Pleuritis R09.1

Pleuritis is an acute inflammation of the mesothelium of the parietal pleura and possibly also of the visceral pleura, which can affect only individual sections or the entire pleura.

Depending on the location of the inflammation, a distinction is made between:

• diaphragmatic pleuritis
• mediastinal pleuritis
• pleurisy interlobaris

A further differentiation divides pleuritis into one with exudate formation and one without exudate formation:

• Pleuritis sicca (dry pleuritis or also called fibrinous pleuritis)
• Pleuritis exsudativa (here there is an effusion between the pleural leaves)

In most cases, the sicca pleuritis develops into an exudative pleuritis.

Purulent pleuritis

The purulent pleuritis corresponds to the exudative form, only here the exudate is always purulent. It occurs almost exclusively in the context of bacterial pneumonia and can be differentiated from exudative pleuritis by a significantly higher leucocyte count in the effusion.

Sicca pleurisy often develops in the following causal diseases (some diseases, however, cause both sicca pleurisy and exudative pleurisy and are therefore present in both groups)

• as accompanying pleuritis in severe bronchitis or severe flu-like infections
• Lung abscess
• Bronchiectasis
• Tuberculosis
• Pneumonia
• Pulmonary infarction
• for infections with the Coxsackie B virus

The exudative pleuritis occurs more frequently:

• Tuberculosis
• as accompanying pleuritis in pneumonia of different genesis
• in the event of a major pulmonary infarction
• Panarteriitis nodosa (pleuranic vasculitis)
• in the context of autoimmune diseases (particularly frequent in collagenoses; here often as early manifestation)
• Uremia
• for rheumatic diseases
• for malignant diseases
• within the framework of a radio station

The following symptoms may occur in the case of pleuritis:

• dry cough
• subfebrile temperatures
• Respiratory, inspiratory and expiratory thoracic pain, particularly in the case of diaphragmatic pleuritis; the pain recedes or disappears when an effusion develops
• retrosternal pain is more indicative of mediastinal pleuritis
• Dyspnoea (especially after the occurrence of effusion)
• in case of pleuritis exsudativa, patients prefer to lie on the diseased side

Sonography: Initially there is a discrete, irregular thickening of the pleural leaves. The pleural reflex band is irregular (so-called pleural roughening). However, the pleura can be displaced depending on breathing.

In the further course of the disease, a narrow, wall-standing effusion between the pleural leaves often occurs and often a small basal angular effusion is found on the affected side of the thorax. In this case - in contrast to the X-ray image - even small effusions (from 20 ml) can be shown.

X-ray: The localisation and extension of the effusion can be assessed on the R1 X-ray. However, only effusions of about 100 ml or more can be shown (when the image is taken lying down and with the lateral beam). In the case of a p.a. image taken standing up, effusions of approx. 200 ml or more can only be displayed.

CT: An HRCT should be performed in cases of bronchiectasis. Otherwise, a CT should only be performed if the diagnosis is unclear.

Depending on the genesis can occur:

• BSG acceleration
• CRP increase
• Leucocytosis

Depending on the suspected cause, the following investigations should also be carried out:

• Germ proof
• Detection of specific antibodies
• Determination of D-dimers (low specificity but high sensitivity)

Detailed examinations of the thorax should be performed first to clarify the etiology of pleurisy (see below).

However, if the cause cannot be found on the basis of the examinations, it is advisable to exclude sources of infection in the entire abdomen, in the mediastinum and also in the craniocervical soft tissues.

Auscultation

• Pleurisy sicca is characterized by fibrinous deposits that cause the typical crunching in- and expiratory rubbing sound, also known as "snowball crunch"
• as soon as an exudate is formed, the respiratory sound is attenuated or eliminated
• above the effusion there is often compression breathing(bronchial breathing within a strip-shaped zone)

Percussion

• initially inconspicuous as long as pleuritis sicca exists
• Attenuation as soon as effusion formation occurs (pleuritis exsudativa)

Vocal fremitus

• initially inconspicuous (pleuritis sicca)
• attenuated to absent as soon as effusion formation occurs in the context of pleuritis exsudativa

Pleural puncture

• In the context of pleuritis exsudativa, a diagnostic pleural puncture (see d.) should be performed if the genesis of the exudate is unclear.
• Puncture is also recommended in cases of large amounts of effusion and associated dyspnea. In this case, multiple punctures or the insertion of a chest drain may be necessary.

• Rib fracture
• Tension pneumothorax
• Myocardial infarction
• Pericarditis
• acute inflammatory changes of the abdomen

- Formation of a pleural rind (see above)

- Empyema

The therapy is carried out within the framework of the underlying disease.

Pleuritis sicca is treated purely symptomatically. Painkillers and cough suppressants are recommended.

In the case of exudative pleuritis, larger quantities of effusion may occur. These should then be relieved by a puncture or - if necessary - by a thoracic drainage.

The prognosis depends on the underlying disease.

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