Overview of the disease
Mycobacterium tuberculosis invades the pleura and causes an inflammatory disease of the pleura, which may include fever, malaise, night sweats, chest pain, irritating dry cough, chest tightness, and dyspnea. Mycobacterium tuberculosis infection of the pleura is treated with anti-tuberculosis medications, which may be supplemented with fluid aspiration, glucocorticoids, and surgery.
Definition
Tuberculous pleurisy is an inflammatory disease of the pleura caused by the entry of Mycobacterium tuberculosis and its metabolites into the pleural cavity of a hypersensitive organism, and is a type of tuberculosis.
Types
Dry pleurisy
It is an early manifestation of tuberculous pleurisy.
It can occur in any part of the pleural cavity, mostly in the apical part of the lungs, followed by the lower part of the lungs.
There is no fluid exudation.
Exudative pleurisy
Most often develops from dry pleurisy and the lesion is mostly unilateral.
There is exudate of varying volume in the thoracic cavity, usually plasma, yellowish, occasionally bloody.
Tuberculous pyothorax
It is mostly caused by improper treatment of exudative pleurisy, breakdown of subpleural tuberculous foci into the pleural cavity, or invasion of the pleura by a large number of Mycobacterium tuberculosis.
If there is a concomitant pyogenic bacterial infection it is called a mixed pyothorax.
Morbidity
Tuberculous pleurisy can occur at any age and is the most common form of pleurisy in children and young adults, with most of our patients being young adults.
In developing countries, 23% of tuberculosis patients are tuberculous pleurisy.
In western developed countries, only 3% to 5% of tuberculosis patients are combined with tuberculous pleurisy.
Causes
Causes
Pathogen
The pathogen is Mycobacterium tuberculosis.
It can be a primary infection or a pleural lesion secondary to tuberculosis.
Route of infection
Mycobacterium tuberculosis invades the pleura through three routes: direct spread, hematogenous dissemination, and lymphatic dissemination.
Pathogenesis
Normally, there is a very thin layer of fluid on the surface of the pleura of the dirty and wall layers, which plays a lubricating role, and the production and absorption of fluid are in dynamic balance.
When the body has a weak allergic reaction to Mycobacterium tuberculosis, only a limited, fibrinous pleurisy (i.e., dry pleurisy) develops.
When the body develops a high-intensity allergic reaction to Mycobacterium tuberculosis, more fluid is produced than absorbed in the chest cavity, which leads to exudative pleurisy.
In the early stages of pleural inflammation, there is first pleural congestion, edema and infiltration of inflammatory cells, shedding of pleural endothelial cells, fibrin exudation from its surface, followed by plasma exudation, forming pleural effusion, and often tuberculous nodule formation in the pleura.
Symptoms
Different types of tuberculous pleurisy present with slightly different symptoms.
Most patients with dry pleurisy have no or few symptoms and often recover spontaneously.
Symptoms of tuberculosis toxicity
There are varying degrees of fever, such as low, moderate or high fever in the afternoon, and chills may be present.
Symptoms such as malaise, night sweats (sweating after going to sleep and stopping after waking up) and loss of appetite may also occur.
When the disease is prolonged, symptoms such as emaciation and anemia may occur.
Respiratory symptoms
Chest pain
Dry pleurisy: localized pinprick-like chest pain, aggravated by deep breathing and coughing.
Exudative pleurisy: irritating chest pain, the degree is more serious, with the appearance and increase of pleural effusion, chest pain can be weakened or disappeared.
Tuberculous pyothorax: if subpleural hole rupture occurs, severe erosion of pleura, more severe chest pain.
Cough
Dry pleurisy: a persistent dry cough.
Exudative pleurisy: at the beginning of the disease, there is mostly irritating dry cough with little sputum.
Tuberculous pyothorax: when accompanied by bronchial fistula, there is a severe irritating cough with a large amount of pus sputum.
Others
Shortness of breath and superficiality may also be present.
When there is a large amount of pleural effusion in exudative pleurisy, or pus accumulates in tuberculous pyothorax, it may compress the surrounding organs, resulting in chest tightness, shortness of breath, palpitation, dyspnea, telangiectasia, and cyanosis.
Complications
Tuberculous tumor of pleura
Mostly seen in young adults, most of them have good immune function.
