Source: Zhejiang
of emergency: Zong Jianping
there is a pleural effusion, could not find a reason, that bothers me nearly 30 years. Not long ago, I encountered another similar case. This is the ninth case in my memory.
Patient, male, 87 years old. Four days before admission, when working in the farmland to weed (spraying "Insect"), the right middle and lateral chest pain occurred, the pain was severe, unbearable, and there was no other discomforts such as radiating pain in the lower back and back. Go home and rest.
After 1 hour in bed, the pain was still obvious. I wanted to go to the doctor, but I didn’t expect to get up and fell to the ground immediately after a dizziness. The family saw him rushing over, so he didn’t want to tell him, and the patient was pale. , Her jaws are closed, sweating profusely, even urination is incontinent, but no convulsions, etc.
The family immediately called a 120 ambulance and sent it to the local hospital for emergency treatment. The family told the doctor that it might be pesticide poisoning. A blood cholinesterase (an indicator of organophosphorus pesticide poisoning) was measured, which was very low (4.67KU), but the patient had a high fever (39.2°C). The chest CT was 2 Exudative changes in the lower lobe of the lung, and pleural effusion on the right side. Head CT and MRI: old cerebral infarction. The local doctors were surprised how high fever, chest pain, and pleural effusion caused by pesticide poisoning, plus a critical condition, were transferred to our hospital.
came to our hospital and did some additional tests: high inflammation index (high sensitivity C-reactive protein 107.8 mg/L↑↑, white blood cell count 11.04×109/L↑, neutrophil percentage 85.5 %); blood D-dimer is slightly higher (507.0ng/ml), blood albumin concentration is very low (26.4(g/L↓); cholinesterase is only slightly lower (2604U/L↓) ).
Because of high fever, first give antibiotics (cephalosporin and sulbactam injection) and antipyretic and analgesic treatment. Considering the history of pesticide exposure, although the cholinesterase is slightly lower in this hospital, it is still given to the patient Used some antidote (Pralidoxime).
The patient has a history of "hypertension" for 20 years, the highest blood pressure is 220/110mmHg, and normal blood pressure control is OK. He underwent "right cataract surgery" at Ningbo Eye Hospital 1 year ago and had no history of other diseases.
The emergency department was admitted to the hospital with "sepsis, pneumonia, and organophosphate poisoning".
After admission, the examination revealed that there was tenderness in the right quarter rib area, reduced right breath sounds, and weakened speech tremor, consistent with chest CT changes (pleural effusion, thickened pleura); both lower lungs There are scattered wet rales, and the main problem is chest infection.
No abnormalities were found in the heart, abdomen, peripheral blood vessels and limbs.
On the day of admission, in order to find out the cause of the pleural effusion, a right thoracentesis was performed immediately, and a total of 150ml of light red pleural fluid was drawn. Immediately, a drainage tube was placed in the thoracic cavity, and about 1500ml of light yellow pleural fluid was drained.
The pleural fluid will be sent for routine, biochemical, bacterial and fungal culture examinations.
Pleural effusion routine: Li Fanta test is positive, red blood cell count 13000.0/ul↑, white blood cell count 100.0/ul, neutrophil ratio 74.0%; high protein content in chest (total protein 40.8g /L, albumin 20.6g/L, white bulb ratio 1.0); pleural fluid biochemical examination: adenosine deaminase 15.0(U/L,Glucose 4.8 mmol/L, lactate dehydrogenase 491U/L; no acid-fast bacilli were found negative in pleural fluid. These routine tests are neither like bacterial infections, nor tuberculosis pleurisy, nor are they like tumors or hypoalbuminemia and heart failure.
As the diagnosis is unknown, the pleural fluid was sent for pathogenic genetic testing.
After several days of anti-inflammatory treatment, the patient's body temperature has been fluctuating around 38~39 degrees, but it has not improved. Several antibiotics (cefoperazone, sulbactam, moxifloxacin, etc.) were changed before and after. After treatment, body temperature still shows no downward trend.
But one phenomenon is more abnormal. Ultrasound indicates that there is a lot of pleural effusion, but the pleural drainage tube rarely leads to fluid. Consider the possibility of poor drainage caused by encapsulated pleural effusion and pleural adhesions. In order to minimize the patient's pleural effusion, reduce compressive atelectasis, and preserve the patient's lung function, a thick pleural drainage tube was used a week later, an Abel drainage tube was placed, and a total of 200ml of light red pleural effusion was drawn out using a syringe. The operation process went smoothly, and the extracted pleural effusion appeared a unique phenomenon. After 5 minutes of pleural effusion, it became a jelly.
At this time, the results of pleural effusion culture came, suggesting gram-positive cocci, and linezolid treatment was added.
Pleural effusion gene detected Forsythia, Fusei nucleoside, which are anaerobic bacteria. It has been reported that Fusei nucleoside can cause empyema. Moxifloxacin was stopped and metronidazole was added. Needle (0.5g, three times a day, intravenous treatment).
In addition to using various antibiotics and supportive treatments, I also thought of various other methods.
In patients with pleural adhesions and separation, poor drainage, blood gas indicating low oxygen partial pressure, considering that pleural adhesions are obvious, the older the patient, excessive adhesions will cause restrictive ventilatory disorders, use urokinase (100,000 Unit) to reduce the adhesion of the pleural cavity.
The result of drainage is still not ideal. Switch to a thicker chest tube for drainage (model 28Fr), and drainage of pleural fluid is still not much.
According to the results of various pathogenic examinations, the anti-inflammatory treatment is ineffective, the high fever does not go away, the pleural effusion quickly wraps the adhesions, and the pleural fluid is jelly-like. In the case of ineffective drainage, I had to remind me of similar cases in the past. In the end, they were cured by pleural dissection, so I asked for a chest consultation again.
After repeated discussions with family members (because of the 87-year-old age, surgery risk is very high), finally agreed to choose surgery. During the operation, it was found that the adhesion of the pleural cavity was obvious, and the pleural fluid was changed like a jelly.
What kind of pleural disease is this? I myself call this pleurisy pleurisy. Similar cases are rare, and one case can be encountered in a few years. In the past 30 years, I have encountered a total of nine cases. I still cannot find the answer and cannot find the cause.
The onset of these patients is mostly in their forties and fifties. They have a rapid onset, high fever, and a large amount of pleural effusion quickly. The pleural fluid is gelatinous and the pleura thickens rapidly; it is difficult to pump or drain the pleural fluid. White blood cells are not high, but the protein content is high. For example, when the thoracic cavity is opened by surgical treatment, the pleural effusion is seen as jelly-like, and it will break after touching it. The operation effect is very good. This is an 87-year-old man, and this is the first time I have encountered such an old man.
This is the pleural effusion that has troubled me for 30 years. Can anyone tell me what causes the jelly-like pleural effusion?
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