• parietal pleura - covers the inner surface of the
thoracic cavity, including the mediastinum,
diaphragm, and ribs.
• visceral pleura - envelops all lung surfaces,
including the interlobar fissures.
• pleural space - coupling the movement of the chest
wall with that of the lungs
– relative vacuum in the space keeps the visceral and
parietal pleurae in close proximity.
– small volume of pleural fluid (0.13 mL/kg of body weight)
serves as a lubricant
– the volume of fluid is maintained through the balance of
hydrostatic and oncotic pressure and lymphatic drainage.
– TB, RA, sarcoidosis, uremia, viruses (Coksackie)
– chest pain (a characteristic symptom )which becomes
stronger during breathing and coughing.
– Cough (is usually dry)
– general indisposition;
– the temperature (subfebrile)
• Respiration is superficial (deep breathing intensifies
friction of the pleural membranes to cause pain).
• Lying on the affected side lessens the pain. Inspection
of the patient can reveal unilateral thoracic lagging
• Percussion fails to detect any changes except
decreased mobility of the lung border on the affected
• Auscultation determines pleural friction sound over the
• Pleural effusion - is an abnormal collection of
fluid in the pleural space resulting from excess
fluid production or decreased absorption.
• Pleural effusion is an indicator of an
underlying disease process that may be
pulmonary or nonpulmonary in origin and
may be acute or chronic.
• Altered permeability of the pleural membranes (eg,
inflammation, malignancy, pulmonary embolus)
• Reduction in intravascular oncotic pressure (eg,
• Increased capillary permeability or vascular disruption (eg,
trauma, malignancy, inflammation, infection, pulmonary
infarction, drug hypersensitivity, uremia, pancreatitis)
• Increased capillary hydrostatic pressure in the systemic
and/or pulmonary circulation (eg, congestive heart failure,
superior vena cava syndrome)
• Reduction of pressure in the pleural space, preventing full
lung expansion (eg, extensive atelectasis, mesothelioma)
• Decreased lymphatic drainage or complete blockage,
including thoracic duct obstruction or rupture (eg,
• Increased peritoneal fluid, with migration across the
diaphragm via the lymphatics or structural defect (eg,
cirrhosis, peritoneal dialysis)
• Movement of fluid from pulmonary edema across the visceral
• Persistent increase in pleural fluid oncotic pressure from an
existing pleural effusion, causing further fluid accumulation
• The estimated prevalence of pleural effusion
is 320 cases per 100,000 people in
industrialized countries, with a distribution of
etiologies related to the prevalence of
• In general, the incidence is equal between the sexes.
• Certain causes have a gender predilection.
– About two thirds of malignant pleural effusions occur in
women. Malignant pleural effusions are significantly
associated with breast and gynecologic malignancies.
– Pleural effusion associated with systemic lupus
erythematosus is also more common in women than in
– Pleural effusions associated with chronic pancreatitis are
more common in males, with the majority of male cases
having alcoholism as the etiology.
– Rheumatoid effusions also occur more commonly in males
than in females.
• Progressive dyspnea
– the most common symptom associated with pleural effusion
– is related more to distortion of the diaphragm and chest
wall during respiration than to hypoxemia
– may be caused by the condition producing the pleural
effusion, rather than by the effusion itself
– often mild and nonproductive
– purulent or bloody sputum suggests an underlying
pneumonia or endobronchial lesion
• Pleuritic chest pain
– raises the likelihood of an exudative etiology
– may be mild or severe
– localized to the chest wall or referred to the ipsilateral shoulder or
upper abdomen, usually because of diaphragmatic involvement
• Other symptoms could be suggestive for the underlying
– increasing lower extremity edema, orthopnea, and paroxysmal
– night sweats, fever, hemoptysis, and weight loss
– acute febrile episode, purulent sputum production
• are variable and depend on the volume of the
• no physical findings for effusions smaller than
• Mediastinal shift away from the effusion - this
is observed with effusions of greater than
• Asymmetrical chest expansion, with
diminished or delayed expansion on the side
of the effusion
• Decreased tactile fremitus,
• Dullness to percussion,
• Diminished or inaudible breath sounds
• Egophony ("e" to "a" changes) at the most
superior aspect of the pleural effusion
• Pleural friction rub
• Other physical findings suggestive for the
underlying cause of the pleural effusion:
– Peripheral edema, distended neck veins, and S3 gallop
suggest congestive heart failure.
