Derrame pleural: [revisión] / Pleural effusion: [review]

El derrame pleural se define como la acumulación anormal de líquido en el espacio pleural; no es una enfermedad, es el resultado del desequilibrio entre la formación y la reabsorción del líquido como manifestación de alguna condición que incluso puede amenazar la vida del paciente. Es una entidad a la cual el clínico se ve enfrentado con frecuencia, la mayoría de las veces es secundaria a enfermedad pleural o pulmonar, pero puede también ser causada por enfermedades extrapulmonares, sistémicas o neoplásicas (bien sea primarias o metastásicas)...

Tuberculose pleural / Tuberculous pleural effusions

O derrame pleural tuberculoso pode ser devido a uma manifestação da forma primária da doença ou da reativação de uma infecção latente pelo M. tuberculosis. Os avanços nos métodos laboratoriais contribuíram sobremaneira para um melhor diagnóstico e para a compreensão da fisiopatologia desta doença. No entanto, embora o derrame pleural predominante linfocítico seja indicativo de tuberculose em nosso meio, uma rotina de abordagem diagnóstica deve ser instituída a fim de orientar o tratamento precoce e evitar seqüelas.

Tuberculous pleural effusion is a common manifestation of the primary form of the disease or consequence of the reactivation of a latent infection due to the M. tuberculosis. Advances in the laboratory methods have contributed to better diagnose and understand the pathophysiology of the effusion secondary to tuberculosis. However, although a predominant lymphocytic pleural effusion is suspicious of tuberculosis, a diagnostic routine shall be instituted to orient treatment and prevent undesirable sequels.

Diagnostic value of Adenosine deaminase isoenzyme [ADA2] and total ADA in tuberculous pleural effusion

Determination of adenosine deaminase [ADA] activity is one of the most promising markers in diagnosing of tuberculous pleural effusion. ADA has two main isoenzymes: ADA1 and ADA2.The ADA2 is the predominant isoform in tuberculous pleural effusion, suggesting its important role as a diagnostic marker. This study was conducted to determine the diagnostic value of ADA and ADA2 measurement in tuberculous pleural effusion. Total ADA and ADA2 isoenzyme activities were measured in 93 case of pleural effusion, including tuberculosis [26males/5females], malignancy [22males/8females], empyema and para-pneumonic [11males/4females], transudate [6males/4females], rheumatoid arthritis and idiopathic [4males/3females]. ADA levels were determined by Giusti and Galanti methods. ADA2 was measured with a potent inhibitor of ADA1 isoenzyme. Total ADA and ADA2 activities in tuberculous exudates were 96.6 +/- 29.1 and 74.4 +/- 29 U/L, respectively. With diagnostic thresholds of 46 and 42 U/L, the sensitivities of ADA and ADA2 for tuberculous exudates were 100% and 97%; their specificities 82 and 88%; and their efficiencies 88% and 93.5%, respectively. All tuberculous exudates, 2 neoplastic, 8 para- infective [including 4 empyemas] and one rheumatoid arthritis had total ADA levels > 46 U/L; of these, only one lymphoma and one rheumatoid arthritis had ADA2/ADA activity ratio > 50%. Considering simultaneous criteria of total ADA more than 46U/L, ADA2 > 42 U/L and ADA2/ADA more than 50%, we had only two false positive results, rising the specificity up to 96%. 1. ADA2 is a more efficient diagnostic marker for Tuberculous pleural effusion compared with total ADA. 2. Overall, diagnostic value of ADA would be enhanced by the determination of its isoenzymes, especially for distinguishing between the tuberculous and para-infective effusions

Empiema tuberculoso / Tuberculous empyema

El empiema tuberculoso es considerado como una entidad poco frecuente y habitualmente es la complicación de una tuberculosis pleural, sin embargo hay condiciones clínicas que pueden favorecer su desarrollo como son el plombage, oleotórax y neumotórax terapéutico, también se puede desarrollar a partir de una cicatriz fibrosa, por una neumonectomía o por una toracoplastia. Su fisiopatogenia es poco conocida, pero a diferencia de la tuberculosis pleural, el empiema de tipo tuberculoso es ocasionado por una infección de la cavidad pleural por el Mycobacterium tuberculosis. Sus cuadros clínico y radiológico no son muy diferentes al derrame pleural tuberculoso, pero la presencia de fístula broncopleural puede complicar su cuadro clínico. El tratamiento requiere de un manejo con medicamentos antituberculosos, conjuntamente con manejo quirúrgico. El manejo quirúrgico se basa en el drenaje del material purulento, y puede ser tan sencillo como el colocar una sonda endopleural, pero en algunos casos será necesario un manejo más agresivo como la pleurotomía abierta o bien, la toracotomía.

Non-Hodgkin's lymphoma masquerading as empyema thoracis.

Non-hodgkin's lymphoma has varied presentations. Malignant lymphoma arising in chronic pyothorax is very rare and has been reported from Japan. We report a case of non-hodgkin's lymphoma presenting as empyema thoracis.

Derrame pleuropericárdio tuberculoso: uma apreciaçäo de conjunto / Tuberculous pleuropericardial effusion: an apreciation of conjoined

Os autores apresentam sua experiência com seis casos de derrame pleuropericßrdio tuberculoso (DPPT), ressaltando a necessidade e a importância do estabelecimento diagnóstico preciso desta enfermidade, fazendo o descrime com outros derrames. Ilustram o trabalho em questäo com a apresentaçäo de seis casos, dando destaque clínico, radiológico, eletrocardiográfico e ecocardiográfico a um deles, que se revelou por demais exuberante, com quadro pleuropericárdico dominando toda a cena.

Review of one hundred cases of empyema thoracis.

One hundred cases of empyema thoracic have been reviewed. Aetiology of empyema was tubercular in 21 per cent cases and non-tubercular in 79 per cent cases. Gram negative organisms were cultured in 84.6% cases, whereas gram positive organisms were cultured only in 15.4% cases. It was observed that management of cases of empyema differed considerably with the presence or absence of BPF, thick or thin pus and size of empyema. It was concluded that all cases of simple empyema with thin pus and only those cases of simple empyema with thick pus where size of empyema is small should be managed by aspiration/s. Cases failed by above method, all cases of simple empyema with thick pus and with moderate to large size of empyema and all cases of empyema with BPF should be straightway managed by intercostal drainage tube connected to water seal. On the whole, cases of empyema with BPF were difficult to manage and needed major surgery in 45.8 per cent cases in comparison to only 2.9 per cent cases of simple empyema.