Pathogenesis of pleural plaques. Relationship of early cellular response and pathology

To study the initial pleural cellular response to asbestos and to determine the relationship between this response and the development of pleural plaques, a model of asbestos pleurisy was developed in both normal and nitrogen-mustard-treated (neutropenic) New Zealand white rabbits. Animals were rendered neutropenic, as it has been shown that neutropenic rabbits do not develop a macrophage influx in the pleural space after the administration of either BCG or bacteria and that the pathology is different from that in normal rabbits treated in a similar fashion. Intrapleural asbestos induced an exudative effusion in normal animals within 4 h, and there was increased metabolic activity through 120 h, with a fall in pleural fluid pH and PO2 and a rise in pleural fluid PCO2. Neutropenic animals similarly developed an exudative pleural effusion but showed no change in metabolic activity of pleural fluid. Normal rabbits showed a marked cellular influx into the pleural space after asbestos treatment, with a peak total cell count of 27,208/microliters at 24 h; the majority of these cells were polymorphonuclear leukocytes. A macrophage influx occurred at 48 h and peaked at 72 h. By 120 h, lymphocytes were the predominant cell. Nitrogen-mustard-treated animals reached a peak of only 5,442 cells/microliters in the pleural space at 24 h, with a small percentage of polymorphonuclear leukocytes. A macrophage peak did not occur in these animals. There was a marked contrast between groups noted at autopsy. Normal animals developed pleural plaque formation, which was evident by 7 days and completely developed by 1 month.(ABSTRACT TRUNCATED AT 250 WORDS)

Lupus pleuritis. Clinical features and pleural fluid characteristics with special reference to pleural fluid antinuclear antibodies

Eighteen patients with lupus erythematosus (LE) and pleural effusions were evaluated. Fourteen patients had lupus pleuritis and four had pleural effusions of other etiologies. All patients were symptomatic, and the presenting signs and symptoms did not help distinguish between lupus pleuritis and pleural effusions of other causes. The presence of LE cells confirmed the diagnosis of lupus pleuritis in seven of eight patients. In 11 of 13 patients with lupus pleuritis, the pleural fluid antinuclear antibody (ANA) titer was greater than or equal to 1:160, and in nine of 13 patients with lupus pleuritis, the pleural fluid to serum (PF/S) ANA ratio was greater than or equal to 1. In the four patients with LE and a pleural effusion of another etiology, the pleural fluid ANA titer was negative in two and low titer in two (1:40, 1:80); the pleural fluid to serum ANA titer was always less than one. Of 67 patients with pleural effusions of other etiologies, the pleural fluid ANA was negative. The signs and symptoms of lupus pleuritis are nonspecific, however; the findings of LE cells in pleural fluid confirms the diagnosis and a high pleural fluid ANA titer (greater than or equal to 1:160) and a PF/S ANA ratio of greater than or equal to 1 strongly supports the diagnosis.

Dimethyl sulfoxide inhibits phagocyte influx into infected pleural spaces and phagocyte locomotion in vitro

Influx of polymorphonuclear leukocytes (PMNs) and monocytes (MNs) into pleural spaces was decreased in dimethyl sulfoxide (DMSO)-treated rabbits infected intrapleurally with Staphylococcus aureus. In addition, pleural fluids contained S. aureus longer and marked pleural thickening with fibrosis occurred in DMSO-treated rabbits. DMSO also inhibited stimulated locomotion of PMN and MN in vitro, suggesting that the aforementioned responses in vivo may have occurred because of DMSO-mediated inhibition of the locomotion of PMN and MN.

The contribution of leukocytes and bacteria to the low pH of empyema fluid

Empyema fluid characteristically has a low pleural fluid pH, and it has been demonstrated that this fluid has a high acid-generating capacity. To evaluate the contribution of leukocytes and bacteria to the low pH of empyema fluid, an experimental model of empyema was used. After the production of a sterile pleural effusion by turpentine in both normal and neutropenic New Zealand white rabbits, either live Streptococcus pneumoniae, killed Streptococcus pneumoniae, or Acinetobacter, an organism that does not undergo fermentation or produce substantial acid, were injected into the pleural fluid. With these manipulations, the contribution of leukocytes and bacteria alone could be assessed. The results showed that both leukocyte phagocytosis and bacterial metabolism contribute to the low pH of empyema fluid and that the number of polymorphonuclear leukocytes per se in clinically observed ranges is not critical to the change in pleural fluid pH.

