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Kelainan Pleura





Dr. Sanarko Lukman Halim,
SpPK
Bagian Patologi Klinik
F.K. UKRIDA
Juli 2011

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Outline
Physiology of the pleura
Pleural effusions
Neoplastic disease of the pleura
Pneumothorax
Chylothorax, and hemothorax
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Analisis Cairan Pleura 1/2
Torasentesis/Thoracentesis kecuali
Cairan tidak cukup
Ada Gagal jantung, efusi bilateral, tidak panas
efusi hilang setelah 3 hari
Transudat atau Eksudat?
Transdat: Gagal Jantung,sirosis hepatis (hepatic
hydrothorax), emboli paru, sindroma nefrotik,
Eksudat: Infeksi, kanker, penyakit jaringan
ikat/connective tissue disease,chylothorax, reaksi
obat.
Kriteria Light/Lights criteria (salah satu)
Total protein cairan pleura/ Total protein > 0.5
LDH c pleura / LDH serum >0.6
LDH c pleura > 2/3 batas atas nilai normal LDH serum




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Analisis Cairan Pleura 2/2
2 Bila Eksudatif
PMN > 50% Parapneumonic, emboli paru, pankreatitis
Limfo > 50% Keganasan,TBC, jamur, pasca pembedahan
Eos > 10% reaksi obat, asbestos, infeksi parasit
Kultur/ pewarn Gram: BTA (bila limfo>50%), Jamur
Glukosa: < 60 mg%: keganasan, hemotoraks,Tb
RA, SLE, infeksi parasit
Tes Adenosine Deaminase (ADA) untuk Tuberkulosa
ADA > 40-60 U/L dengan limfo >50% TBC
3. Bila diagnosa tidak jelas
Emboli paru. Thorascopy, biopsi










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Pleural effusion
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Definisi Efusi Pleura
Increased amount of fluid within the pleural
cavity
Stedmans Medical Dictionary
Accumulation of fluid between the layers of the membrane
that lines the lungs and the chest cavity
Medline Plus
Urgent pleural disorders
Pleural emergencies:
haemorrhage - haemothorax
elevated pleural pressure
- tension pneumothorax
- massive pleural effusion


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Key Points
Differentiation between transudates and
exudates.
The characteristic pleural findings for specific
diseases (i.e. CHF, SLE, RA, tuberculosis,)
Differentiation and management of
parapneumonic effusions .
Causes and diagnosis of neoplastic disease of the
pleura
Causes and management of the various types of
pneumothorax
Causes and management of chylothorax
Causes and management of hemothorax


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Tipe
Hydrothorax
Hemothorax
Chylothorax
Pyothorax / Empyema
Etiologi
Paru
Bukan Paru
Asites (sirosis)
Sindroma nefrotik/
Meigs syndrome



Efusi Pleura
Klasifikasi
a. Transudate
Ultrafiltrate of plasma
Small group of
etiologies
b. Exudate
Produced by host of
inflammatory conditions
Large group of
etiologies
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Causes of Pleural Effusion
Congestive heart failure 500,000
Pneumonia 300,000
Malignancy 200,000
Pulmonary embolism 150,000
Viral 100,000
Cirrhosis with ascites 50,000
GI disease 25,000
Collagen-vascular disease 6,000
Tuberculosis 2,500
Asbestos 2,000
Mesothelioma 1,500
Light,RW: Pleural Diseases (3
rd
) edition, Philadelphia: Lea & Febiger, 1995, p 76
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Diagnostic evaluation of the pleura
Radiography
Thoracentesis
Video-assisted thoracic surgery
(thoracoscopy)
Thoracotomy

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Differentiation of transudates & exudates
Transudates

< 0.5


< 0.6

< 2/3 the upper
limit for serum
Exudates

> 0.5


> 0.6

>2/3 the upper
limit for serum
Pleural Fluid

Pleural/serum
Protein

Pleural/serum
LDH

Pleural
LDH

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Transudative Pleural Effusions
Congestive heart failure
Pericardial disease
Hepatic hydrothorax
Nephrotic syndrome
Urinothorax
Myxedema
Pulmonary embolism (sometimes)
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Exudative Pleural Effusions4
Parapneumonic effusions
Tuberculous
Fungal
Viral
Parasitic
Pulmonary embolism
Abdominal disease
Collagen vascular disease
Post cardiac injury
Asbestos


