Tuberculous pleurisy in children

Introduction to tuberculous pleurisy in children Tuberculous pleurisy is an exudative inflammation caused by tuberculosis directly invading the pleura from the primary lesion of the proximal pleura, or spreading to the pleura via lymphatic blood. Often accompanied by pleural effusion, due to high protein in tuberculous pleurisy exudate, easy to cause pleural adhesions and hypertrophy. The pleurisy is often unilateral, and both sides are often prompted by disseminated tuberculosis. Common in children over the age of 3, mainly occurred in the primary infection within 6 months, the primary lesions are mostly in the ipsilateral lung, often can not be found. The onset is highly sensitive to the tuberculosis of the child. Clinically, it is often divided into three types: dry pleurisy, exudative pleurisy, and tuberculous empyema (rare). basic knowledge Sickness ratio: 0.05%-0.06% Susceptible people: children Mode of infection: droplet spread Complications: tuberculous empyema

Causes of tuberculous pleurisy in children

Cause:

Primary tuberculosis is a disease caused by Mycobacterium tuberculosis invading the body for the first time. There are 4 types of Mycobacterium tuberculosis: human, bovine, bird and mouse, while human pathogenic bacteria are human tuberculosis and tuberculosis. Most of the pediatric tuberculosis in China is caused by human tuberculosis. The tuberculosis has strong resistance. In addition to acid, alkali and alcohol resistance, it is strong for cold, heat, dryness, light and chemicals. Tolerance, damp heat has strong bactericidal power against tuberculosis, it can be killed at 65 ° C for 30 min, 70 ° C for 10 min, 80 ° C for 5 min to kill, dry heat sterilization is poor, dry heat 100 ° C takes more than 20 min to kill, Therefore, dry heat sterilization, the temperature needs to be high, the time needs to be long, the tuberculosis bacteria in the sputum is killed within 2 hours under direct sunlight, and the ultraviolet ray only takes 10 minutes, instead it can survive for several months in the dark, in the sputum If tuberculosis is disinfected with 5% carbolic acid (phenol) or 20% bleaching solution, it takes 24 hours to take effect.

Pathogenesis

The pathways leading to tuberculous pleurisy are:

1 The lymphatic tuberculosis bacteria flow back to the pleura through the lymphatic vessels.

2 Tuberculosis lesions adjacent to the pleura rupture, so that the products of tuberculosis or tuberculosis infection directly into the pleural cavity.

3 acute or subacute hematogenous disseminated tuberculosis caused by pleurisy.

4 The body's allergicity is high, and the pleura is highly responsive to tuberculosis toxins.

5 Thoracic tuberculosis and rib tuberculosis to the pleural cavity. Previously, the opinion that tuberculous pleural effusion is allergic to tuberculosis toxin is one-sided, because needle pleural biopsy or thoracoscopic biopsy has confirmed 80% tuberculous pleurisy wall pleura There is a typical pathological change of tuberculosis. Therefore, direct infection of the pleura by Mycobacterium tuberculosis is the main pathogenesis of tuberculous pleurisy.

Early pleural congestion, leukocyte infiltration, followed by lymphocyte infiltration predominance, fibrinous exudation on the pleural surface, followed by serous exudation, due to a large amount of fibrin deposition in the pleura, can form a wrapped pleural effusion or extensive pleural thickening The pleura often has nodules formed.

Pediatric tuberculous pleurisy prevention

1. Control the source of infection and reduce the chance of infection

Tuberculosis smear-positive patients are the main source of tuberculosis in children. Early detection and rational treatment of smear-positive tuberculosis patients is a fundamental measure to prevent tuberculosis in children. Infants and young children suffer from active tuberculosis, and their family members should be examined in detail. , PPD, etc.), regular physical examinations for primary and child care institutions, timely detection and isolation of infectious sources, can effectively reduce the chance of tuberculosis infection in children.