Tuberculous pleurisy gradually develops fibrous connective tissue hyperplasia, pleural adhesions, caseous necrotic foci, and finally the localized lesion absorbs and concentrates to become a fibrous tissue-coated caseous mass.
Most of them have fever, cough, chest pain and chest tightness, but the clinical symptoms are not typical and have no obvious specificity.
Acute tuberculous pyothorax with bronchopleural fistulae
Coughing up a large amount of pus sputum, sometimes bloody.
Extrapulmonary tuberculosis
Such as osteoarticular tuberculosis, renal tuberculosis, and intestinal tuberculosis, the corresponding symptoms of the respective diseases are present.
Consultation
Department of Medicine
Infectious Diseases Department
If you have a history of close contact with a patient with tuberculosis or have pre-existing tuberculosis and develop symptoms such as unexplained fever, fatigue, excessive sweating at night, chest pain, chest tightness, etc., it is recommended that you consult a doctor promptly.
Respiratory medicine
If you have the above symptoms, you can also consult the Respiratory Medicine Department and be referred to the Infectious Diseases Department or a specialized hospital for treatment after confirmation of the diagnosis.
Emergency Medicine
In case of emergencies such as difficulty in breathing or sedentary breathing, it is recommended to consult the emergency department immediately.
Preparation for medical treatment
Preparing for your visit: registering, preparing your documents, and frequently asked questions
Tips for medical treatment
Chest auscultation, chest X-ray and chest CT may be required. Wear loose-fitting clothes and avoid wearing clothes made of metal. Those who are pregnant or planning to become pregnant should inform the doctor in advance.
Avoid contact with people around you, wear masks and gloves, cover your mouth and nose when sneezing, and try not to take public transportation before seeking medical treatment.
For patients with high fever, physical cooling can be done first, such as applying cold compresses to the forehead and wiping hands, feet and armpits with warm water.
Checklist for medical preparation
Symptom Checklist
Especially focus on the time of onset of symptoms, special manifestations, etc.
Is there fever? What is the highest degree? Is there a pattern?
Is there coughing and sputum? Is there blood in the sputum?
Is there any night sweating in bed?
Is there any chest pain, chest tightness, difficulty in breathing?
How long have these symptoms been present?
List of medical history
Has there been any contact with patients presenting with similar symptoms? Have you ever traveled to a tuberculosis infected area?
Are there any chronic medical conditions such as diabetes?
Any history of tuberculosis?
Have you received BCG vaccination?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests: blood count, erythrocyte sedimentation rate
Imaging tests: Chest X-ray, Chest CT scan
Medication List
Medication used in the last 3 months, if available, bring the box or package with you to the doctor’s office.
Anti-tuberculosis drugs: isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin
Diagnosis
Diagnosis based on
Medical history
May have a history of TB or contact with a TB patient.
Clinical manifestations
Symptoms
There are varying degrees of fever, malaise, night sweats, anemia, emaciation, etc. Chest pain, cough, chest tightness, palpitations, dyspnea, etc. may also be present.
Physical signs
Dry pleurisy: pleural friction sounds may be detected.
Exudative pleurisy and tuberculous pyothorax
Visual examination: restriction of respiratory movement can be found, localized pressure pain, and fullness of the thorax and widening of the rib space can be seen.
Palpation: tracheal mediastinum can be found to be displaced to the healthy side, and the intensity of fibrillation can be changed.
Auscultation: localized turbid or solid tones on percussion, weakened or absent respiratory sounds, and weakened or absent voice conduction can be found.
Auscultation: weakened or absent respiratory sounds can be found.
When tuberculous pyothorax has a long course, the mediastinum is shifted to the affected side by scar pulling, the chest wall is invaginated due to scar contraction, the ribs are clustered together, the rib space is narrowed, and the spine is scoliotic; some patients have pestle finger.
Laboratory tests
Blood counts
Total peripheral blood leukocyte count is normal or slightly elevated.
Can be used for differential diagnosis of pleural effusion.
Sputum smear and bacterial culture
Sputum smear examination and bacterial culture may be positive when combined with tuberculosis.
Tuberculin skin test (PPD test)
The result of the test is strongly positive, which is an important reference for the diagnosis of the disease.