The pleuropulmonary manifestations of the postcardiac injury syndrome

This study was designed to investigate the frequency and diagnostic importance of the pleuropulmonary manifestations of the postcardiac injury syndrome. A retrospective study of 35 patients (2 to 76 years old) with clearly defined postcardiac injury syndrome is presented. Twenty-one cases followed cardiac surgery, and 14 appeared after myocardial infarction. The onset of the syndrome was an average of 20 days following injury. The major clinical findings were pleurisy (91 percent; 32/35), fever (66 percent; 23/35), pericardial rub (63 percent; 22/35), dyspnea (57 percent; 20/35), rales (51 percent; 18/35), pleural rub (46 percent; 16/35), elevated erythrocyte sedimentation rate (96 percent; 25/26), and leukocytosis (49 percent; 17/35). The chest roentgenogram was abnormal in 94 percent (33/35). Pleural effusion was present in 83 percent (29/35), parenchymal infiltrates in 74 percent (26/35), and an enlarged cardiac silhouette in 49 percent (17/35). Analysis of pleural fluid was performed on 16 samples from 12 patients and revealed a bloody exudate with a pH greater than 7.40. The data presented document that pleuropulmonary involvement is a common manifestation of postcardiac injury syndrome. In addition, we discuss how these findings can be used to differentiate this syndrome from other clinical entities that may appear following cardiac injury, ie, parapneumonic effusions, congestive heart failure, and pulmonary embolism.

The pathogenesis of the low pleural fluid pH in esophageal rupture

To determine the possible mechanisms responsible for the low pH pleural effusion associated with esophageal rupture we evaluated the following possibilities: (1) gastric acid reflux, (2) bacterial metabolism, and (3) leukocyte metabolism. Neither elimination of gastric hydrogen ion contribution by distal esophageal ligation nor elimination of bacteria with antibiotics prevented the progressive fall in pleural fluid pH after esophageal rupture. Only elimination of polymorphonuclear leukocytes from the pleural space by rendering animals leukopenic with nitrogen mustard, prevented a low pH effusion after esophageal rupture. It appears that pleural fluid leukocyte metabolism is primarily responsible for the low pH effusion associated with esophageal rupture.

Inflammatory responses in experimental tuberculosis pleurisy

A model of tuberculous pleurisy in New Zealand white rabbits was developed to describe the sequential cellular and biochemical changes in pleural fluid. Bacille Calmette-Guérin (BCG) in 4 X 10(7) colony-forming units was introduced into the right pleural space of rabbits previously sensitized by intradermal BCG. Pleural fluid was obtained via serial thoracenteses. A normal-pH, normal-glucose, exudative effusion was seen through 144 hours. Polymorphonuclear leukocytes were the first cells to respond to the introduction of tubercle bacilli in the pleural space; they remained the predominant cell for the first 24 hours and were followed by macrophages, which peaked at 96 hours, and then by lymphocytes. Numerous granulomata were observed on both the visceral and parietal pleura ten days following intrapleural instillation of BCG. We propose that the polymorphonuclear leukocyte influx is not a nonspecific response to pleural injury and that such a leukocyte response, either itself or through its interaction with the macrophage, plays a role in host defense mechanisms against the tubercle bacilli.

Controlled hyperventilation in patients with intracranial hypertension. Application and management

When elevated intracranial pressure (ICP) complicates the course of various forms of cerebral edema, the likelihood of survival with full recovery is greatly diminished. Controlled mechanical hyperventilation effectively lowers ICP in some patients by causing cerebral vasoconstriction. Improved survival occurs in patients with elevated ICP from head trauma and intracranial infection treated with hyperventilation; however, no benefit has been demonstrated in patients with increased ICP from strokes or hypoxic brain damage. Proper management of the hyperventilation requires knowledge of basic cerebral circulatory physiology. Arterial Paco2 tensions should be maintained between 25 and 30 mm Hg. Vasoconstrictive effects of hyperventilation diminish after 48 to 72 hours when renal mechanisms compensate for the respiratory alkalosis. When hyperventilation is discontinued, the Paco2 must be gradually returned to normal values, since sudden changes may cause a marked rise in ICP.

Cardiac tamponade complicating the postpericardiotomy syndrome

Cardiac tamponade is a rare complication of the postpericardiotomy syndrome in the absence of anticoagulation therapy. Three cases are presented where cardiac tamponade developed as a result of the postpericardiotomy syndrome with normal coagulation parameters. The pericardial effusions were serous in two and serosanguinous in the third case. Pericardial fluid studies were consistent with an exudate. The effusion resolved following a single pericardial tap and short-term corticosteroid therapy in one case. Repeated pericardiocentesis and drainage via an indwelling catheter were required in the other two cases.

The differential diagnosis of pleural effusions

The presence of pleural effusion enables a physician to obtain a specimen of a body cavity fluid easily. With a systematic analysis of the pleural fluid, in conjunction with the clinical features and ancillary laboratory data, a clinician should be able to arrive at either a presumptive or definitive diagnosis in approximately 90 percent of cases. Selectivity should be exercised in ordering analyses on pleural fluid. The first important deductive step is to decide whether the effusion is a transudate (due to imbalances in hydrostatic or oncotic pressures) or an exudate (inflammatory); serum protein and lactate dehydrogenase measurements will be decisive. The differential diagnosis of a transudate is relatively limited and usually easily discernible from the clinical presentation. The differential diagnosis of exudate poses a more difficult challenge for clinicians. The use of certain pleural fluid tests such as leukocyte count and differential, glucose, pH and, when indicated, pleural fluid amylase determinations, helps to narrow the differential diagnosis of an exudative pleural effusion.

