Vpotnye (exudative) pleurisy

Among patients with exudative pleurisy is dominated by persons aged 20-25 years. Curve incidence of pleurisy gives two stroke: in spring and autumn.
The clinical picture. To begin vpotnye P. also characterized by chest pain. In the basis of the pain is the same disease process, which in dry P., the difference is only in degree exudative reaction. Clinically to foresee in what cases the dry pleurisy go into exudative, very difficult. To begin vpotnye P. characteristic usually higher temperatures (to 39.0-39,5 degrees), rarely found in dry P. accumulation effusion and separation pleura flank pain weaken, and then completely stopped.
Cough (see) is an early and persistent symptoms exudative pleurisy: often a dry cough, but may acquire coloradony character at a pressure of enlarged lymph nodes (bronchogenic) on the vagus nerve. The accumulation of effusion coughing decreases, but increasing shortness of breath (see).
A big breath with a slight effusion due to intoxication. The massive accumulation of fluid (more than 500 ml), causing the displacement of the mediastinum, significantly complicates the conditions of breath. Severe shortness of breath, sometimes life-threatening symptoms.
In exudative pleurisy experiencing a disruption of the heart. Sooner appears tachycardia (see). The shift of the mediastinum pleural effusion is accompanied by swelling of the neck veins, obstructing blood flow to the heart.
When pleurisy often develop functional disturbance in the regulation of metabolic processes. Perverted water-salt metabolism, the delay in the body of water and salt. Daily diuresis is reduced to 200-300 ml Develop hypoproteinemia and hyperglobulinemia, disturbed activity of enzyme systems, decreases the intensity of oxidative processes, upset currency of vitamins, develops hypofunction of the adrenal glands, etc. the Greatest degree of biochemical disorders observed in the pleura TB, empiema and pyopneumothorax.
Changes in the peripheral blood of individual values when P. not have. ROHE usually sped up to 40-60 mm per hour. Marked leukopenia with neutropenia and eosinopenia.
Recognition of the already small effusion (about 300 ml) is possible with the help of x-ray (literoticapics) and targeted percussion studies. Comparing the location of the bottom border of light in a vertical and horizontal position of the patient, C. X. Vasilenko (1926) found that the offset this percussion borders are at least one transverse finger indicates the presence in the pleural cavity free effusion.
The speed of accumulation of effusion different: young people this process is completed within a few hours or days, and the elderly, the fluid builds up slowly and rarely reach large sizes. Pleural exudate in accumulating rib-diaphragmatic, rib-mediastinal, mediastina-diaphragmatic sinuses.

Fig. 4. Contact the spread of tuberculosis (group paratracheal lymph nodes on the visceral pleura) in the event of serous exudative pleurisy: 1 and 2 - limited dissemination in the early stages of pleurisy; 3 - widespread dissemination.

