in the pleural fluid increased significantly, with neutral particles Cell-based, pleural fluid culture can have pathogenic bacteria growth.
3. Malignant pleural effusion
Pulmonary malignant tumors, breast cancer, direct invasion or metastasis of lymphoma, pleural mesothelioma, etc. can produce pleural effusion, and pulmonary tumors with pleural effusion are the most common, tuberculous pleural effusion and tumor The identification points of pleural effusion are shown in Table 1. Tuberculous pleurisy sometimes needs to be differentiated from systemic lupus erythematosus, rheumatoid pleurisy and other pleural effusions. These diseases have their own clinical characteristics, and identification is not difficult.
