tuberculous empyema
Introduction
Introduction to tuberculous empyema Tuberculous empyema is caused by rupture of tuberculosis or subthalamic cheese-like lesions, infection of the pleura, and may be caused by the direct spread of paraspinal abscesses of spinal tuberculosis. Tuberculosis surgery with bronchial pleural palsy or pleural cavity infection can also cause pneumothorax. In addition, exudative pleural effusions do not absorb for a long time, and some can gradually develop into empyema. Since the widespread use of anti-tuberculosis drugs, the incidence of tuberculous empyema has been greatly reduced. basic knowledge The proportion of illness: 0.03% Susceptible people: no special people Mode of infection: contagious Complications: chronic empyema
Cause
Tuberculous empyema cause
The etiology and pathogenesis of tuberculous empyema:
Tuberculous pleurisy is not completely treated (35%):
If the treatment of severe tuberculous pleurisy is not complete, the inflammation will cause infection through lymphatic or blood circulation, and the tuberculosis lesions invade the pleura and cause tuberculous empyema.
Other factors (30%):
Pulmonary tuberculosis spontaneous pneumothorax secondary infection, directly invade the pleura, or the lesion rupture will bring tuberculosis directly into the chest, while allowing gas into the chest, and form a pus and chest, and even bronchopleural fistula. The empyema can also be a combination of artificial pneumothorax or surgery for tuberculosis. Bone tuberculosis or chest wall tuberculosis can also invade the chest.
Pathological changes:
In the early stage of tuberculosis infection of the chest, acute inflammation, congestion, and exudation can occur, forming scattered nodules of tuberculosis. The pleural effusion is serous, containing white blood cells and fibrin. After a long period of time, it gradually becomes chronic tuberculous empyema. The fiberboard is thick and hard, and often has calcification. The shrinkage of the fiberboard narrows the rib gap, the ribs are deformed, the cross section is triangular, the intercostal muscles are atrophied, and the spine is convex to the healthy side. The empyema can be localized or full of empyema. Sometimes the empyema ruptures to the intercostals, and even invades the ribs, forming a cold abscess or breaking the skin to form a sinus, long-term pus unhealed.
Prevention
Tuberculous empyema prevention
The disease is mainly early detection, early diagnosis, early treatment, early tuberculous empyema is not much, after active and effective anti-tuberculosis treatment, strengthen nutrition, appropriate rest, may absorb better, if there is a large amount of fluid, you can chest puncture pumping The liquid promotes absorption, but care should be taken to prevent secondary infections. Thoracic closed drainage should be avoided before secondary infections with uncontrollable drugs, because the pathological changes of tuberculosis cause fibrosis of the lung tissue, but cannot expand, after closed thoracic drainage The abscess can't be eliminated, but it will increase the chance of mixed infection.
Complication
Tuberculous empyema complications Complications chronic empyema
1, self-destructive empyema
The disease is a common complication of tuberculous empyema. The wall pleural rupture of tuberculous empyema, spontaneous discharge of its contents, can enter many parts, the most common is the subcutaneous tissue of the chest wall, CT can simultaneously show lesions inside and outside the chest, Both are thick-walled enveloped effusions and can show enthalpy between the two.
2, pleural malignancy
Tuberculous empyema complicated with pleural malignancy is relatively rare, although its pathogenesis is unknown, but chronic inflammation is the most important factor, its pathological type is more, the diagnosis is relatively difficult, such as the following signs can suggest this complication:
(1) increased chest density;
(2) The soft tissue of the chest wall is swollen, the fat line is blurred, or both appear at the same time;
(3) There is bone destruction near the empyema;
(4) The calcified pleura is widely moved inward;
(5) A new gas-liquid level occurs in the cavity of the empyema. At this time, a CT examination should be performed. It can be found that there is a soft tissue density around the empyema, and the enhanced scan is enhanced. In the diagnosis, the pleural tumor and the self-destructive empyema should be noted. Identification, tumor often has necrosis or degenerative cystic changes, but the CT value can be similar to empyema. It is important to find the shape of the soft tissue mass, the thickness of the wall is irregular and the soft tissue density in the cavity is convex, which may indicate the pleura. Malignant tumors, sometimes CT is difficult to make a definitive diagnosis of pleural malignancy, but can provide a biopsy site.
3, in addition to the above complications, chronic empyema complicated with residual effusion, stump puncture after pleural pneumonectomy, intractable sinus, etc. have also been reported.
Symptom
Tuberculous empyema symptoms Common symptoms Dyspnea dry cough chest tightness cardiac tamponade signs congestion hemoptysis high fever pleural effusion rib gap narrowing purulent
In the early stage of tuberculosis infection, acute inflammation, hyperemia, exudation, formation of scattered tuberculous nodules, pleural effusion is serous, containing white blood cells and fibrin, and gradually become chronic tuberculous empyema after a long period of time. The fiberboard is thick and hard, and often has calcification. The fiberboard shrinks to narrow the rib space. The rib deformation is triangular in cross section, the intercostal muscles are atrophied, and the spine is convex to the healthy side. The empyema can be localized or full empyema, sometimes empyema. Collapse to the intercostals, and even invade the ribs, form a cold abscess or break the skin to form a skin sinus, long-term pus.
