Inflammatory process of an acute or chronic type of pleura (pleura is
defined as the serous membrane that completely covers the lung - visceral
pleura - and the chest cavity - parietal pleura).
Formation of a more or less abundant effusion in the pleural cavity.
Depending on the quality of the exudate, the following are distinguished:
serofibrinose pleurisy. hemorrhagic pleurisy, purulent pleurisy or empyema.
The etiology of pleurisy is usually viral, bacterial, and tubercular.
Sometimes it is later, however, to ongoing pathological processes (connective
tissue diseases, neoplasms, or more frequently it is related to heart
failure with exacerbation of bronchoinfective processes, etc.).
Never, however, exclude neoplastic conditions correlated to mesotheliomas
and / or bronchogenic neoplastic processes: the writer has had the
experience of a chronic left pleural effusion which, in the last time,
turned out to be related to bronchogenic squamous tumor, a very frequent in
elderly smokers.
In this specific case the patient, as a young man, as well as smoker had
been a worker in charge of the Belgian coal mines.
There are different types of pleurisy. In general, there is a tendency to
distinguish between dry pleurisy (also known as fibrin pleurisy) and
exudative pleurisy (also known as serum-fibrin pleurisy).
;Within these two categories there are other sub-classifications. Dry
pleurisy is characterized by the very low presence of exudate in the pleural
cavity. It is the most common form of pleurisy in tuberculosis.
It usually occurs with high fever but this symptom may often also lack
dyspnoea.
The objective symptoms consist in: enlargement of the affected thorax, abolition of the tactile vocal tremor and hypophonesis "thigh" in the lower
part of the thorax, hypophonesis that fades upwards in a hyperphonetic area with a convex line upward (line of Damoiseau-Ellis).
Absence of physiological vesicular murmur at the dull area. During the first few days, pleural rubbing can be heard, which then disappears when the
formation of the liquid moves away the pleural sheets.
The main symptom of pleurisy is sudden pain; the subject generally feels a painful type of tendency that tends to get worse with breathing and in case
of cough, another symptom often present.
Pain is not always intense, in some cases, in fact, the subject, more than pain, senses a feeling of vague annoyance.
The pain originates from the inflammatory process of the parietal pleura (innervated by the intercostal nerves), since the visceral one does not possess
sensitivity.
Generally the pain is located in the area affected by the inflammatory
process, but it can also be felt in more distant areas (for example the
abdomen or the thoracic base), in other cases the pain can be felt at the
neck and shoulder (the central area of the diaphragmatic pleura is
innervated by the phrenic nerve, the most important nerve of the cervical
plexus).
A characteristic sign of pleurisy is the so-called rubbing; it is basically
a very special noise that can be heard with the aid of a phonendoscope
placed on the thoracic zone affected by the pathology; in certain cases the
pleural rubbing becomes even palpable in the form of a thrill.
Rubbing is generally, though not always, associated with pain. In the event
of a significant pleural effusion, the reduction or absence of physiological
vesicular murmur (the audible noise on the whole healthy lung), percussion
dullness, absent vocal twitching, etc. are becoming evident.
Chest CT: the bilateral pleural fluid level
in old cardiopathic decompensated is appreciated
at the cross section
If the pleural effusion is particularly abundant, dyspnoea may occur. In these
cases the maneuver of the evacuative thoracentesis and the diagnostic tests of
the pleural fluid, for example culture and chemical-physical, is appropriate.
But already at an initial examination the expert doctor orients itself: the
citrine yellow liquid directs towards the exudates, if it is blood, one must
suspect a neoplasm.
The BNP research, moreover, will allow to exclude diseases related to heart
failure and also an echocardiographic investigation will allow to study the
heart pump if it is depressed or not.
Radiological examination: homogeneous opacity of the lower part of the thorax
ending with a convex line upward and oblique downward in the latero-medial
direction. The mediastinum is usually moved contralateral.
The exploratory toracentesis results in a liquid usually citrine-yellow, whose
drops, dropped into a cylinder containing water and some drops of acetic acid
form a species of "cigarette smoke" comparable clouds (Rivalta test).
Characteristics of neoplastic pleurisy: can continuously reform without giving
other symptoms, except for dyspnea, until the appearance of the neoplasm; it is
almost always hemorrhagic and can be characterized by retraction rather than by
the expansion of the affected limb.
Therapy: evacuation of liquid with intake of air (about one third of the liquid
extracted), administration of antipyretics plus basic therapy (broad-spectrum
antibiotics, antituberculosis, antineoplastic depending on the etiological
diagnosis).
Chest x-ray: left hemifrene ascending for outcomes of chronic pleural effusion
The two radiological plates of the standard thorax refer to a cardiopathic
patient, undergoing congestive myocardial decompensation, who had a bronchial
infusion process with a consensual exudative effusion on the left.
The two plates refer to the time of entry into the ward, and then to discharge,
the one to follow below.