2. Popularization of BCG vaccination

Practice has proved that vaccination with BCG is an effective measure to prevent tuberculosis in children. BCG was invented by French physicians Calmette and Guerin in 1921, so it is also called BCG. China has vaccinated BCG in the neonatal period and inoculated BCG in the upper left arm of the left upper arm. Intradermal injection, the dose is 0.05mg / time, the scratch method is rarely used, the Ministry of Health notified in 1997 to cancel the 7-year-old and 12-year-old BCG re-integration plan, but if necessary, the child with negative age test Multiple cropping can be given, and BCG vaccine can be injected in the same day as the hepatitis B vaccine.

Contraindications to vaccination with BCG: positive lignin response; eczema or skin disease; recovery period of acute infectious disease (1 month); congenital thymic dysplasia or severe combined immunodeficiency disease.

3. Prophylactic chemotherapy

Mainly used for the following objects:

(1) Infants under the age of 3 have not been vaccinated with BCG and have a positive test.

(2) Close contact with patients with open tuberculosis (multiple family members).

(3) The sputum test has recently changed from negative to positive.

(4) The sputum test is a strong positive responder.

(5) Positive test of sputum: children need to use adrenocortical hormone or other immunosuppressive agents for a long time.

The drug used for chemopreventive drugs is mainly isoniazid, the dose is 10mg/(kg·d), the course of treatment is 6-9 months, the newborns of the newly born tuberculosis parents under the age of 6 and the newborns born to the tuberculosis women, regardless of the knot If the results of the test are all the same, the isoniazid should be given. The dose is the same as above. After 3 months of administration, the test is performed. If it is positive, the isoniazid is continued for 9 months; if the test is negative (<5mm) ), then stop the isoniazid.

Anti-HIV-positive children with a history of tuberculosis should receive isoniazid for 12 months regardless of the outcome of the nodule test.

If the tuberculosis patient contacted by children is resistant to isoniazid, the chemotherapeutic drug should be changed to rifampicin, 15mg/(kg·d), 6-9 months; if it is resistant to isoniazid and resistant to rifampicin, It is recommended to give pyrazinamide plus ofloxacin for 6 to 9 months, or pyrazinamide plus ethambutol for 6 to 9 months.

Pediatric tuberculous pleurisy complications Complications tuberculous empyema

It can form interlobular pleurisy, mediastinal pleurisy, encapsulated effusion and lung fund. If the treatment is not timely or the treatment is improper, it will soon develop into a packaged effusion. In the treatment of simple tuberculous pleurisy, the prescribed course of treatment is not completed. About 2/3 of the patients in 5 years have other parts of tuberculosis or severe tuberculosis, such as disseminated tuberculosis, tuberculosis, and chest wall tuberculosis. When the lung cavity and cheese-like lesions are close to the pleural area, it can cause tuberculous pus. It can also be gradually gelatinized or even purulent, becoming a tuberculous empyema. One side of pleural thickening to form fibronectin bound lung function can be complicated by contralateral emphysema, can also lead to chronic pulmonary heart disease, and even cardiopulmonary failure.

Pediatric tuberculous pleural inflammatory symptoms Common symptoms Fatigue High heat Low heat trachea and mediastinal shift Chest pleural pleural friction sounds attenuated a cough chest pain chest pain pleural thickening

Exudative pleurisy is more common in older children, most of whom are older than 3 years old, and occur mostly within the first half of the first year of infection.

Symptom

Onset can be urgent, more urgent, more onset of fever, start high fever, gradually retreat to low fever after 1 to 2 weeks, and have chest pain, fatigue, cough and shortness of breath on the affected side, and increased chest pain on the side of the cough If acupuncture is used, the chest pain can be alleviated or disappeared after the fluid is increased. The difficulty of breathing and the presence or absence of cyanosis are related to the amount of fluid. When there is a large amount of fluid, there may be difficulty in breathing and chest tightness.

