Pleurisy : Inflammation of the Pleura

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Pleurisy is an inflammation of the pleura, often characterised clinically by pain worsened by respiration and cough. The pleura is a thin, transparent membrane that covers the lungs and also limes the inside of the chest wall: The surface that covers the lungs lies in close contact with the surface that lines the chest wall. Between the two thin flexible surfaces is a small amount of fluid that lubricates them as they slide smoothly - Over one another with each breath. Air, blood, fluid or other material can get between the pleural surfaces, creating a space. If too much material accumulates, one or both lungs, may not be able to expand normally with breathing, resulting in the collapse of a lung. Pleurisy, an inflammation of the pleura, develops when an agent (usually a virus or bacterium) irritates the pleura, resulting in inflammation. Fluid may accumulate in the pleural space (a condition called pleural effusion), or fluid may not accumulate (a condition called, dry pleurisy). After the inflammation subsides, the pleura may return to normal, or adhesions may form that make the pleural layers stick together.

Etiology :
Pleurisy may result from (1) Pleural injury by a process in the underlying lung (e.g., Pneumonia, Infarction); (2) entry of an infectious agent or irritating substance into the pleural space (e.g., as in amoebic empyema or, pancreatic pleurisy); (3) transport on an infectious or noxious agent or nepolastic cells directly to the pleura by the bloodstream or lymphatics (e.g. as in TB pleural effusion; uremic pleurisy, pleural carcinomatosis or collagen vascular disease such as rheumatoid disease and SLE); (4) Pleural trauma; the conducting airways and respiratory tissues; or (6) rarely, pleural effusion related to long-standing ingestion of dantrolene sodium.

Pathology:
In early stages, the pleura usually becomes oedematous and congested, cellular inflammation occurs, and fibrinous exudate develops on the pleural surface: Exudate may be reabsorbed or organised into fibrous tissue with resultant pleural adhesions. Some diseases (e.g., pleurodynia due to coxsackie B virus) may run. their course with out significant exudation of fluid from the inflamed pleura, the pleurisy remaining dry or fibrinous. More often, however, following this early stage, pleural exudate develops due to an outpouring from damaged vessels of fluid rich in plasma protein. Occasionally, marked fibrous or even calcific thickening of pleura occurs without an antecedent acute pleurisy (e.g. asbestos pleural pluques, idiopathic pleural calcification).

Essentials of Diagnosis:

Dyrspnoea if effusion is large: may be asymptomatic.
Pain of pleurisy often precedes the plural effusion.
Decreased breath sounds, flatness to percussion egophony.
The underlying cardiac or pulmona disease may be the major source of symptoms and signs.
X-ray evidence of pleural fluid.

Symptoms and Diagnosis:
The most common symptom of pleurisy is chest pain, which usually begins suddenly. The pain varies from vague discomfort to an intense stabbing pain. It may be felt only when the person breathes but may be worsened by deep breathing and coughing. The pain results from inflammation of the outer pleural layer and is usually felt in the chest wall right over the site of the inflammation. However, the pain may be felt also or only in the abdomen or neck and shoulder as referred pain.

Breathing may be rapid and shallow because deep breathing induces pain; the muscles on the painful side move less than those on the normal side. If a large amount of fluid accumulates, it may separate the pleural layers, so the chest pain disappears, large amounts of fluid can cause difficulty in expanding one or both lungs when breathing, causing respiratory distress. Pleurisy is often easy for doctors to diagnose because the pain is so distinctive. Using a stethoscope, a doctor may hear a squeaky rubbing sound, called a pleural rub. Even though a chest X-ray won't show pleurisy, it may reveal a rib fracture, evidence of lung disease, or a small collection of fluid in the pleural space.

Treatment :
The treatment of pleurisy depends on the particular cause. If the cause is a bacterial infection, for example, antibiotics are prescribed. If the cause is a viral infection, no treatment is needed for the infection. If the cause is an auto-immune disease, treacing it often allows the pleurisy to resolve.

Analgesics such as acetaminophen or ibuprofen usually help relieve chest pain regardless of the cause of the pleurisy. Codeine and other narcotics are stronger pain relievers, but they tend to suppress coughing, which is not a good idea because deep breathing and coughing help prevent pneumonia. Thus, a person with pleurisy is encouraged to breathe deeply and cough when breathing becomes less painful. Coughing may be less painful if the person or a helper holds a pillow firmly against the part of the chest that hurts. Wrapping the entire chest in wide, nonadhesive elastic bandages helps relieve severe chest pain. However, binding the chest to reduce expansion during breathing increases the risk of pneumonia.

Indolent infection in the pleural space must be treated by a long course of appropriate antibiotic therapy. For example, TB pleurisy responds to treatment with two simultaneously given anti tuberculosis drugs (e.g., isoniazid and rifampin); amphotericin B is effective in coccidioidal pleural effusion. Pleural fluid in such cases usually reabsorbs spontaneously.

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