Pleural mesothelioma in differential diagnostics of a tubercular exudative pleuritis

Background. Difficulties of differential diagnostics of exudative pleuritis due to pleura mesothelioma and such one of tubercular etiology can take a long time that is the reason of delayed well-timed and correct treatment order. Etiological diagnostics of exudative pleuritis has to be based on an integrated approach taking into account the data of clinical inspection of a patient, a laboratory research of pleural exudate, radial, instrumental, pathomorphological and surgical methods. The aim of our study is to establish the features of diagnosis of exudative pleuritis due to pleura mesothelioma by determining of informativeness and value of applied diagnostic methods for further use for differential diagnostics with exudative pleuritis of tubercular etiology on the cases of own clinical observations. Materials and methods. Four clinical cases of diagnostics of pleura mesothelioma in the patients with exudative pleuritis at Municipal Institution “Zaporizhzhia Regional Antituberculous Clinical Dispensary” were analyzed. Results. Four cases of pleura mesothelioma were diagnosed at Municipal Institution “Zaporizhzhia Regional Antituberculous Clinical Dispensary” within differential diagnostics of exudative pleuritis of obscure origin. In all cases the following similar features of pleura mesothelioma were observed: patients were male; patients complained about dyspnoea at exercise stress, thorax pain (on the side of mesothelioma localization), general weakness, periodic cough; the patients denied tuberculosis contact; the general blood test revealed only lymphopenia against the background of the accelerated ESR; micobacteria of tuberculosis were not revealed at all; steady accumulation of an exudate, despite its systematic evacuation; cytologic research of pleural liquid was characterized by a moderate turbidity, serous (serous and hemorrhagic) character, with the specific weight of 1015–1016, rising of protein to 33–66 g/l, positive Rivalta’s test, a lymphocytosis of 93–100 %, a proliferation of mesothelium with dystrophia signs in cytoplasma, groups of cells with enlarged nucleoluses in cell cores; aspirate of epithelial lining fluid (even in the absence of pathology of a tracheobronchial tree) is presented by alveolus cells and bronchial epithelium, glandular groups of cells with hyperplasia signs; typical signs of pleura mesothelioma of pleural cavity at ultrasound examination were: identification of formations of rounded shape, various echogenicity, the sizes and quantity (depending on a form: nodular or diffusive), with accurate contours of masses which intimately adjoins to visceral pleura and the structure often contains from single to numerous small hyperechogenic inclusions against the background of liquid; in all cases video-assisted thoracoscopy data of visceral pleura was confirmed by pathohistological examination. Conclusions. All applied diagnostic methods were high-informative that allowed quickly diagnose and prescribe the correct treatment. On their basis the algorithm of differential diagnostics of specific exudative pleuritis and caused pleura mesotheliomas were roentgenography of thoracic organs (if possible computer tomography), an ultrasonic examination of thoracic organs, cytologic research of pleural liquid, video thoracoscopy with biopsy of parietal pleura, research of pleura smear and pathohistological examination of biopsy material.