Negative intrapleural pressure and refrakternaya the lungs to create conditions for the peculiar location of the top border of exudate in the parabolic line Ellis - Damaso - Sokolova. It goes from the spine outwards and upwards to the posterior axillary line, and then drops down to the mid-clavicle line. Thus, the higher the location of the exudate reaches rear-axillary line.
Tuberculous pleurisy. TB infection can affect subpleural lymph nodes: settling in them, Mycobacterium tuberculosis partially are immured and die, partially, preserving their virulence, spread through the lymph system and cause subpleural cortical imparity or exudative pleurisy. Lymphogenous P. clinically benign. Possible hematogenous drift of TB infection in the pleural cavity with the development of pleural plaques tuberculosis bumps. The initial focus is active tuberculosis process in hilar lymph nodes. Hematogenous P. are more difficult. Contact the path of infection (Fig. 4) occurs when the active ferruginous-mediastinal tuberculosis with the defeat of the visceral pleura and much less when subpleural localization caseous pneumonia.
Clinically pleurisy tubercular etiology is manifested in the form of serous, sero-fibrinous or significantly less bleeding and purulent exudative P. Temperature curves for tuberculosis pleurisy diverse. The period of rise of the exudate matches usually higher body temperature with a small (about 1 degree) daily fluctuations. By the beginning of the third week the temperature political reduced. Sometimes rapid resorption of the exudate is accompanied by a significant increase of temperature with large daily fluctuations (the absorption of protein). The General condition of patients remains satisfactory. Sometimes on the grounds of tuberculosis intoxication develop instability of mood, mental depression, lethargy, apathy, increasing weakness, night sweats, progressive weight loss. In the acute phase of pleural exudate marked leukopenia with relative eosinophilia and limfotsitoz, acceleration ROHE to 45-50 mm per hour. In severe cases, there is a tendency to hypochromic anemia, small the neutrophilic leucocytosis with a shift to the left and more significant acceleration ROHE.
The transition serous tuberculous pleurisy in purulent can occur in elderly and debilitated patients with progressive course hematogenous disseminated or fibrous-cavernous pulmonary tuberculosis. Pus is a sterile, and sometimes it has any of Mycobacterium tuberculosis.
Rheumatic pleurisy occurs more frequently in children and adolescents with severe forms of rheumatic pancarditis. Essentially rheumatic P. refers to rheumatic polyserositis, independent clinical significance is not differ a benign course.
Para - and metapneumoviruses pleurisy caused by the involvement of the pleura in the area pneumonic infiltration. Parapneumonic (cinnamonensis) P. develop in the midst of pneumonia, especially in early childhood, in the form of reactive inflammation of the pleura (the pus often sterile and absorbed as the elimination of pneumonia) or in connection with the breakthrough subpleural purulent. Metapneumovirus (postpneumonic) pleurisy develop soon after the crisis and, as a rule, become a distinct diseases. They are accompanied by high temperature and other characteristic Clinical signs of pleural empyema (see below Purulent pleurisy).
Exudative pleurisy in the kollagenozov independent clinical significance is not. A long with a tendency to relapse. Diagnostic criteria: severe weight loss with no known reason, erythematous rash, especially on the face, swollen lymph nodes, changes in protein and protein fractions in blood serum, and so on; in addition, it should be noted that the kollagenozov develop mainly in women.

Exudative pleurisy with embolic heart attacks, lung develops as a consequence of engagement in reactive inflammatory process visceral piece of pleura with the formation of the first fibrinous overlays, and then sero-fibrinous and serous hemorrhagic effusion, pleural effusion is often the only sign of a hidden flowing phlebothrombosis and tromboflebitov (symptom centuries Cherkas).
Exudative pleurisy in malignant tumors is not rare. Critical in the pathogenesis of these ekssoudace is a violation of the permeability of the blood and lymphatic vessels of the lungs and pleura, and the disorder of blood in lymph circulation to the blockage of the lymph nodes metastases.
In rare primary cancer of the pleura (mesothelioma) first occur contamination and infiltration of tumor cells parietalnah piece of pleura, losing its physiological capacity for absorption of fluids. Under these conditions at the beginning of the disease is the accumulation of large amounts of exudate. Later damage visceral piece of pleura exudation gradually reduced and eventually stopped altogether.
Leading clinical symptoms of pleurisy with mesothelioma are persistent and sharp pain in the chest, not diminishing the accumulation of effusion. Exudate often hemorrhagic nature, bilateral, rapidly accumulating. Body temperature is usually normal.
Much more often there are the cancer pleurisy secondary origin. The earliest and most permanent signs are dry (hacking) cough, shortness of breath and chest pain. The accession of secondary infection and the emergence of pneumonic infiltration, often with abscess formation, accompanied temperature reaction wave-like character with the neutrophilic leucocytosis and sharp acceleration ROHE.
Exudative P. in sarcoma or chlamydia mediastinal lymph nodes are characterized by rapid accumulation of hemorrhagic effusion, symptoms compression of the mediastinum.
Purulent pleurisy - see below.