Interferon gamma release assay (IGRA)
The test result is positive, which can play a supplementary or auxiliary role in the diagnosis on the basis of conventional diagnosis.
Tuberculosis antigen test
Currently, the antigens examined are Lipids of arabinose mannan (LAM), Mycobacterium tuberculosis recombinant protein 38 kilodalton protein, 16 kilodalton protein, and Mycobacterium tuberculosis-specific protein TB-SA.
It is of significance in the auxiliary diagnosis of tuberculous pleurisy.
Routine and biochemical examination of pleural effusion
Appearance: straw-yellow fluid with occasional bloody exudate.
Cellular composition: leukocyte count is increased, and neutrophils often predominate in the acute phase, but it quickly changes to predominantly lymphocytes and monocytes.
Chemical analysis: specific gravity >1.018, pH <7.40, decreased glucose level, protein mostly >40 g/l, positive Levantine test, which helps in the differential diagnosis of pleural effusion.
Adenosine deaminase (ADA): >45 units/liter, pleural effusion ADA to serum ADA ratio >1, higher sensitivity in diagnosing tuberculous pleurisy.
Lactate dehydrogenase (LDH): >200 units helps in the differential diagnosis of pleural effusion.
Mycobacterium tuberculosis test for pleural effusion
Helps in confirmatory diagnosis of the disease.
Positive pleural fluid smear for Mycobacterium antacidum is low, about 5.9%.
Pleural fluid culture is positive in about 25%.
Molecular biology tests such as pleural fluid Xpert MTB/RIF have the advantages of high sensitivity, high specificity and rapidity, and are important in the diagnosis of tuberculous pleurisy.
Other immunologic tests
Complement C3 and C4: Their levels are not seen to be elevated and are helpful in identifying pleural effusions due to SLE, rheumatic diseases, etc.
Anti-nuclear antibody (ANA), anti-double-stranded DNA (ds-DNA) antibody: used to identify pleural effusion caused by SLE.
Rheumatoid factor: to identify pleural effusions due to rheumatoid diseases.
Tumor Markers
Carcinoembryonic antigen (CEA): for differential diagnosis of malignant pleural effusion.
Other tumor markers: e.g. Glycosylated tumor-associated antigen, cytokeratin 19 fragment, neuron-specific enolase, mesothelin, etc.
Imaging
Chest X-ray
Dry pleurisy is unremarkable.
Decreased translucency on the affected side is seen when pleural fibrin deposits are 2 to 3 mm, and decreased diaphragmatic motion on the affected side is seen in base of lung pleurisy.
When the volume of pleural effusion exceeds 200 milliliters, the angle of the rib diaphragm can be seen to become obtuse; it is usually unilateral moderate volume of effusion, which is manifested as a homogeneous and dense shadow in the lower chest that is externally high and internally low, and the upper edge is concave, and rarely the entire affected side is a dense shadow.
Other foci within the lungs may be detected, such as nodules, patchy shadows, foci of fibroplasia, or calcifications predominantly in the upper lungs.
Precautions
X-rays should be performed with caution in special populations, such as infants, young children, and pregnant women.
Remove metal objects from the chest before the examination, such as necklaces around the neck and underwear with metal braces.
Lung CT examination
With high resolution of human tissue, dry pleurisy can find thickened pleura with localized inflammatory reaction, and can also find a very small amount of effusion.
It can identify pleural thickening, encapsulated effusions, and large cystic masses in the lungs or mediastinum.
It can detect intrapulmonary lesions and enlarged mediastinal lymph nodes and is more sensitive than chest X-ray.
Precautions: Fasting is generally not required, but for enhanced scanning and abdominal plain scanning only, fasting for at least 4 hours before the examination.
Ultrasound
Ultrasound is far more sensitive than X-ray in detecting pleural effusion.
It can find liquid dark area and pleural thickening, and can also measure a small amount of fluid in the angle of the rib diaphragm, and can estimate the depth and volume of pleural effusion, and distinguish whether the effusion is segregated or fibrotic.
In the case of encapsulated or fibrotic septated effusions, it can provide precise puncture localization to guide tube drainage and pleural puncture biopsy.
Pathologic examination
The structure and pathologic changes of the biopsy tissue can be directly observed, and typical tuberculous pathologic changes can be detected with a 60% to 80% positive rate.
