Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis in Korea. Tuberculous pleurisy presents a diagnostic and therapeutic problem due to the limitations of traditional diagnostic tools.
There have been many clinical research works during the past decade. Recent studies have provided new insight into the tuberculous pleurisy, which have a large impact on clinical practice.
This review is a general overview of tuberculous pleurisy with a focus on recent findings on the diagnosis and management. Tuberculous pleurisy is the first or second most common form of extrapulmonary tuberculosis as well as the main cause of pleural effusion in many countries 1.
The relative incidence of tuberculous pleurisy is usually expected to be higher in a high tuberculosis prevalence setting. In Korea, 2, new tuberculous pleurisy cases were notified in , which accounted for 7. Immune status can also influence the incidence of tuberculous pleurisy. Because the main mechanism is a delayed hypersensitivity reaction, one might hypothesize that the immunocompromised hosts are less likely develop tuberculous pleurisy than the immunocompetent host.
However, incidence of tuberculous pleurisy is higher in human immunodeficiency virus HIV -infected patients than in non-infected patients 6.
On the other hand, higher incidence is not observed in renal transplant and dialysis patients 7. Rupture of a subpleural caseous focus in the lung into the pleural space is thought to be the initial event in the pathogenesis of primary tuberculous pleurisy 8.
Pleuritis tb adalah pdf viewer
This hypothesis is based on the observation by Stead et al. The three other patients in this study had parenchymal disease. Mycobacterial antigens enter the pleural space and interact with T-cells previously sensitized to mycobacteria, then result in a delayed hypersensitivity reaction. Tuberculous pleurisy usually presents as an acute illness. The most common presenting symptoms are nonporoductive cough and pleuritic chest pain.
Other symptoms include fever, night sweats, weight loss, malaise, and dyspnea varying in severity according to the size of effusion. As a general rule, an acute illness is more likely to occur in younger patients who are more immunocompetent Patients with tuberculous pleurisy tend to be younger than patients with pulmonary tuberculosis TB.
However, in industrialized countries the mean age of patients with tuberculous pleurisy tends to be older. In a study from the United States, the mean age of 14, patients reported between and was In Korea, the age distribution of patients with tuberculous pleurisy notified in was as follows: less than 20 years, 4.
This data showed similar incidence across all age groups. Therefore, tuberculous pleurisy should be considered in any adult or elderly patient with a unilateral pleural effusion. The definitive diagnosis of tuberculous pleurisy depends upon the demonstration of tubercle bacilli in the sputum, pleural fluid, or pleural biopsy specimens The tuberculous pleural fluid is usually clear and straw colored, but may be turbid or serosanguinous. Polymorphonuclear cells may predominate during the first 2 weeks following the onset of symptoms, but a shift towards lymphocytic predominance was observed at repeat thoracentesis Chest radiography usually reveals a small-to-moderate unilateral pleural effusion.
Chest computed tomography CT scan improves the diagnostic accuracy by documenting associated parenchymal lesions and lymphadenopathy.
Advances in the diagnosis of tuberculous pleuritis
CT can also help to rule out other diseases and to detect complications associated with tuberculous pleurisy. Ultrasonography helps by demonstrating fibrin bands, septations, and loculated pleural effusion. It has been suggested that patients with tuberculous pleurisy without coexisting parenchymal lesion are sputum negative and, therefore, noncontagious.
However, Conde et al. Therefore, in patients with suspected tuberculous pleurisy it is important to obtain sputum, even in the absence of parenchymal involvement. It is also limited by lengthy delays of up to 8 weeks in obtaining results if solid culture media are used.
The use of liquid culture media with bedside inoculation of the pleural fluid can provide higher yields and faster results than do conventional methods The volume of fluid used for inoculation in liquid culture did not seem to influence the proportion of positive cultures The lymphocyte percentage in pleural fluid was negatively associated with the probability of a positive effusion culture Microscopic-observation drug susceptibility culture was associated with greatly increased diagnostic sensitivity and shorter time to diagnosis, compared with solid culture Histological analysis and mycobacterial culture of pleural biopsied tissue have traditionally been the gold standard diagnostic method.
A blind needle biopsy of pleura using Cope's or Abraham's needle has been the most sensitive diagnostic test for tuberculous pleurisy. The introduction of thoracoscopy has had a very important impact on diagnosis. Diacon et al. Thoracoscopy can be medical or video-assisted. It helps visualize the entire pleural surface and allows interventions such as target biopsy, breaking the septae, adhesionolysis, and efficient drainage of effusion.
Videothoracoscopic Decortication For Chronic Tuberculous Pleuritis
Thoracoscopy could also provide superior opportunity for drug susceptibility testing because of biopsing larger area and higher culture yields. An earlier meta-analysis of 40 studies came to very similar conclusions Pai et al.