2. Signs

When there is little fluid, there is no obvious signs. In the early stage of cellulose exudation, there may be pleural friction sound. When there is more fluid, the affected side is full, the intercostal space disappears, the respiratory movement is weakened, the palpation is reduced, the percussion is dull, and the auscultation breath sound is obvious. Below the healthy side, even a little blisters can be heard. When the fluid is accumulated in a large amount, the trachea moves to the healthy side. In the chronic phase, the pleural thickening, adhesion, and wrapping can cause the thoracic depression of the diseased side, and the respiratory movement and respiratory sounds are weakened.

3. Check the body

It can be seen that the affected side is more bulging than the healthy side, the intercostal space is widened or full, the thoracic respiratory motility is weakened, the turbidity or the actual sound is diagnosed, the auscultation of the breath sound is reduced or disappeared, and the pleura can be heard when the exudate just appears or disappears. Friction sound.

Examination of tuberculous pleurisy in children

In the early stage of tuberculous pleurisy, the total number of white blood cells in the blood can be increased or normal, neutrophils predominate, and then the white blood cell count is normal, and converted to lymphocytes, and the erythrocyte sedimentation rate increases.

The appearance of pleural fluid is mostly grass yellow, transparent or slightly turbid, or frosted glass. A few pleural fluids can be yellow, dark yellow, serous blood and even blood. The specific gravity is above 1.018. The Rivalta test is positive, the pH is about 7.00~7.30, and there are nucleated cells. Number (0.1 ~ 2.0) × 109 / L, the acute phase is dominated by neutrophils, and then lymphocytes predominate, protein quantitation 30g / L or more, such as greater than 50g / L, more support for the diagnosis of tuberculous pleurisy, glucose Content <3.4mmol/L, lactate dehydrogenase (LDH)>200U/L, adenosine deaminase (ADA)>45U/L, interferon->3.7/ml, carcinoembryonic antigen (CEA)<20g /L, flow cytometry cells are polyploid, tuberculosis antigens and antibodies have been reported to measure pleural effusion, although the concentration of pleural effusion in tuberculous pleurisy is significantly higher than non-tuberculous, but the specificity is not High, limiting its clinical application, the positive rate of Mycobacterium tuberculosis in pleural effusion is less than 25%, such as smear after pleural effusion centrifugation, pleural effusion or pleural tissue culture, polymerase chain reaction (PCR), etc. Positive rate, pleural effusion mesothelial cell count <5%.

Pleural biopsy

Acupuncture pleural biopsy is an important method for the diagnosis of tuberculous pleurisy. In addition to feasible pathological examination, biopsy pleural tissue can also be cultured with tuberculosis. For example, changes in parietal pleural granuloma suggest the diagnosis of tuberculous pleurisy, although other diseases such as fungi. Sexual disease, sarcoidosis, tuaremia and rheumatic pleurisy can have granulomatous lesions, but more than 95% of pleural granulomatous lesions are tuberculous pleurisy, such as pleural biopsy failed to detect granulomatous lesions, biopsy Specimens should be stained with acid, because tuberculosis can be found in the specimen by accident. The first pleural biopsy can detect 60% of tuberculous granuloma changes, and biopsy 3 times is about 80%, such as biopsy specimen culture plus microscopy. The positive rate of tuberculosis diagnosis is 90%. The pleural biopsy can also be performed under thoracoscopic direct vision. The positive rate is higher.

2. X-ray inspection

When the pleural effusion is below 300ml, there may be no positive findings in the posterior anterior X-ray film. When the effusion is small, the rib angle becomes dull, and the effusion volume is more than 500ml. The supine position is observed in perspective, due to the accumulation of liquid in the lower part of the chest cavity. Spreading, seeing sharp rib angles, can also suffer from lateral lie, showing a strip of shadow on the outside of the lungs. The medium effusion shows a uniform density increase in the lower part of the chest, and the shadow is covered. The liquid has a high outer side of the upper edge and a low arc shadow on the inner side. When a large amount of pleural effusion occurs, most of the lung field is evenly densely shadowed, the shadow is covered, and the mediastinum is displaced to the healthy side.

