Tuberculous pleurisy in children

In children and adolescents, pleurisy may occur as a complication of tuberculosis of the intrathoracic lymph nodes and primary tuberculosis complex, as well as an independent disease.

If a clinical and radiological examination clearly reveals a picture of tuberculosis, pleurisy is regarded as a complication. In cases where changes are not detected, pleurisy is considered an independent form of tuberculosis. In the pathogenesis of pleurisy of tuberculous etiology in children and adolescents, the main importance is the nature of the initial tuberculous process, the routes of penetration of the pathogen into the pleural sheets, and the specific and nonspecific reactivity of the patient. The spread of infection can occur by contact, hematogenous and lymphogenous routes. In some cases, a breakthrough of the caseous contents of the lymph node into the pleural cavity is possible.

According to pathogenesis, three types of pleurisy can be distinguished:

• perifocal;
• predominantly allergic;
• pleural tuberculosis.

Perifocal pleurisy develops as a result of the pleura being involved in inflammation in the presence of a subpleurally located tuberculous focus or affected bronchopulmonary lymph nodes. The volume of exudation in perifocal pleurisy is usually small. The spread of the pathogen and toxins from the affected bronchopulmonary lymph nodes often occurs by the lymphogenous route due to the flow of tissue fluid, which creates conditions for the penetration of mycobacteria into the pleura. Hypersensitization of this area leads to the fact that both specific and nonspecific irritants (trauma, hypothermia, hyperinsolation, etc.) cause hyperergic inflammation of the pleura, provoking the accumulation of exudate (according to the type of paraspecific inflammation). Pleural damage can also occur hematogenously. In these cases, tubercular changes of the pleura of varying length develop, i.e. pleural tuberculosis. The volume of exudation may vary, such pleurisy often manifests itself as migrating, recurrent. The disease proceeds in waves, has a tendency to protracted course.

Symptoms of tuberculous pleurisy

A distinction is made between dry (fibrinous) and exudative pleurisy.

Dry pleurisy in children and adolescents may be a manifestation of active, most often primary or disseminated pulmonary tuberculosis as a result of lymphohematogenous spread of infection. The clinical picture of dry pleurisy is characterized by the appearance of chest pain, subfebrile or febrile body temperature, complaints of an intoxication nature (general weakness, malaise, poor appetite, weight loss). If signs of lung or intrathoracic lymph node damage come to the fore, then it is not always possible to recognize the onset of pleurisy. Pain is the main symptom of dry pleurisy, intensifies with deep breathing, coughing, sudden movements, is often localized in the lower lateral parts of the chest and can radiate both upward (to the neck, shoulder) and downward (to the abdominal cavity), simulating an "acute abdomen". To distinguish pain in dry pleurisy from pain in intercostal neuralgia, remember the following sign: in dry pleurisy, the child tries to lie on the affected side, the pain intensifies when leaning towards the healthy side, and in intercostal neuralgia - towards the affected side. Percussion reveals some limitation of mobility of the lower pulmonary edge on the affected side. Auscultation reveals a characteristic pleural friction noise in a limited area, usually detected in both phases of respiration. Dry pleurisy is usually not detected by radiography, but fluoroscopy may reveal limited mobility of the diaphragm dome. Later, if the fibrinous deposits were significant, adhesions and overgrowth of the costophrenic sinus may appear. Blood changes are usually not observed, ESR may increase moderately. Tuberculin tests are positive or hyperergic. If specific changes in the lungs are not determined, then the anamnesis, characteristic pleural friction noise, tuberculin sensitivity and duration of the disease become of decisive importance.

Symptoms of tuberculous pleurisy

Diagnosis of tuberculous pleurisy

The accumulation of exudate in the pleural cavity occurs in many diseases of the lungs, pleura and other organs, which complicates etiological diagnostics. In adolescents, pleurisy is more often tuberculous (75%). Among pleurisy of non-tuberculous etiology, it is necessary to note exudation in pneumonia of various origins, rheumatism, collagenoses, circulatory failure, tumors, trauma, etc.

In differential diagnostics of pleurisy, anamnesis data indicate the tuberculous nature of pleurisy: contact with a patient with tuberculosis, hyperergic reaction to the Mantoux test or a turn in the tuberculin test. If exudative pleurisy has developed against the background of a turn, most likely this is pleurisy of tuberculous etiology, and the child needs urgent chemotherapy.

Diagnosis of pleurisy