Pleural pathology

Question 1

Causes of pleural inflammation

Answer 1

• Primary inflammatory diseases
• Infections - usually secondary to lung
• Pulmonary infarction
• Emphysema
• Pleural neoplasms
• Frequently there is pleural effusion

Question 2

No pleural effusion =

Answer 2

pleuritic chest pain and pleural rub during breathing (on auscultation)

Question 3

Pleural fibrosis Pathogenesis

Answer 3

Can prevent normal expansion and compression of the lung during respiration causing breathlessness, can form adhesions and obliterate the cavity

Question 4

Pleural decortication =

Answer 4

removing fibrous tissue to improve respiration

Question 5

Pleural fibrous plaques =

Answer 5

Markers of asbestos exposure

Question 6

Parietal pleural fibrous plaques

Answer 6

• Associated with low level asbestos dust exposure

- Asymptomatic but may be visible on chest radiographs

Question 7

Diffuse pleural fibrous plaques

Answer 7

• Associated with high level asbestos dust exposure

- Symptomatic - prevents normal expansion and compression of the lung during breathing causing breathlessness

Question 8

Pathological fluids in the pleural cavity

Answer 8

• Pus = empyema or pyothorax – secondary to pneumonia
• Blood = haemothorax – trauma, ruptured thoracic aortic aneurysm
• Bile = chylothorax – usually trauma

Question 9

Liquid/serous fluid in the pleural cavity =

Answer 9

Pleural effusion

Question 10

Transudate PEs

Answer 10

• low protein and lactate hydrogenase
• Low capillary oncotic or high hydrostatic pressure
• High hydrostatic pressure = left ventricular failure, renal failure (backlog in pulmonary circulation); low oncotic pressure = hypoalbuminemia

Question 11

Exudate PEs

Answer 11

• high protein and lactate dehydrogenase
• Pathological capillaries lose semi-permeability
• Caused by inflammation with/without infection e.g. pneumonia

Question 12

Signs of pleural effusion

Answer 12

• dull to percuss, reduced breath sounds

- breathlessness, pleuritic pain

Question 13

Treatment of PE’s

Answer 13

• Breathlessness = remove the fluid by aspiration – extreme cases = pleurodesis
• Treat the underlying cause = test pleural fluid (cytology and biopsy),

Question 14

Gas/air in pleural cavity =

Answer 14

pneumothorax

Question 15

Open pneumothorax

Answer 15

Chest wall perforation in trauma - external air is drawn into the pleural cavity during inspiration, reducing potential lung expansion

Question 16

Closed pneumothorax

Answer 16

A lung perforation, usually not traumatic, connects the lung air spaces to the pleural cavity. Lung air is drawn into the pleural cavity during inspiration, reducing potential lung expansion

Question 17

Tension pneumothorax

Answer 17

Open or closed pneumothorax may be valvular – lets air in during inspiration but nothing out in expiration. This may compress mediastinal structures – venae cavae, heart which then may compress the contralateral lung

Question 18

Diagnosis of a pneumothorax

Answer 18

• Symptoms = breathlessness mainly
• Signs = cyanosis, trachial deviation
• Percussion = hyper-resonant; auscultation = reduced breath sounds

Question 19

Treatment of pneumothorax

Answer 19

• Any = valvular aspiration (if tension (emergency) = aspirate with needle)
• Open = cover chest wound with occlusive adhesive dressing
• May resolve spontaneously, if recurrent = pleurodesis

Question 20

Primary pleural neoplasm =

Answer 20

Malignant mesothelioma

Question 21

Malignant Mesothelioma aetiology

Answer 21

• Asbestos – 80-90% of cases – MM develops 15 years to over 60 years after exposure
• Thoracic irradiation
• BAP1 (BRCA1-associated protein 1) mutations – uveal (eye) melanomas and mesotheliomas

Question 22

Malignant Mesothelioma histology

Answer 22

• Tubulopapillary epithelioid and spindle cell sarcomatioid
• May also be desmoplastic = poorly differentiated
• To differentiate between MM and non-small cell carcinomas e.g. adenocarcinoma

Question 23

Malignant Mesothelioma definition

Answer 23

• A neoplasm of mesothelial cells that line serous cavities - pleura, peritoneum, pericardium, tunica vaginalis
• More common in men

Question 24

Malignant Mesothelioma types

Answer 24

• Early = can produce large pleural effusion, Malignant cells may be shed into the effusion
• Advanced = the mesothelioma can spread around the pleural cavity, although metastases are rare

Question 25

Asbestosis

Answer 25

• Asbestosis is a usual interstitial pneumonia-like progressive pulmonary interstitial fibrosis caused by high level exposure to asbestos dust
• Impairs both gas exchange and lung expansion and contraction during breathing

Question 26

Asbestos corns

Answer 26

benign hyperkeratotic wart-like skin lesions associated with asbestos exposure