Pleural effusion in lung cancer

Pleural effusions are common in the setting of lung cancer. The clinician must establish whether the effusion is malignant, ruling out the possibility of curative surgery; paramalignant, which may or may not rule out surgery; or unassociated with the cancer. A pleural effusion associated with lung cancer is an ominous finding, but a small percentage of patients in this setting will be candidates for curative surgery. When a malignant pleural effusion is diagnosed by cytology or histology, the clinician must decide on the most appropriate form of palliative therapy for the symptomatic patient. In the symptomatic patient with a reasonable life expectancy, chest tube drainage with the instillation of tetracycline hydrochloride appears to be the most effective and least morbid form of palliative therapy.

Superior vena cava syndrome as a cause of pleural effusion

The development in the postoperative period of the superior vena cava syndrome resulted in a persistent right-sided, transudative pleural effusion. It appears that the increased systemic venous pressure from left innominate thrombosis leading to superior vena cava obstruction in association with chest tube drainage connected to suction (increased intrapleural negative pressure) produced hydrostatic imbalances that resulted in increased pleural fluid formation and collection.

Empyema after internal jugular catheterisation in rheumatoid arthritis

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The value of chest roentgenograms in acute asthma in adults

Chest roentgenograms were obtained in 90 episodes of acute asthma in adults coming to an emergency room. Of these 90 roentgenograms, 50 (55 percent) were interpreted as normal, 33 (37 percent) showed hyperinflation, and 6 (7 percent) showed minimal interstitial abnormalities unchanged from previous roentgenograms. One (1 percent) showed a new alveolar infiltrate in a patient with allergic aspergillosis. There was no significant correlation between chest roentgenogram interpretation and hospitalization. Our data show that the incidence of specific abnormalities on chest roentgenogram in adults with uncomplicated acute asthma is low and suggests that the information obtained from the roentgenogram is rarely helpful to outpatient management. Chest roentgenograms probably are indicated only when there is clinical evidence of pneumonia, a complication of asthma, or a pulmonary disorder that mimics asthma.

Salicylate-induced pulmonary edema. Clinical features and prognosis

To assess the course and prognosis of salicylate-induced pulmonary edema, we reviewed the records of 36 consecutive patients admitted with serum salicylate levels greater than 30 mg/dL. Pulmonary edema developed in eight patients, and pulmonary infiltrates were never seen in 28 patients. Several features distinguished the two patient groups. Persons with pulmonary edema were older, ingested salicylates chronically, and had a history of smoking. They also were more likely to present with neurologic abnormalities. proteinuria, and serum salicylate levels greater than 40 mg/dL. The severity of pulmonary edema ranged from moderate (no assisted ventilation) to severe (characteristics of adult respiratory distress syndrome requiring assisted ventilation with positive end-expiratory pressure). Pulmonary edema resolved concomitant with a decline in serum salicylate levels. We conclude that certain patients are at increased risk for salicylate pulmonary edema, which responds to measures that lower serum salicylate levels.

Tuberculosis in association with pregnancy

A review was made of the records of 27 patients admitted to National Jewish Hospital who developed or experienced a reactivation of pulmonary tuberculosis during pregnancy or the first 12 month post partum. Sixteen patients had drug-resistant disease, and 11 had drug-susceptible disease. The drug-resistant group had more extensive radiographic abnormalities(p less than 0.01), longer sputum conversion times (p less than 0.05), and a higher incidence of pulmonary complications and death (p = 0.05). Patients with tuberculosis associated with pregnancy have the same clinical presentation as nonpregnant patients. Tuberculosis during pregnancy should be treated, and the drugs that appear to be safest for the fetus include isoniazid, para-aminosalicylic acid, ethambutol, and rifampin.

The effect of common sclerosing agents on the rabbit pleural space

New Zealand white rabbits received intrapleural instillations of either tetracycline (7, 20, and 35 mg/kg), HCI (0.01N), quinacrine (10 mg/kg), nitrogen mustard (0.2 mg/kg), bleomycin (1.5 mg/kg), or NaOH (0.5%). All sclerosing agents produced a neutrophil-predominant, exudative pleural effusion within 12 h of instillation. By 48 h the pleural fluid was predominantly mononuclear. Despite the large pH range of the sclerosing agents (tetracycline, 2.0; NaOH, 13.0), the pleural fluid pH was always between 7.40 and 7.49 during the 144-h observation period. There was no difference in protein concentration, leukocyte count, or neutrophil differential with either the 3 different doses of tetracycline or the 5 other sclerosing agents. Autopsies at 30 days showed that only the 35 mg/kg dose of tetracycline produced pleural symphysis. We concluded that the common sclerosing agents produce a similar type of pleural effusion, but only tetracycline leads to pleural fibrosis; this effect appears to be dose-dependent. The pH of the sclerosing agent per se probably has little effect on the development of pleural symphysis.