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Hemotorak
pleural fluid with Ht > 50% blood Ht
CAUSES:
chest trauma: penetrating / non penetrating
(lung blood vessels, chest wall, diaphragm, pleural
adhesions, mediastinum, large vessels, abdomen)
iatrogenic
(pleural biopsy, subclavian or jugular CVC placement,
thoracentesis, transthoracic or transbronchial NA,
esophageal variceal TH,...)
nonthraumatic
(pleural malignancy, anticoagulant TH, spontaneous
rupture of vessel (AO aneurism), bleeding disorder,
thoracic endometriosis)
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Characteristics of a Complicated Parapneumonic Effusion
Glucose < 60 mg/dL
pH < 7.2
Positive culture
Pleural LDH > 3x the upper limit for serum
Pleural fluid is loculated
Empyema
Pus in pleura space
Positive gram stain


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Tuberculous Pleuritis
Acute illness 2/3 of cases; chronic illness in 1/3
Unilateral effusion
1/3 will have parenchymal disease
Exudative, lymphocyte predominant effusion

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Diagnosis of Tuberculous Pleuritis
PPD may be negative in up to 30%
Culture
Pleural fluid for
Adenosine deaminase
Interferon-gamma
Polymerase chain reaction (PCR) for tuberculous DNA
Biopsy
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Neoplastic disease of the pleura
Lung 36%
Breast 25%
Lymphoma 10%
Ovary 5%
Stomach 2%
Unknown 7%
Sahn, SA: In Fishman, JA 9ed): Fishmans Pulmonary Diseases
and Disorders, 3
rd
ed. McGraw Hill, NY, 1998
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Clinical Manifestations of Plural
Metastasis

Dyspnea 57
Cough 43
Weight loss 32
Chest pain 26
Malaise 22
Fever 8
Chills 5
Asymptomatic 23
Symptom Patients with
symptom (%)
Chernow, B., Sahn, SA., Am J Med, 1977
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Characteristics of Malignant Pleural Effusion
Usually exudative (though occasionally
transudative)
Mononuclear cell predominant
(lymphocytes, macrophages, and
mesothelial cells)
1/3 will have low pH (less than 7.3)
Sahn, SA, Clin Chest Med, 1998
Good, TJ, et al: American Review of Respiratory Disease, 1985
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Secondary Spontaneous Pneumothorax
Etiology
COPD
Cystic fibrosis
Interstitial lung disease such as sarcoidosis or
eosinophilic granuloma
Pneumocystis
Recurrence rates higher that for primary
spontaneous pneumothorax
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Chylous Pleural Effusion
Defined by the presence of chyle (lymph) in the
pleural space.
Diagnosis
Appearance often milky. Must differentiate
chylous from chyliform effusion
Chemical confirmation
Triglyceride > 110 mg/dL
If triglyceride is between 50-110 mg/dL,
send fluid for lipoprotein electrophoresis.
Chylomicrons confirms a chylothorax
If triglyceride is < 50, it is not chylous
Chyliform effusion has elevated cholesterol
and occurs in long standing effusions.


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Causes of Chylous Effusion
Tumor 54%
Lymphoma
Trauma 25%
Surgical
Other
Idiopathic 15%
Miscellaneous 6%

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Chyliform Effusions
Milky pleural fluid due to elevated
cholesterol of lecithin-globulin complexes
Most commonly associated with
tuberculosis, rheumatoid arthritis,
therapeutic pneumothorax
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Hemothorax
Pleural fluid hematocrit greater that 50% that of
peripheral blood
Causes
Traumatic (penetrating or non-penetrating)
Iatrogenic (thoracic surgery or line placement)
Non traumatic (from metastatic pleural disease),
spontaneous rupture of an intrathoracic vessel, bleeding
disorders
Complication of anticoagulant therapy
Treatment is immediate chest tube (both to evacuate
the fluid and monitor for additional bleeding)