Biopsy tissue smear or culture or molecular biology examination can be carried out to improve the positive detection rate of Mycobacterium tuberculosis and thus the diagnosis rate of tuberculous pleurisy.
It can be used for differential diagnosis of tumor and pleural granulomatous lesions.
Thoracoscopy
Allows direct visualization of pleural lesions.
Biopsy or pleural fluid can be taken for pathological examination, which helps in the diagnosis and differential diagnosis of the disease.
Fiberoptic bronchoscopy
This test can be performed to clarify the diagnosis if there is a suspicion of tuberculosis or bronchial tuberculosis, lymph node-bronchial fistula, airway obstruction, or if hemoptysis is present.
Some biopsies and secretions can also be removed for pathologic or etiologic examination.
Diagnostic Criteria
Clinical diagnosis
Tuberculous pleurisy can be diagnosed clinically if there are clinical manifestations of tuberculous pleurisy, pleural effusion is exudate, adenosine deaminase is elevated, tuberculin skin test is moderately positive or strongly positive, or γ-interferon release test is positive, or antibodies against Mycobacterium tuberculosis are positive.
Confirmed diagnosis
Anyone who meets one of the following items:
There are chest imaging manifestations of tuberculous pleurisy, and pleural effusion or pleural pathology consistent with tuberculous pathologic changes.
There is a chest imaging manifestation of tuberculous pleurisy, and a pleural effusion smear positive for Mycobacterium antacidum, or a positive culture of Mycobacterium and strain identification as Mycobacterium tuberculosis complex, or a positive nucleic acid test for Mycobacterium tuberculosis.
Differential diagnosis
Pneumatoid pleural effusion and pyothorax
Similarities: fever, cough, sputum, chest pain, pleural effusion.
Differences: Patients with pneumonic pleural effusion and pyothorax have the following characteristics.
Most of them have a history of lung infection or septic infection of neighboring organs.
Routine blood tests may show elevated white blood cell count, neutrophilia and left shift of nucleus.
Chest X-ray examination may first see infiltrative shadows in the lung parenchyma, or manifestations such as lung abscess and bronchiectasis.
Malignant pleural effusion
Similarities: chest pain, coughing up sputum.
Differences: Malignant pleural effusion is characterized by the following.
May have a history of malignant tumor.
It is more common in people over 45 years old.
Sputum is often bloodstained, chest pain is mostly dull in nature, and wasting symptoms are obvious.
There is a possibility of finding tumor foci on imaging.
Pleural effusion is mostly bloody, with large volume and rapid growth, elevated levels of CEA and tumor markers, and LDH more than 500 units/liter.
Thoracic fluid cytology, pathology, fiberoptic bronchoscopy and thoracoscopy are helpful for further diagnosis and differentiation.
Rheumatoid pleurisy
Similarities: cough, chest pain, pleural effusion.
Differences: rheumatoid pleurisy is characterized as follows.
Most often seen in male patients over 60 years of age.
There is a history of rheumatoid arthritis for more than 10 years.
Most often present with cough, chest pain, shortness of breath after activity, joint pain, or no obvious symptoms.
Pleural effusion is mostly small or moderate in volume, can be unilateral and bilateral, yellow or yellow-green, or milky or bloody; pleural effusion white blood cell count is increased, LDH is increased, and glucose level is significantly decreased.
Complement C4 is elevated, rheumatoid factor is positive, and immunologic tests may aid in the diagnosis.
Lupus pleurisy
Similarities: fever, chest pain, cough, pleura, pleural effusion.
Differences: lupus pleurisy is characterized by the following.
History of lupus erythematosus.
Pleural effusions are mostly bilateral, grass-green exudate, LDH is elevated, and lupus cells (LE cells) are detected.
Complement C3 and C4 are decreased, and anti-ANA and ds-DNA antibodies are positive. The diagnosis is clear based on laboratory tests.
Rheumatic pleurisy
Similarities: fever, cough, chest pain, dyspnea.
Differences: rheumatic pleurisy is characterized by the following.
There is a history of rheumatic fever.
There may be manifestations of rheumatic fever, such as irregular fever, wandering polyarthritis (often symmetrically involving large joints such as elbows and knees, and there may be localized redness, swelling, heat and pain).
