Mechanism of development and main types
Pleural pathology in secondary tuberculosis is directly related to the presence of destructive changes in the lungs. The main triggering factor for severe urgent conditions is cavity rupture. When the wall of the cavity is destroyed, infected contents inevitably break through into the pleural cavity.
This event triggers a cascade of severe pathological processes:
- Pneumothorax: penetration of air into the space between the pleural leaves.
- Pleurisy: secondary inflammation of the serous membranes.
- Tuberculous empyema: accumulation of purulent masses caused by the entry of mycobacteria (M. tuberculosis) and necrotic detritus from the lesion site.
- Bronchopleural fistulas: formation of a persistent pathological connection between the lumen of the bronchial tree and the pleural cavity, which makes the inflammatory process chronic.
Complete restoration of lung tissue after such processes is impossible; pronounced residual effects always persist.
Pain syndrome and differential diagnosis
Assessment of chest pain is of critical diagnostic significance. Misinterpretation of symptoms can cost the patient's life.
- In tension pneumothorax, progressive compression of lung tissue and displacement of mediastinal organs are observed. This leads to rapidly escalating acute respiratory and cardiovascular failure.
- Mediastinal emphysema is accompanied by pronounced pain syndrome, which can mimic the clinical picture of myocardial infarction.
Underdiagnosis of the true pleural nature of pain and perceiving it as cardiac (ischemic) leads either to delayed detection of such dangerous conditions as pneumothorax or pulmonary embolism, or to completely unjustified interventions.
Surgical treatment and emergency care
Treatment of complicated forms of lung diseases requires radical measures. The basic and strictly mandatory procedure for pneumothorax, pyopneumothorax, and empyema is pleural drainage. In tension pneumothorax, this manipulation is of an emergency nature.
Depending on the severity of injuries, various surgical techniques are used:
- Minimally invasive techniques: temporary endoscopic occlusion of the affected bronchus.
- High-tech (large-scale) surgeries: lung removal (pneumonectomy), permanent occlusion of the main bronchus or pulmonary artery branch, as well as thoracomyoplasty.
Surgical intervention is also strictly indicated in the development of bronchial fistulas, pulmonary hemorrhage from damaged large vessels, as well as in the presence of tuberculomas larger than two centimeters and a fibrocavernous process.
Background pathologies: fibrocavernous and cirrhotic tuberculosis
Pleural complications most often accompany fibrocavernous tuberculosis, which is the most frequent form of secondary lesion according to autopsy data, in which patients are extremely contagious and require strict isolation.
If the disease transitions to the terminal stage — cirrhotic tuberculosis — the morphological picture changes dramatically. The lung deforms, becomes dense and immobile due to the extensive development of scar tissue. Linear scars form in place of healed cavities, and diffuse pneumosclerosis arises. It is in this stage that massive interpleural adhesions (fusion of the leaflets) form in the pleural cavity, and numerous bronchiectases form in the bronchi. The prognosis is extremely unfavorable; recovery of such patients is practically impossible.
For quick memorization of the indications for mandatory drainage, use the acronym "PPE": Pneumothorax, Pyopneumothorax, Pleural empyema.
Class and exam questions
Is it always necessary to operate on a patient with a cavity rupture?
Yes, when contents rupture into the pleura and pneumothorax or empyema develops, emergency drainage is mandatory. Subsequently, with significant damage, major interventions such as thoracomyoplasty or pneumonectomy are indicated.
How to distinguish pleural pain in complications from myocardial infarction?
Misinterpretation often occurs with mediastinal emphysema. However, in pleural complications, the pain is accompanied by progressive lung compression and mediastinal shift, which causes acute respiratory failure.
What is the morphology of the pleura in terminal cirrhotic tuberculosis?
In the cirrhotic form, the lung deforms and densifies due to sclerosis. Massive interpleural adhesions form within the pleural cavity itself, making the lung immobile.
What else to study on this topic
- Morphological picture and epidemiological hazard of fibrocavernous tuberculosis
- Canalicular and contact routes of infection spread through the respiratory tract
- Sputum-borne lesion of the gastrointestinal tract (tuberculous ileitis)
- Fatal complications: secondary amyloidosis and chronic cor pulmonale
- Indications for elective resections: tuberculomas and cavernous forms
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