The clinical manifestations of tuberculous empyema are very inconsistent. Most of the onset symptoms of tuberculosis are slow, with fatigue and low fever as the main symptoms, followed by night sweats, chest tightness, dry cough, etc. The absorption of early pleura in the empyema is stronger, and the symptoms of poisoning are more obvious. If there is more empyema, symptoms such as shortness of breath and difficulty in breathing may occur. When bronchial pleural effusion occurs, irritating cough associated with body position may occur, and a large amount of purulent sputum of the same nature as pleural fluid may be coughed up, and even hemoptysis may occur. Cough and purulent sputum increase in the lateral position, if the tuberculosis spread due to bronchopleural palsy, the symptoms of poisoning will be very obvious, the condition is critical, the symptoms of the infection are the same as those of the acute empyema, the leukocytosis, the symptoms are the same as the acute pus The chest is similar, and the signs are the same as those of suppurative chronic empyema.
X-ray examination is easier to diagnose tuberculosis in the contralateral lung. Tuberculosis in the affected side is often covered by effusion, so it is difficult to determine the nature. Therefore, when there are many lymphocytes in the pus, or the normal bacterial culture is negative, Tuberculous empyema should be considered, tuberculosis patients with empyema, should first consider the diagnosis of tuberculous empyema, pus culture-positive, or pathological examination of the parenchyma wall tissue can help to confirm the diagnosis.
Examine
Tuberculous empyema examination
(1) X-ray findings are basically the same as chronic empyema, and it is easier to diagnose tuberculosis in the contralateral lung. The tuberculosis lesions in the affected side are often covered by effusion, so it is not easy to determine the nature. The puncture of the thoracic puncture is thin. The pus may contain dry and cool substances. The tuberculosis bacteria should be found in the pus, but it is difficult to find tuberculosis in clinical tests. Therefore, when there are many lymphocytes in the pus, or the normal bacteria culture is negative, Tuberculous empyema should be considered. Tuberculosis patients with empyema should first consider the diagnosis of tuberculous empyema.
(2) Tomography can show the size of the abscess, and at the same time can show the extent of tuberculosis and lesions in the lungs.
(3) CT examination can better understand the subtle changes in the abscess and lesions.
(4) Thoracic puncture extracts pus is thin, pus can contain cheese-like substances, tuberculosis can be found in pus, lymphocytes in pleural fluid are more and pus culture is positive, under normal circumstances, puncture in pus Tuberculosis is difficult to detect in clinical tests.
Diagnosis
Diagnosis and diagnosis of tuberculous empyema
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory findings.
Differential diagnosis
(1) pleural mesothelioma:
Because of the similarities between early performance and X-ray examination results, it may be misdiagnosed as tuberculous empyema. The reasons for misdiagnosis are as follows:
1 has typical symptoms of tuberculosis, anti-tuberculosis treatment has been effective;
2 The affected side is collapsed and the intercostal space is narrowed;
3 lung CT did not see pleural unevenness;
4 yellow exudate in the chest;
5 no obvious weight loss and blood in the sputum, with the following conditions should be thought of pleural mesothelioma may:
a. Continue to heavier chest pain;
b. Uncontrollable pleural effusion, especially bloody pleural effusion;
c. The pleural effusion has no obvious improvement after anti-tuberculosis and anti-inflammatory treatment;
d. The pleura is thickened and uneven. If necessary, CT and pathological examinations are performed to assist in diagnosis and reduce misdiagnosis.
(2) Pulmonary cyst:
It is a cystic lesion of the lung parenchyma that is formed by congenital dysplasia. It is divided into liquid cyst, balloon swelling and fluid balloon swelling. When the cyst is small, it can be asymptomatic or mild. If the huge fluid cyst is difficult to identify with empyema. Tuberculous empyema is a kind of special bacterial infection. Its clinical manifestations are not as obvious as purulent infections. Therefore, it is easy to delay diagnosis. The reasons for misdiagnosis may be as follows:
1 For elderly patients, there is no clinical symptoms of tuberculosis, tuberculous pleurisy and acute tuberculous empyema before medical treatment;
2MRI showed similar signs of diseased lung cysts;
3 In recent years, with the advancement of anti-tuberculosis drug therapy and the variation of tuberculosis strains, the clinical manifestations of some tuberculosis have been atypical, and the clinical attention is not enough, so the two need to be differentially diagnosed.
(3) malignant pleural effusion:
The clinical manifestations of senile tuberculous empyema and pleural metastasis of lung cancer are lack of specificity. Both can have fever, chest tightness, shortness of breath, cough, pleural fluid is exudate, due to aging of the lungs and pleura of the elderly, parietal pleural pleural effusion Reabsorption is slow, some patients are treated in non-specialty hospitals, causing the disease to be delayed and misdiagnosed as malignant pleural effusion. In order to avoid misdiagnosis of tuberculous empyema in the elderly, it is necessary to raise awareness and vigilance against the disease. Fever, long-term unexplained pleural effusion and unclear diagnosis, pleural fluid is exudate, common anti-tuberculosis and chest drainage difficult patients should consider this disease, timely video-assisted thoracoscopic or surgical exploration.