Pleural effusion is mostly bilateral and is fibrinous plasma with small amount. In the acute stage, it is exudate, with neutrophils mainly, mixed with erythrocytes, and lymphocytes and eosinophils increase in the later stage. Individual cases show hemorrhagic effusion.
Actinomyces pleurisy
Similarities: fever, cough, sputum, chest pain and pleural effusion.
Differences: Actinomyces pleurisy is characterized by the following.
There may be a history of pulmonary actinomycosis.
Sputum is purulent. Involvement of the pleura, chest wall can appear local redness, swelling, pressure pain, hardening of peripheral tissues, can form chest wall abscesses and fistulas, and its secretions can be found in the “sulfur particles”, actinomycetes, which helps to confirm the diagnosis of this disease.
Fungal pleurisy
Similarities: fever, cough, sputum, chest pain, dyspnea, lethargy, fatigue.
Differences: fungal pleurisy is characterized as follows.
Patients tend to have risk factors for fungal infection, such as neutropenia, treatment with immunosuppressants and glucocorticoids, trauma, and major surgery; or a history of an immunocompromised primary.
Patients may have high or low-grade fever, and may present with hemoptysis; or they may have wasting and fatigue if the disease is prolonged, or they may have symptoms of the primary disease.
Routine blood tests for leukocytosis.
Most pleural effusions are small in volume and the signs are not obvious. Fungal culture of pleural effusion may reveal fungi, which helps in the diagnosis of the disease.
Amebiasis Pleural Effusion
Similarities: fever, lethargy, chest pain, cough, pleural effusion.
Differences: amebiasis pleural effusion is characterized by the following.
History of amebiasis, e.g. amebic liver abscess, pulmonary amebiasis.
There are mostly symptoms of the primary disease, chocolate-colored (tan) sputum may be clucked out, and there may be severe chest pain.
The pleural effusion is chocolate colored.
Amebic pathogens can be detected in the pleural effusion and sputum, which helps to clarify the diagnosis.
Schistosoma pleurisy
Similarities: fever, night sweats, coughing up sputum, dyspnea, etc.
Differences: Schistosoma pneumoniae pleurisy is characterized as follows.
The patient has a history of living in an endemic area and a history of eating crabs and crayfish raw.
There may be symptoms of urticaria, diarrhea, abdominal pain, coughing rust-colored sputum.
The pleural effusion is grass green and clear, and a few may be bloody or purulent. The pleural effusion contains more eosinophils, and sometimes Charcot-Rayden crystals can be found.
Schistosoma pneumoniae eggs can be detected in pleural fluid and sputum, which helps to clarify the diagnosis.
Scrub typhus pleurisy
Similarities: fever, cough, chest pain, etc.
Differences: Scrub typhus pleurisy is characterized as follows.
The patient has a history of living in an endemic area.
The larval bite first appears as a red papule, which becomes a blister and then ruptures, with central necrosis and crusting, forming a brown or black crust, which falls off to form an ulcer.
Pleural effusion is small to moderate, unilateral or bilateral, and is usually self-absorbed as the disease progresses.
Immunologic tests may help in the diagnosis.
Treatment
Treatment aims
Control tuberculosis.
To alleviate pleural thickening and adhesions remaining after absorption of pleural effusion, as well as sequelae caused by pleural thickening, such as secondary bronchiectasis.
Chemotherapy
Treatment principle
Early, regular, whole course, appropriate amount, combined.
The whole treatment program is divided into two stages: intensive and consolidation.
Commonly used anti-tuberculosis drugs
First-line anti-tuberculosis drugs: isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin and five other drugs.
Second-line anti-tuberculosis drugs: sodium para-aminosalicylate, colistin, kanamycin, propylthioisonicotinamide, levofloxacin and rifapentine.
Isoniazid (isoniazid, INH, H)
The most bactericidal of the single anti-tuberculosis drugs, especially with early bactericidal activity. Usage is oral.
Occasional drug-induced hepatitis occurs after use, and caution is needed in those with abnormal liver function.
Vitamin B6 (pyridoxine) may be taken if peripheral neuritis occurs.
Rifampicin (RFP, R)
Rifampicin (RFP, R) is a bacteriostatic drug that, in combination with isoniazid, can significantly shorten the course of treatment. Usage is by mouth.
