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pleuritis (pleurisy)

Inflammation of the pleura (from french: pleura: side & itis: inflammation), parietal pleura & visceral pleura. Etiology: 1) pulmonary infection a) acute viral infection (influenza) b) pneumonia c) pulmonary tuberculosis 2) pulmonary embolism 3) pneumothorax 4) chest trauma - rib fracture 5) thoracic surgery - heart surgery 6) connective tissue disease a) systemic lupus erythematosus b) rheumatoid arthritis 7) autoimmune hepatitis 8) lung cancer (rarely) 9) idiopathic Clinical manifestations: - pain with inhalation & exhalation - pain aggravated by coughing - dyspnea - dry cough - fever & chills, depending on cause - whn pleural effusion is associated with pleurisy, the pain usually disappears because the fluid serves as a lubricant - friction rub may be heard on auscultation Laboratory: 1) complete blood count (CBC) 2) serology a) antinuclear antibody b) rheumatoid factor Special laboratory: - thoracentesis if pleural effusion - video-assisted thoracoscopic surgery (VATS) for pleural biopsy Radiology: - chest X-ray PA, lateral, decubitus positions a) pneumonia b) pleural effusion - computed tomography (CT) Complications: - pleural effusion Management: 1) depends upon etiology 2) NSAIDs may provide symptomatic relief 3) cough suppressant may relieve pain associated with coughing 3) pleural infection - antibiotics should cover anaerobic infection, except those with culture proven pneumococcal infection - macrolides are not indicated unless suspicion of atypical pathogens - penicillins, penicillins combined with beta-lactamase inhibitors, metronidazole & cephalosporins penetrate the pleural space well - aminoglycosides should be avoided - empiric antibiotics for hospital-acquired empyema should include treatment for MRSA & anaerobic bacteria - intravenous antibiotics should be changed to oral therapy once there is clinical & objective evidence of improvement in sepsis - intrapleural antibiotics are not recommended [3] - intrapleural injection to promote drainage - intrapleural t-PA + DNase therapy improves fluid drainage, & reduces surgical referral & duration of hospital stay [4,6] - intrapleural streptokinase does not improve mortality, need for surgery, or length of hospital stay [4,5]

Related

pleura

Specific

rheumatoid pleurisy tuberculous pleurisy

General

serositis pleural disorder chest pain

References

  1. Pleurisy Mayo Clinic Health Manager http://www.mayoclinic.com/health/pleurisy
  2. Kass SM, et al. Pleurisy. American Family Physician. 2007;75:1357. PMID: 17508531
  3. Davies HE et al for the BTS Pleural Disease Guideline Group Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010 Aug;65(Suppl 2):ii41-53 PMID: 20696693 corresponding NGC guideline withdrawn Dec 2015
  4. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
  5. Maskell NA, Davies CW, Nunn AJ et al U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3;352(9):865-74. PMID: 15745977 Free Article
  6. Rahman NM, Maskell NA, West A et al Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. PMID: 21830966 Free Article
  7. What are pleurisy and other disorders of the pleura? National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/dci/Diseases/pleurisy/pleurisy_whatare.html
  8. Pleurisy fact sheet. American Lung Association. http://www.lungusa.org/site/apps/nlnet/content3.aspx?c=dvLUK9O0E&b=2060321&content_id=%7B653829A9-6104-4561-BFC5-528F5419BEC2%7D oc=1