Porous diaphragm syndromes

Porous diaphragm syndromes are a group of seemingly disparate clinical symptom complexes involving a wide variety of unrelated medical specialties. However, they are linked by a common anatomical feature, a defect in the diaphragm. They usually present with thoracic symptomatology--pleural effusions, pneumothorax, hemothorax, empyema--mediated by this defect. Management of these syndromes utilizes principles of thoracic surgical practice including thoracotomy and thoracoscopy.

A syndrome of fibrosing pleuritis, pericarditis, and synovitis with infantile contractures of fingers and toes in 2 sisters: "familial fibrosing serositis"

We describe a family in which 2 sisters born to consanguineous parents developed childhood onset fibrosing pleuritis in association with constrictive pericarditis and bilateral deforming arthropathy of large and small joints of upper and lower extremities including flexion contractures of several fingers (camptodactyly) and toes. One patient also had mitral value prolapse. Histopathological examination of the synovium and pericardium revealed fibrosis, and ultrastructural study of synovium showed abundant inter and intracellular mesh of 9 nm microfibrils. We describe this distinct clinicopathological entity with pleiotropic manifestations, the common features of which appears to be the fibrosis of serous membranes. Therefore, the term "familial fibrosing serositis" is proposed for this entity.

Diseases of the pleura

In this review, three aspects of pleural disease are discussed. Although it was thought for many years that the origin of pleural fluid was the capillaries in the parietal or visceral pleura, recent evidence suggests that in many cases the origin of pleural fluid is the interstitial space of the lung. The interstitial space of the lung appears to be the source of the pleural fluid in patients who have congestive heart failure, parapneumonic effusions, pulmonary embolism, and lung transplants. The Hantavirus pulmonary syndrome is characterized by rapidly progressive, noncardiogenic pulmonary edema in relatively young, previously healthy individuals. The mortality rate with this syndrome is approximately 60%, and at autopsy most patients have large pleural effusions. Patients after lung transplantation frequently have profuse drainage from their chest tubes because most of the fluid that enters the lung must exit through the pleural space. The incidence of pleural effusion is very high in patients who have a complication of their lung transplantation, but the pleural fluid findings in patients after lung transplantation have not been well studied. Similarly, virtually all patients who undergo liver transplantation have a right-sided pleural effusion. The effusion usually reaches its maximum size around the third postoperative day. If the effusion increases in size after this time, serious complications should be suspected. The approach to pleural diseases has been altered with the advent of videothoracoscopy. Videothoracoscopy should be considered in patients who have undiagnosed pleural effusions and are not improving; in patients who have had recurrent pneumothorax, or a spontaneous pneumothorax with a persistent airleak or unexpanded lung; or in patients who have a traumatic hemothorax with clotted blood.

[Immediate and long-term results of pulmonary resection in bronchiectasis]

Under analysis were the nearest results of resection of the lungs for bronchoectasias in 360 patients aged from 5 to 68. Favorable nearest results were noted in 96.4% of the patients operated upon, with no lethal outcomes. Pleural complications met in 11% of the cases proved to be consequences of inadequate hermetic quality of the pulmonary and bronchial sutures. Remote results from 1 to 10 years were studied in 267 patients. Complete recovery was achieved in 29.9%, considerable improvement in 53.2%, the condition failed to change in 13.8%, aggravation was noted in 3.1%. Best results were obtained after operations performed at the age of 5-10 years, radical treatment in unilateral and bilateral bronchoectasias. Long-term results of the operations were influenced by pleuropulmonary complications, not treated chronical bronchitis, emphysematous alterations in the residual portions of the lungs.

Subarachnoid-pleural fistula in traumatic paraplegia

Subarachnoid-pleural fistulas caused persistent pleural effusion in 2 patients with traumatic paraplegia. The fistulas were diagnosed by myelography and radioisotope scan. Most of the previously reported cases of this rare entity have been treated by operative closure of the fistula. Both of the reported patients recovered: one underwent insertion of chest tubes to promote drainage and the other had no specific therapy. The authors believe conservative treatment should be attempted before surgery is considered.