It is recommended to be taken in the morning on an empty stomach or half an hour before breakfast to maintain peak blood levels for a longer period of time.
It is normal to have reddish-orange coloration in urine, stool, and tears after taking the drug.
Transient transaminase elevation may occur after use of the drug, can be added to protect the liver treatment, and observation; if jaundice occurs, need to stop the drug immediately.
Adverse reactions such as influenza-like symptoms, skin syndrome, thrombocytopenia, etc. may also occur after use of the drug.
The use of this drug is prohibited in female patients up to the third month of pregnancy, and should be used with caution in female patients who are more than 3 months pregnant.
Pyrazinamide (pyrazinamide, PZA, Z)
is a bactericidal drug and is administered orally.
It is one of the three indispensable drugs, along with isoniazid and rifampicin, in a standard short course of chemotherapy.
Common adverse effects include hyperuricemia, liver damage, lack of appetite, arthralgia, and nausea.
Ethambutol (EMB, E)
It is a bacteriostatic drug and is used orally.
Adverse reactions are optic neuritis, vision and visual field should be tested regularly during treatment, and any visual abnormalities require prompt medical attention.
The drug should not be used in pediatric patients.
Chemotherapeutic regimen
Common tuberculous pleurisy
Daily dosing regimen: 2HRZE/7HRE.
Intensive phase: isoniazid, rifampicin, pyrazinamide, and ethambutol, taken at once, for 2 months.
Consolidation phase: isoniazid, rifampicin and ethambutol, taken at once, for 7 months.
Severe tuberculous pleurisy
Includes tuberculous pyothorax, encapsulated pleural effusion, tuberculous tumor of the pleura, and combination with tuberculosis elsewhere.
Daily dosing regimen: 2HRZE/10HRE
Intensive phase: isoniazid, rifampicin, pyrazinamide and ethambutol once daily for 2 months.
Consolidation phase: isoniazid, rifampicin and ethambutol once daily for 10 months.
Drug-resistant tuberculous pleurisy
The general rules of treatment regimen are as follows.
Strictly avoid selecting only one new drug to add to the original failed regimen.
The World Health Organization recommends the use of newer generation fluoroquinolones whenever possible.
Do not use cross-resistant drugs.
The regimen should contain at least 4 second-line sensitizing drugs.
This includes at least pyrazinamide, fluoroquinolones, injectable kanamycin or amikacin, ethylthio or propylthioisonicotinic acid hydrazide, and para-aminosalicylic acid (PAS) or cycloserine.
Drug dosage is determined by body weight.
The intensification period should be 9 to 12 months, with a total treatment period of 20 months or more, depending on the outcome of treatment.
Sputum culture is the best way to monitor the effect of treatment.
All medications should be used under the supervision of a doctor and should not be used blindly, changed or adjusted in dosage.
Glucocorticoid
Patients with acute tuberculous exudative pleurisy with severe systemic toxicity symptoms and large pleural effusion can try to add oral prednisone along with anti-tuberculous treatment.
When the body temperature is normal, the systemic toxicity symptoms are reduced, and the amount of pleural effusion is significantly reduced, the dosage should be gradually reduced or even discontinued.
Discontinuation of drugs should not be too fast, or easy to rebound phenomenon, the general course of treatment for 4 to 6 weeks.
When using glucocorticosteroids, it is necessary to pay attention to adverse reactions or tuberculosis dissemination.
All drugs should be used under the guidance of a doctor, and should not be used blindly, changed or adjusted the dose of drugs.
Fluid extraction treatment
In principle, the pleural fluid should be pumped out as soon as possible, or intercostal insertion of fine tube drainage, so as not to cause pleural adhesion; can also relieve pulmonary and cardiovascular compression, improve respiratory function; can also reduce the symptoms of toxicity, help to reduce body temperature, lung reopening.
For those with large amount of pleural effusion (pleural effusion located above the 2nd anterior rib), fluid aspiration should be performed 2 to 3 times a week until the pleural effusion disappears completely.
The first fluid draw should not exceed 800 milliliters, and each subsequent draw should not exceed 1,000 milliliters.
In the process of fluid extraction treatment, the patient’s response should be closely observed. If there is pulmonary redundant edema, severe cough caused by mediastinal swing, chest tightness and other discomforts, the fluid extraction should be stopped immediately, and dexamethasone should be injected intravenously at 5 to 10 mg.