– Edema may also be a manifestation of nephrotic
syndrome; pericardial disease;
– Cutaneous changes with ascites suggest liver disease
– Lymphadenopathy or a palpable mass suggests
• homogenous increase in density spread over
the lower lung fields
• Apparent elevation of the hemidiaphragm,
lateral displacement of the dome of the
diaphragm, or increased distance between the
apparent left hemidiaphragm and the gastric
air bubble suggests subpulmonic effusions
• Lateral decubitus films more reliably detect smaller
• Layering of an effusion on lateral decubitus films
defines a freely flowing effusion and, if the layering
fluid is 1 cm thick, indicates an effusion of greater
than 200 mL that is amenable to thoracentesis.
• Failure of an effusion to layer on lateral decubitus
films indicates the presence of loculated pleural
fluid or some other etiology causing the increased
Radiograma de faţă şi profilul drept.
Incidenţa AP - opacitate neomogenă în câmpul pulmonar inferior pe
dreapta,caracterul căreia se poate defini din imaginea de profil - pleurezie
încarcerată în scizura interlobară oblică cu aspect de lentilă biconcavă.
Diverse aspecte radiografice la pacienţi cu pleurezii încarcerate.
A - profil drept; colecţia lichidiană încarcerată în scizura interlobară orizontală prezintă o
opacitate ovală;opacitatea inferioară atestă lichid liber în marea cavitate.
B - radiogramă în poziţie oblică, pleurezia parietală încarcerată se prezintă ca opacitate
ovoidă, bine delimitată în câmpul inferior stâng.
Analysis of pleural fluid
Normal pleural fluid
• Clear ultrafiltrate of plasma that originates from
the parietal pleura
• pH of 7.60-7.64
• Protein content of less than 2% (1-2 g/dL)
• Fewer than 1000 white blood cells (WBCs) per
• Glucose content similar to that of plasma
• Lactate dehydrogenase (LDH) less than 50% of
• Frankly purulent fluid indicates an empyema
• A putrid odor suggests an anaerobic empyema
• A milky, opalescent fluid suggests a chylothorax, resulting most
often from lymphatic obstruction by malignancy or thoracic duct
injury by trauma or surgical procedure
• Grossly bloody fluid may result from trauma, malignancy,
postpericardiotomy syndrome, or asbestos-related effusion and
indicates the need for a spun hematocrit test of the sample; a
pleural fluid hematocrit level of more than 50% of the peripheral
hematocrit level defines a hemothorax, which often requires tube
Exsudate vs Transudate
• Ratio of pleural fluid to serum protein greater than
• Ratio of pleural fluid to serum LDH greater than 0.6
• Pleural fluid LDH greater than two thirds of the upper
limits of normal serum value
Clinical judgment is required when pleural fluid test
results fall near the cutoff points
Exsudate vs Transudate
• The criteria from Light et al and these alternative criteria
identify nearly all exudates correctly, but they misclassify
approximately 20-25% of transudates as exudates, usually
in patients on long-term diuretic therapy for congestive
heart failure (because of the concentration of protein and
LDH within the pleural space due to diuresis).
• Using the criterion of serum minus pleural protein
concentration level of less than 3.1 g/dL, rather than a
serum/pleural fluid ratio of greater than 0.5, more
correctly identifies exudates in these patients.
• Although pleural fluid albumin is not typically measured, a
gradient of serum albumin to pleural fluid albumin of less
than 1.2 g/dL also identifies an exudate in such patients.
Pleural Fluid Cell Count Differential
• Pleural fluid lymphocytosis,
– lymphocyte values greater than 85% of the total
nucleated cells, suggests TB, lymphoma,
sarcoidosis, chronic rheumatoid pleurisy, yellow
nail syndrome, or chylothorax.
– Pleural lymphocyte values of 50-70% of the
nucleated cells suggest malignancy.
Pleural Fluid Cell Count Differential
• Pleural fluid eosinophilia (PFE)
– most often caused by air or blood in the pleural space.
