Sunday, 24 November 2013

Pleural disease – Pleural effusion – Types of Pleural effusion

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall.
B. Pleural effusion
It is a condition of collection of fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume, etc.
B.1. Types of Pleural effusion are depending to fluid accumulations
B.1.1. Hydrothorax
Pleural effusion as a result of Serous fluid accumulation. In many case, it is a result of cirrhosis.
According to the study by the Harvard Medical School, patients with cirrhosis and portal hypertension often have abnormal extracellular fluid volume regulation, resulting in accumulation of fluid as ascites, oedema or pleural effusion. These complications carry a poor prognosis with nearly half of the patients with ascites dying in the ensuing 2-3 years(1).
Other cases may be result as a complicating peritoneal dialysis. According to the study by The Chinese University of Hong Kong, Hydrothorax complicating continuous ambulatory peritoneal dialysis (CAPD) appears in approximately 2% of all patients(2).
B.1.2. Dyspnea
Pleural effusion as a result of blood accumulation within the pleural cavity. In most cases, it is a result from a injury to the thorax resulting to ruptured blood to spill into the pleural space. According to the study by the Medical Centre Alkmaar, haemothorax is a problem commonly encountered in medical practice and is most frequently related to open or closed chest trauma or to invasive procedures of the chest(3).There is a report of two cases where seemingly insignificant low-energy trauma precipitated massive haemothoraces in elderly patients with underlying osteoporosis, ultimately resulting in their immediate causes of death(4) and a case of haemothorax is described which occurred after the removal of a small pig-tail chest tube (8.5 F) that was inserted in the second intercostal space in the mid-clavicular line, for primary spontaneous pneumothorax management(5).
B.1.3. Chylothorax
Pleural effusion as a result of lymphatic fluid accumulation within the pleural cavity.
1. Chylothorax congenital
According to the study of University of Erlangen-Nuernberg, Chylothorax after surgery on congenital heart disease in newborns and infants may appear due to injury of the thoracic duct, due to venous or lymphatic congestion, central vein thrombosis, or diffuse injury of mediastinal lymphatic tissue in association with secondary chest closure(6). Other in the study of Chylothorax after congenital diaphragmatic hernia repair indicated that severity of preoperative cardiopulmonary derangement and not anatomical or technical factors predicts chylothorax occurrence after CDH repair(7).
2. Acquired chylothorax
a. Postoperative chylothorax
Chylothorax may also be a rare but severe complication of thoracic and esophageal surgery. At an early stage, chylothorax can lead to severe cardiorespiratory and volemic complications. In case of chronicization, malnutrition and immunologic complications can occur, responsible for a mortality rate of up to 50%(8).
b. Tumors
Chylothorax in paediatric age is a life-threatening clinical entity that cause serious respiratory, nutritional and immunologic complications. Chylothorax in the absence of trauma or tumour is uncommon and lymphangiomatosis of the bone, although extremely rare, has been associated with these condition, according to the study by Azienda ospedaliera-Università di Padova(9),
B.1.4. Pleural empyema (Pyothorax)
Pleural effusion as a result of accumulation of pus within the pleural cavity. According to the study by the Osaka University Graduate School of Medicine, Pyothorax-associated lymphoma (PAL) is a non-Hodgkin lymphoma of exclusively B-cell phenotype developing in the pleural cavity of patients after more than 20-year history of pyothorax resulting from an artificial pneumothorax for the treatment of pulmonary tuberculosis or tuberculous pleuritis.10). They also report a rare case of an 82-year-old woman with pain on the left side of the chest a PAL with dual genotype, i.e., simultaneous immunoglobin (Ig) and T-cell receptor (TcR) gene rearrangement(11).
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