Overview.
Tuberculous pyothorax is often caused by rupture of tuberculosis cavities or subpleural caseous lesions and infection of the pleura, or by direct spread of paravertebral abscesses from spinal tuberculosis. It can also be caused by pneumothorax due to bronchopleural fistula or pleural cavity infection complicated by tuberculosis surgery. In addition, some of the long-term non-absorbable exudative pleurisy effusion may develop into pus chest. Since the widespread use of anti-tuberculosis drugs, the incidence of tuberculous pyothorax has been significantly reduced.
Etiology
There are several ways for tuberculosis bacilli to enter the thoracic cavity: infection caused by lymph or blood circulation, direct invasion of pleura by tuberculosis foci in the lungs, or rupture of the foci to bring tuberculosis bacilli directly into the thoracic cavity, and to make the gas enter the thoracic cavity, to form tuberculous pus-pneumothorax, bronchopleural fistula. Bone tuberculosis or chest wall tuberculosis can also invade the chest cavity. Tuberculous pyothorax is also a complication of artificial pneumothorax or surgical treatment of tuberculosis.
Symptoms
Most cases of tuberculous pyothorax start slowly, with malaise and low-grade fever as the main symptoms, followed by night sweats, chest tightness and dry cough. The absorption of pleura is stronger in the early stage, and the symptoms of toxicity are obvious. Symptoms such as shortness of breath and dyspnea occur when more pus accumulates. When bronchopleural fistula occurs, there is an irritating cough and coughing up pus related to body position. Cough and pus and sputum increase in the healthy lateral position. When tuberculosis dissemination occurs due to bronchopleural fistula, toxic symptoms are obvious and the condition is critical. Those with acute onset of the disease have obvious signs of toxemia, such as chills, high fever, excessive sweating, dry cough, chest pain, and so on.
The signs of tuberculous pyothorax are similar to those of exudative pleurisy. The chest wall may have tenderness and mild edema. In chronic cases, the thorax collapses, the trachea moves to the affected side, the intercostal space narrows, respiratory movement is limited, solid sounds on percussion, decreased breath sounds, and may be accompanied by pestle-like fingers (toes). When there is a large amount of pus in the chest cavity, the affected side of the chest is full, respiratory movement is reduced, the rib space is flattened, percussion is turbid, the mediastinum, trachea and heart edge turbid sounds are biased toward the healthy side, respiratory sounds are weakened or disappeared, and the speech tremor is weakened. In the late stage of the disease, the mediastinum is pulled toward the affected side by scarring. The chest wall is invaginated due to the contraction of the pleural scar, the intercostal space is narrowed, and the spine is curved to the healthy side.
Examination
1. X-ray manifestations
Similar to chronic pyothorax, it is easy to diagnose tuberculosis foci in the contralateral lungs, while tuberculosis foci in the affected lungs may be covered by effusion and not easy to characterize. Thoracentesis extracts thin pus containing dry cool material.
2. Body radiography
It can show the size of the abscess cavity, whether there is tuberculous lesion in the lung and the extent of the lesion.
3.CT examination
To learn more about the pus cavity and the subtle changes in the lesion.
Diagnosis
Based on typical symptoms, signs, elevated white blood cell count, X-ray and thoracocentesis, the diagnosis is established if the pus is yellowish, thin, contains caseous material, no pathogenic bacteria grow on smear and culture, and Mycobacterium tuberculosis is found in the pus. The wall of the pus cavity is pathologically examined and has the typical features of tuberculosis, which can lead to a definite diagnosis. Early stage of pyothorax is not easy to distinguish from exudative pleurisy. When bronchopleural fistula is suspected, methylene blue (methylene blue) can be injected into the chest cavity, and the sputum becomes blue can be confirmed, and the negative result can not exclude bronchopleural fistula.
Differential diagnosis
1. Pleural mesothelioma
Pleural mesothelioma is characterized by: ① persistent chest pain. ② Uncontrollable hemorrhagic pleural fluid. ② Uncontrollable bloody pleural fluid. ③ No obvious improvement of pleural effusion after anti-tuberculosis and anti-inflammatory treatment. ④Thickened and uneven pleura. If necessary, CT and pathologic examination should be done to assist the diagnosis.
2. Pulmonary cyst
Pulmonary cysts are cystic lesions of lung parenchyma formed by congenital developmental abnormalities. They are divided into fluid cysts, air cysts and fluid-air cysts. When the cysts are small, they may be asymptomatic or have mild symptoms. If the huge fluid cysts are fashionable, it is difficult to distinguish them from pyothorax.