– pulmonary embolism with infarction or benign asbestos
– parasitic disease (especially paragonimiasis)
– fungal infection (coccidioidomycosis, cryptococcosis,
– PFE does not exclude a malignant effusion
– PFE makes tuberculous pleurisy unlikely
– makes the progression of a parapneumonic effusion to an
Pleural Fluid Cell Count Differential
• Mesothelial cells greater than 5% of total
nucleated cells makes a diagnosis of TB less
• Markedly increased numbers of mesothelial
cells, especially in bloody or eosinophilic
effusions, suggests pulmonary embolism as
the cause of effusion.
Pleural fluid cytology
• The reported diagnostic yields in cytology vary
from 60-90%, depending on the extent of
pleural involvement and the type of primary
• Cytology findings are positive in 58% of
effusions related to mesothelioma.
Other tests for pleural fluid
• Triglyceride, cholesterol
• Immunological markers (RF, DNA anti-body, etc.)
• Microbiological examination
• Transudative effusions are usually managed by
treating the underlying medical disorder.
• However, whether transudates or exudates, large,
refractory pleural effusions causing severe respiratory
symptoms, even if the cause is understood and
disease-specific treatment is available, can be drained
to provide relief.
• The management of exudative effusions depends on
the underlying etiology of the effusion. Pneumonia,
malignancy, or TB causes most diagnosed exudative
pleural effusions, with the remainder typically deemed
• Complicated parapneumonic effusions and empyemas
should be drained to prevent development of fibrosing
• Malignant effusions are usually drained to palliate
symptoms and may require pleurodesis to prevent
• Medications cause only a small proportion of all
pleural effusions and are associated with exudative
• However, early recognition of these iatrogenic causes
of pleural effusion avoids unnecessary additional
diagnostic procedures and leads to definitive therapy,
which is discontinuation of the medication.
• Implicated drugs include medications that cause drug-
induced lupus syndrome (eg, procainamide,
hydralazine, quinidine), nitrofurantoin, dantrolene,
methysergide, procarbazine, and methotrexate.
• Morbidity and mortality of pleural effusions are
directly related to cause, stage of disease at the time
of presentation, and biochemical findings in the
• Morbidity and mortality rates in patients with
pneumonia and pleural effusions are higher than
those in patients with pneumonia alone.
– Parapneumonic effusions, when recognized and treated
promptly, typically resolve without significant sequelae.
– However, untreated or inappropriately treated
parapneumonic effusions may lead to empyema,
constrictive fibrosis, and sepsis.
• Development of a malignant pleural effusion is
associated with a very poor prognosis, .
– The most common associated malignancy in men is lung
cancer, and the most common associated malignancy in
women is breast cancer.
– Median survival ranges from 3-12 months, depending on
• A lower pleural fluid pH is often associated with a
higher tumor burden and a worse prognosis.
ILD Associated with Connective Tissue
• Clinical findings suggestive of a CTD should be sought
in any patient with ILD
• musculoskeletal pain, weakness, fatigue, fever, joint
pains or swelling, photosensitivity, Raynaud's
phenomenon, pleuritis, dry eyes, dry mouth)
• The CTDs may be difficult to rule out since the
pulmonary manifestations occasionally precede the
more typical systemic manifestations by months or
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint 0
2-10 large joints 1
1-3 small joints (large joints not counted) 2
4-10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5
Negative RF AND negative ACPA 0
Low positive RF OR low positive ACPA 2
High positive RF OR high positive ACPA 3
SYMPTOM DURATION (0-1)
<6 weeks 0
≥6 weeks 1
ACUTE PHASE REACTANTS (0-1)
Normal CRP AND normal ESR 0
Abnormal CRP OR abnormal ESR 1
≥6 = definite RA
What if the score is <6?
Patient might fulfill the criteria…
Prospectively over time
Retrospectively if data on all four
domains have been adequately
recorded in the past
• Pulmonary Involvement is more common in male (3/1)
• Ocasional is the first manifestation
1)PLURISY with or without pleural effusion
– low GLU, high LDH, low Ph,
– RF may be positive, WBC is more LYM.
2)PULMONARY NODULE multiple, in periphery,
– Can cause PTX, hemoptysis and may became infected.
– In CWP diffuse nodular fibrotic proces (Caplan sdr).
2)PULMONARY FIBROSIS: more in base of lung
3)BRONCHIOLITIS OBLITERANS: granulation and
fibrosis of bronchioles. it cause symptoms
of asthma. in spirometry : obstructive
pattern. not responsive to treatment.
4)BOOP: diffuse infiltration in CXR, restrictive
pattern, good response to steroid.
