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Chapter 3: Pleural effusion, pneumothorax, pleurisy 125

sinuses leading to sinusitis, rhinorrhea and epistaxis. It Polyarteritis nodosa
may be very deforming. In the lungs it causes nodular
See page 379.
masses, which may cavitate or infiltrations which can
leadtocough,dyspnoea,pleuriticpainandhaemoptysis.
It affects the kidneys in 90% of cases, manifesting as Churg–Strauss syndrome
oliguria, haematuria and uraemia.
See page 380.
Macroscopy/microscopy
An inflammatory small vessel arteritis with predom- Pleural effusion, pneumothorax,
inantly mononuclear infiltrates. There are necrotising pleurisy
granulomata of the respiratory tract. Kidney biopsy re-
veals a focal necrotising glomerulonephritis.
Pleural effusion
Investigations Definition
1 Full blood count: anaemia of chronic disease, neu-
A pleural effusion is defined as an accumulation of fluid
trophilia.
in the pleural space.
2 The ESR is usually very high.
3 U&Es to assess renal function.
Aetiology
4 Urine microscopy shows red cell casts.
The effusion is classified as transudate or exudate based
5 Lung function testing.
on the protein content (see Table 3.15).
6 The finding of anti neutrophil cytoplasmic antibod-
ies (cANCA) – PR3 (directed against a serine pro-
tease termed proteinase C) has a specificity of 90% Table 3.15 Causes of pleural effusion
and a sensitivity of 50% in early disease but closer to Type of effusion Pathogenesis Cause
100% in established disease. Finding pANCA (anti-
Transudate Increased Cardiac failure
myeloperoxidase) is less specific of Wegener’s, i.e. it is (<30 g/L protein) hydrostatic Constrictive
found in other inflammatory conditions. pressure pericarditis
7 Transbronchial or open lung biopsy. Decreased Hypoalbuminaemia,
8 Renal biopsy to assess the pattern and severity of oncotic e.g. nephrotic
pressure syndrome, cirrhosis
glomerulonephritis.
Miscellaneous Hypothyroidism
Meigs’ syndrome
Management (usually a
Cyclophosphamide and high-dose steroids to induce re- right-sided effusion
and a benign
mission. Relapse is prevented by long-term low-dose im-
ovarian fibroma)
munosuppression.Inpulmonaryhaemorrhageorsevere Exudate (>30 g/L Infections Bacterial including
acute renal failure, plasma exchange may be used. Oral protein) TB, empyema,
co-trimoxazole is used for nasal involvement. pneumonia
Neoplasms Metastatic carcinoma
Primary lung
Prognosis carcinoma
Once fatal in 1–2 years now much improved due to the Mesothelioma
use of cyclophosphamide and other immunosuppressive Pulmonary Thromboembolic
agents. infarction disease
Connective Rheumatoid disease,
tissue SLE
disease
Goodpasture’s syndrome Abdominal Pancreatitis,
disease subphrenic abscess
See page 246.