3. Malignant pleural effusion
In case of fever, unexplained prolonged pleural effusion, the nature of pleural fluid is exudate, and there is no treatment by anti-tuberculosis and thoracentesis, this disease should be considered, and TV thoracoscopy or surgical exploration can help to confirm the diagnosis.
Complications
1. Self-exploding pyothorax
This disease is a common complication. The wall pleura of tuberculous pyothorax ruptures, discharges the contents, passes through the chest cavity, and enters the subcutaneous tissue of the chest wall.CT can show the lesions inside and outside the chest cavity, presenting thick-walled encapsulated effusion, and also show the fistula tract between the two.
2.pleural malignant tumor
The complication of pleural malignant tumor is relatively rare, the most important factor is chronic inflammatory stimulation, and its pathology is more types. If the following signs appear, it is suggestive of this complication: ① density enhancement of the chest cavity. ② Swelling of the soft tissues of the chest wall and blurring of the fat line, or both. Bone destruction. ③Bone destruction. ④Widespread inward displacement of calcified pleura. ⑤ Intracavitary neoplastic fluid and gas planes.
3.Other
Chronic pyothorax with postoperative complication of residual cavity effusion, stump fistula after total pneumonectomy of pleura, persistent sinus tract, etc.
Treatment
The treatment principle of tuberculous pyothorax is to eliminate the abscess cavity and control pleural infection. The presence of secondary infection or bronchopleural fistula should be clarified. Penicillin G injection is the drug of choice when controlling secondary infection.
1. Simple tuberculous pyothorax
In addition to systemic anti-tuberculosis treatment, repeated thoracic cavity pus extraction, irrigation and local injection of anti-tuberculosis drugs should be carried out. Withdraw pus 2-3 times a week, each time with 2% sodium bicarbonate or saline to flush the pus cavity, in the pus cavity injected p-ammonia salicylate, isoniazid or streptomycin. The pus can be gradually reduced and thinned, the lungs open up, and the pus cavity gradually shrinks to disappear.
2. Tuberculous pyothorax with secondary infection
In addition to pus extraction, irrigation and local anti-TB treatment, antimicrobial drugs should be added for peripheral and local treatment. Penicillin G is injected intramuscularly, intrapleural injection, or treated with other antibiotics. After secondary infection is controlled, it is treated as simple tuberculous pyothorax.
3. Bronchopleural fistula
Bronchopleural fistula is a serious complication. In addition to secondary infection, bronchial dissemination of tuberculous foci may occur. Thoracic drainage should be given first, and surgical treatment should be performed when the condition improves.
4. Chronic tuberculous pyothorax
Chronic pyothorax is characterized by long-term purulent inflammation, pleural thickening, significant fibrosis and purulent granulomatous tissue proliferation. Lung atelectasis, seriously affecting pulmonary function. With bronchopleural fistula, the lesion may undergo bronchial dissemination. Surgical treatment can eliminate the abscess cavity and reopen the lung. Preoperatively, it is necessary to know whether there is active tuberculosis in both lungs and the function of the healthy side of the lung. If the lung lesion is indicated for surgical resection, accompanied by bronchial stenosis, and it is estimated that the lung cannot be reopened, lobectomy or total lung pleurodesis with thoracic reshaping should be performed at the same time as resection of the abscess cavity. If the lung lesion is no longer active, only the residual cavity of the abscess is resected; if there is a bronchopleural fistula, fistula repair is performed at the same time.
Questions you may be concerned about
What should I do if I have tuberculous pyothorax?
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1. Drug treatment: tuberculous pyothorax is a lung abscess caused by untimely treatment of lung infection, first of all, anti-tuberculosis drugs such as isoniazid and antibiotics such as cefadroxil can be used to treat together, and then review the effect of treatment.
2. Surgery: If the condition does not improve after drug treatment, and if the accumulated pus is still not drained out after thoracentesis or closed chest drainage, such as chest CT examination suggesting the existence of lung atelectasis or abscess formation of fibrous plate, surgery can be considered to remove the accumulated pus completely.
It is recommended to go to the hospital for regular anti-tuberculosis treatment in a timely manner, and if infection occurs during the treatment period, it should be treated in a timely manner so as not to cause complications such as pyothorax.
Prevention
Early detection, early diagnosis and early treatment are recommended for this disease. In the early stage of tuberculosis, there is not much pus accumulation, so it should be treated with anti-tuberculosis therapy, strengthen nutrition and proper rest, and may be absorbed and improved.