Radiografia unei paciente cunoscută cu
AR de 24 ani (tratament de fond
administrează ultimii 2 ani Metotrexat
10 mg săptămânal) prezintă leziuni
minime manifestate prin reticulaţie fină
în câmpurile pulmonare inferioare, dar
afectarea articulară este mult mai severă.
Radiografia unui pacient cu AR cu leziuni pulmonare
severe, distorsionare pronunţată a arhitectonicii
pulmonare, modificări fibrochistice cu aspect de „fagure
de miere” mai exprimate bazal bilateral, cu tendinţă de
extindere pe toată aria pulmonară.
Tomografia plană (8 cm) confirmă
prezenţa fagurelui prepoderent
periferic şi nu atestă infiltraţii
pulmonare, deşi la aceşti pacienţi este
foarte dificil a exclude pneumonia.
Deformările articulare nu impresionează,
dar acest pacient a avut factori de risc
importanţi pentru dezvoltarea leziunilor
-prezenţa nodulilor reumatoizi subcutani,
-titre înalte de factor reumatoid.
Artrita reumatoidăArtrita reumatoidă
HRCT demonstrează prezenţa leziunilor
interstiţiale atât la pacienţii simptomatici (69-
80%) cât şi la asimptomatici (20-29%)
Semnele sunt cele tipice pentru pneumonitele
Distinctiv la HRCT se determină “fagure de
miere” progresiv de la bazele pulmonare spre
Poate fi prezent şi emfizemul pulmonar în
asociere cu bronşiectazii, inclusiv la cei
Radiografia în incidenţă PA la o pacientă cu istoric de AR de 17 ani (A) evidenţiază în
câmpul pulmonar inferior drept şi stâng opacităţi "în voal" (de intensitate foarte slabă),
care au fost eronat interpretate drept infiltraţie pulmonară. La examenul în incidenţă
laterală dreaptă (B) se confirmă etiologia pleurală (îngroşări
• RadiograRadiografia în incidenţă PAfia în incidenţă PA la ola o paciepacientă cu AR de ... ani, evidenţiază în câmpul pulmonar inferiorntă cu AR de ... ani, evidenţiază în câmpul pulmonar inferior
drept şi stâng opacităţi “în voal” (de intensitate foarte slabă), care au fost eronat interpretate dreptdrept şi stâng opacităţi “în voal” (de intensitate foarte slabă), care au fost eronat interpretate drept
infiltraţie pulmonară, dar la examenul în incidenţă laterală este confirmată etiologia pleuralăinfiltraţie pulmonară, dar la examenul în incidenţă laterală este confirmată etiologia pleurală
(îngroşări pleurale).(îngroşări pleurale).
Radiografia de faţă la un pacient cu artrită reumatoidă.
Pneumonită bilaterală (infiltraţie în cîmpul pulmonar inferior şi mediu pe stînga şi în
cîmpul superior şi mediu pe dreapta).
(Colecţia doctor în medicină, conferenţiar Matcovshi S.)
1. Malar rash: Fixed erythema over malar areas, sparing nasolabial folds
2. Discoid rash: Erythematous raised patches with keratotic scaling and follicular
3. Photosensitivity: Skin rash after exposure to sunlight, history or physical
4. Oral ulcers: Oral or nasopharyngeal, painless, by physical exam
5. Arthritis:Tenderness, swelling, effusion in 2 or more peripheral joints
6. Serositis: A) pleuritis or B) pericarditis
7. Renal disorder A) proteinuria>0.5g/24hour or 3+ or B) cellular casts
8. Neurological disorder: A) seizures or B) psychiatric disorder (having excluded
other causes, e.g. drigs)
9. Haematological disorder: A) haemolytic anaemia or B) leucopenia or C)
10. Immunologic disorder: A) positive LE cells or B) raised anti-native DNA
antibdy binding or C) anti-Sm antibody or D) false positive serological test for
11. Positive antinuclear antibody:
Criteria of the ARA for the classification of SLE
• In the course of disease 60-70% develop pleural or
• It can be primary , secondary (drug) or infection.
• The most common cause of pulmonary infilteration in
SLE is infection.
• Pulmonary function testing, particularly DLCO, reveals
abnormalities in many patients with SLE.