Some tuberculous pleural effusions can be expressed as special types. Common ones are:

1 inter-leaf effusion: The liquid accumulates in one or more interlobular spaces and exhibits a sharp-edged fusiform shadow or rounded shadow. The lateral pleural sheet shows that the effusion position is related to the interstitial space.

2 Subpulmonary effusion: The liquid mainly accumulates between the lung base and the diaphragm, often coexisting with the pleural pleural effusion. In the upright position, the sputum is increased from the normal 1/3. At the outer third of the 1/3, the middle part is relatively flat, and the effusion on the left side of the lung is characterized by an increase in the distance between the shadow and the gastric vesicle. The flank angle of the affected side becomes dull. If the effusion is suspected, the patient is lying on the side of the patient. After 20 minutes, the chest was examined or the chest was examined. At this time, the liquid was scattered, and the outer edge of the affected side showed a band-like shadow, and the diaphragm was visualized. The thicker the band shadow, the more the fluid accumulated.

3 wrapped effusion: a localized pleural effusion formed by pleural adhesion, rib pleural effusion often occurs in the lower posterior lateral wall, a small number can occur in the front chest wall, X-ray signs in the upright position or appropriate tilt position It can be displayed that the bottom edge is attached to the chest wall, the inner edge protrudes sharply to the lung field, and the uniform density is fusiform or elliptical shadow, and the shadow edge and the chest wall are obtuse.

4 mediastinal effusion: the effusion of the mediastinal pleural cavity, the anterior mediastinal effusion appears as a shadow along the edge of the heart and large blood vessels, the right anterior superior mediastinal effusion shadow is similar to the thymus shadow or the right upper lung without the shadow, take the right lateral position After the left anterior oblique 30° position for 20 to 30 minutes, the posterior anterior chest radiograph of the position is displayed, showing that the upper mediastinum shadow is significantly widened, and the anterior and posterior mediastinal fluid must be differentiated from the enlarged shadow or pericardial fluid of the heart, and the posterior mediastinum The fluid appears as a triangular or ribbon shadow along the spine.

3. Ultrasound examination

Ultrasound detection of pleural effusion is highly sensitive, accurate positioning, and can estimate the depth of pleural effusion and the amount of fluid accumulation, suggesting that the puncture site can also be differentiated from pleural thickening.

Diagnosis and diagnosis of tuberculous pleurisy in children

diagnosis

According to the medical history and clinical manifestations, tuberculous pleurisy can be diagnosed, the clinical manifestations are mainly moderate fever, relieved after initial chest pain, dyspnea, physical examination, X-ray examination and ultrasound examination can make diagnosis of pleural effusion, diagnostic thoracic puncture Routine examination of pleural fluid, biochemical examination and bacterial culture are necessary measures for diagnosis, and these measures can diagnose 75% of the cause of pleural fluid.

Differential diagnosis

Atypical tuberculous pleurisy should be identified with the following diseases:

1. Bacterial pneumonia with empyema: children are younger, more common in children under 5 years old, and tuberculous pleurisy is more common in children over 5 years old, lung signs and X-ray examination, chest puncture examination can help Identification.

2. Viral pneumonia combined with pleural effusion: more common in infants and young children, clinical manifestations of heavier, cough, wheezing, severe cases with heart failure.

3. Rheumatic pleurisy: more common in older children, and occurs in the extreme period of rheumatic fever, erythrocyte sedimentation rate is often higher.

4. Malignant tumor with pleural effusion: pleural effusion is mostly leakage or bloody, pleural effusion grows faster after effusion, and the positive rate of pleural effusion pathology is higher, which can be used as a diagnosis. in accordance with.

5. Mycoplasma pneumonia with pleurisy: not uncommon in recent years, such as timely condensation test and mycoplasma antibody determination, can be identified.

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