Internal thoracoscopic treatment
It is suitable for patients with encapsulated effusion, which can cut off adhesions, eliminate residual cavity, peel and remove fibrin membrane on the pleural surface, and promote lung reopening.
Internal thoracoscopy is a safe and effective minimally invasive diagnostic and therapeutic technique that does not require general anesthesia and costs less than surgical thoracoscopy.
Intrapleural drug injection
Generally, tuberculous pleurisy can be treated through reasonable treatment, and there is no need to inject drugs into the chest cavity.
Anti-tuberculosis drugs
For patients with chronic encapsulated effusion or tendency to pyothorax or tuberculous pyothorax, 500 ml of sodium bicarbonate solution can be injected into the thoracic cavity for irrigation, followed by isoniazid, streptomycin, rifampicin, para-aminosalicylate, dexamethasone, and so on.
Fibrinolysis
It has the effect of reducing the viscosity of pleural cavity effusion, facilitating the adequate drainage of pleural cavity effusion, making pleural cavity effusion easy to be extracted and absorbed, and preventing the thickening and adhesion of pleura.
Commonly used drugs are urokinase and streptokinase, which are injected into the pleural cavity with saline, fully contacted and retained, and then withdrawn from the pleural cavity effusion.
Surgical treatment
For chronic tuberculous pyothorax, chronic encapsulated pleural effusion pleural thickening to form a very thick fibrous plate, internal thoracoscopy is not easy to peel off, should be considered to carry out pleural fibrous plate stripping surgery.
For chronic tuberculous pyothorax lungs can not be reexpanded, thoracic reshaping surgery can be considered.
For tuberculous pyothorax with non-functional diseased lung, pleuropneumonectomy is feasible.
Prognosis
Cure
Most cases of tuberculous pleurisy can be cured with regular treatment.
Some patients with dry pleurisy may recover spontaneously if they have strong autoimmunity.
Dangers
Tuberculous pleurisy in combination with tuberculosis may cause spread of the disease among the population, affecting the health and safety of family members and the community.
If the disease is not actively treated or the treatment is incomplete and irregular, there is a possibility of drug resistance and recurrence, and it may be transformed into chronic encapsulated pleurisy, pleural tuberculoma, or even tuberculous pyothorax.
During the treatment of tuberculous pleurisy, liver and kidney function damage, visual impairment, hearing impairment, etc. may occur if anti-tuberculosis drugs are not used properly.
Daily
Daily management
Dietary management
It is recommended that a split meal system be practiced during treatment to protect the health of the family.
Diet should be light, easy to digest and nutritionally balanced, avoiding spicy, stimulating, raw and cold food.
It is recommended to eat more food rich in high quality protein, such as eggs, milk, lean meat, fish and shrimp, soybean products.
It is recommended to eat more fresh fruits and vegetables.
Pay attention to replenish sufficient amount of water daily, it is recommended that 1,000 to 2,000 milliliters per day is appropriate.
Life management
In terms of exercise, suitable and moderate exercise can be chosen after the condition has improved to improve the body’s immunity.
Regular work and rest, avoid staying up late, and ensure 8 hours of sleep per day.
Psychologically, build up confidence in treating the disease and avoid excessive negative emotions.
Home care
Washcloths, bath towels, bedsheets and personal clothes should be disinfected regularly, and replaced and disinfected in time if contaminated by sneezing and coughing.
Open windows for ventilation 2 to 3 times a day and use air sterilizers to purify the air in the room.
Patients and family members need to pay attention to wear a good mask, especially during the patient’s coughing and sputum.
Patients and family members need to develop good hygiene habits, and need to wash their hands frequently and not spit.
Immunocompromised infants, young children and the elderly should appropriately reduce contact with the patient during treatment.
Family members of the patient should care about the patient, give enough support and encouragement, and should not discriminate against the patient.
Prevention
If there are patients with infectious tuberculosis around, attention should be paid to wearing a good mask, good personal protection and appropriate isolation.
Newborns should be vaccinated with BCG vaccine as required, which can effectively prevent tuberculous meningitis, blood-borne tuberculosis and its complications.
For immunocompromised high-risk groups, prophylactic chemotherapy can be carried out under the guidance of doctors when necessary.