PATTERN OF INVOLVEMENT
1) LUPUS PNEUMONITIS (acute, chronic)
• Acute it is due to activation of immune mechanism,
• Chronic form progress to pulmonary fibrosis
2)PULMONARY HTN (vasoconstriction, emboli, capilaritis)
• vasoconstriction is associted with Raynaud and emboli
associted with LA, APLA
3) PLEURITIS WITH OR WITHOUT PLEURAL effusion is the most
common pulmonary manifestation: it may be unilateral or
• It is exudative with normal glucose and low LDH, low C3 and C4,
ANA and LE cell may be positive, WBC may be predominantly
PMN or LYM.
• Diferential with infection, emboli
4) Other lung manifestations include the following: atelectasis,
diaphragmatic dysfunction with loss of lung volumes,
pulmonary vascular disease, pulmonary hemorrhage, uremic
pulmonary edema, infectious pneumonia, and BOOP.
PATTERN OF INVOLVEMENT
Radiogramă de faţă în LES.
Bilateral bazal atelectazii discoide. Sinusurile costodiafragmale opacifiate
(colecţie lichidiană pleurală minimă bilateral).(Colecţia doctor Elena Volcovski)
Radiogramă de faţă şi tomografie convenţională (secţia 7 cm) în lupusul
eritematos sistemic. Bilateral infiltraţie în cîmpurile pulmonare superioare -
pneumonită lupică. Configuraţie mitrală a cordului, bombarea conului pulmonar.
(Colecţia doctor în medicină, conferenţiar Matcovshi S.)
Scleroderma Diagnostic Criteria
• One major criterion: scleromatous skin
changes proximal to the metacarpal-
• Two of three minor criteria: sclerodactyly,
digital pitting scars, bi-basilar pulmonary
fibrosis on CXR
• Clinical evidence of ILD is present in about one-half of
• Pulmonary function tests show a restrictive pattern
and impaired diffusing capacity, often before any
clinical or radiographic evidence of lung disease
• LEADING CAUSE OF DEATH .
1)PULMONARY FIBROSIS: more in base of lung,
ILD pattern, dry cough, dyspnea at exertion and then at
rest, restrictive pattern, low DLCO.
2)Superimposision of lung cancer (Adenocarcinoma)
3)PULMONARY HTN: more common in CREST than
systemic form (in systemic form pulmonary fibrosis is
4)PLURAL INVOLVEMENT & ASPIRATI0N PNEUMONIA
Radiograma de faţă (A) şi profilul drept (B) la o pacientă cu scleroză sistemică prezintă
opacităţi "în sticlă mată" şi multiple opacităţi reticulonodulare bilateral, în câmpurile
pulmonare inferioare se
conturează imaginea "în fagure de miere".
La CT pulmonar (C) se determină leziuni fibrotice avansate
cu îngroşarea septurilor, zone de pneumoscleroză şi dezvoltarea fagurelui subpleural. De
notat, predilecţia leziunilor subpleural şi în lobii inferiori.
ACR Diagnostic Criteria
• 1. Symmetrical weakness
– Limb-girdle and neck flexors, with or without
• 2. Biopsy
• 3. Elevation of muscle enzymes in serum
– CK, aldolase, LDH, AST, ALT
• 4. EMG evidence
• 5. Dermatologic features
– Gottron’s sign, heliotrope rash, shawl sign, etc.
4 criteria, no rash
3 criteria, no rash
2 criteria, no rash
Rash + 3 criteria
Rash + 2 criteria
Rash + 1 criteria
• ILD IN 10% OF PATIENT
• Diffuse reticular or nodular opacities with or without an alveolar
component occur radiographically, with a predilection for the lung
• ASPIRATION PNEUMONIA (due to pharyngeal muscle
• HYPOVENTILATION (due to resp muscle weakness)
• PLEURAL INVOLVEMENT IS RARE.
• ANTI JO1 (antihistidyl t RNA synthetase) is present in patient with
antineutrophil cytoplasmic antibody (c-ANCA)
need to confirm diagnosis
• often 3-4 biopsies necessary
• nasopharynx commonly involved good site
• open pulmonary biopsy occasionally needed
• untreated mortality of 90% at two years
Opacităţi multiple macronodulare cu margini mprecise, bilaterale cu evoluţie spre
Radiografia toracelui repetată după 2,5 luni tratament cu prednisolon şi ciclofosfamidă
arată reducerea dramatică a infiltraţiei pulmonare.