However, these tests had low and variable sensitivity and, therefore, were not useful in excluding the disease. The low test sensitivity is mainly the result of the technical aspects of nucleic acid extraction, the presence of inhibitors in the pleural fluid, and the paucibacillary nature of the disease Several studies have evaluated the performance of Xpert using pleural fluid. Recent study using pleural tissue sample showed that Xpert did not detect any of the identified TB cases Because conventional diagnostic tests have known limitations, newer and more rapid diagnostic tests are needed.
Although numerous potential markers have been evaluated in pleural effusion, the majority have limited diagnostic accuracy. ADA is the enzyme catalyzing the conversion of adenosine to inosine and deoxyadenosine to deoxyinosine. Since , when Piras et al. Four meta-analyses 34 , 35 , 36 , 37 , including 77 studies in total, were performed in the last few years. All meta-analyses demonstrated uniformly high diagnostic performance of pleural fluid ADA.
Higher ADA levels are associated with a greater chance of a patient having tuberculosis, while persistent low level on repeated thoracentesis strongly argue against tuberculosis The diagnostic usefulness of ADA depends not only on its sensitivity and specificity but also on the local prevalence of tuberculous pleurisy.
This imply the practical use of the test in different populations In populations with a high prevalence of tuberculous pleurisy, elevated ADA level might be considered as a confirmatory test justifying treatment initiation.
In contrast, in countries with a low prevalence of tuberculous pleurisy, the negative predictive value remains high even though the positive predictive value of pleural ADA declines. Therefore, a negative ADA test may justify abandoning further diagnostic procedures for tuberculosis.
There are two major concerns about the interpretation of ADA level, false-negative and false-positive result. Some patients in the early phase of tuberculous pleurisy may have low pleural fluid ADA levels, but subsequent elevated ADA level could be demonstrated in virtually all patients at repeat thoracentesis It has been suggested that in immunocompromised patients ADA might be a less sensitive marker of tuberculous pleurisy.
However, later studies demonstrated that ADA is a reliable marker of tuberculous pleurisy in HIV-infected patients with a low CD4 T-cell count 40 and in renal transplant recipients An important issue is also that of false-positive results in patients with non-tuberculous pleural effusion.
The main disease are parapneumonic effusion and empyema.
High pleural fluid ADA has also been reported in malignancies e. Two approaches have been proposed to increase the specificity of the ADA test However, as the test is more expensive and does not add much to routine clinical practice, its use is so far limited.
The second approach is to combine ADA level and other clinical and laboratory data. Greco et al. However, from the clinical point of view, the differences seem to be irrelevant. Their use allows the reduction of the number of more invasive diagnostic procedures, but in some cases biopsy methods still play an important role Although interferon-gamma release assays IGRAs were primarily designed to detect latent tuberculosis, it is expected that it might also contribute to the diagnosis of tuberculous pleurisy.
Tuberculous Pleurisy: An Update
Based on the evidence so far, the IGRAs are not recommended to make a diagnosis of tuberculous pleurisy. Unfortunately, the majority have limited diagnostic accuracy. Combinations of tests, especially combinations that include ADA, seem to perform better than any single test 50 , 51 , 52 , A decision tree analysis that contained simple clinical age, fever and laboratory pleural fluid ADA data allowed differentiation between tuberculous and malignant effusion with high accuracy Further work is necessary to identify the best combination that will be most useful in clinical practice.
Figure 1 suggests an algorithmic approach for diagnosing tuberculous pleurisy. The first diagnostic step always includes the processing of pleural fluid for biochemical and microbiological studies as well as examination of the sputum for mycobacteria.
If an exudative pleural effusion of lymphocytic predominance and negative cytology, pleural fluid ADA can be used as a screening test.
Algorithmic approach to tuberculous pleurisy. TB: tuberculosis; ADA: adenosine deaminase.
In this situation, if the patient's clinical picture is not typical for tuberculous pleurisy, further diagnostic procedures such as a needle biopsy or thoracoscopy should be considered. Nevertheless, if the patient has a typical clinical picture of tuberculous pleurisy, the possibility of tuberculous pleurisy can be further evaluated with needle biopsy of the pleura or thoracoscopy. These data from the observation studies in pre-antibiotic era emphasize the importance of proper diagnosis and treatment of tuberculous pleurisy.
The treatment of tuberculous pleurisy has three goals 1 to prevent the subsequent development of active tuberculosis, 2 to relieve the symptoms of the patient, and 3 to prevent the development of a fibrothorax 8. A standard, 6-month short course regimen composed of isoniazid and rifampicin, intensified with pyrazinamide for the first 2 months, is considered adequate in most uncomplicated cases.
Ethambutol should be included in the initial regimen until the results of drug susceptibility tests are available.
Although patients with tuberculous pleurisy were successfully treated with only isoniazid and rifampicin for 6 months 56 , 57 , it must be taken into account that such a regimen can only be applied in areas with low drug resistance. The drug resistant pattern of tuberculous pleurisy broadly reflects that of pulmonary tuberculosis 2. In a epidemiological analysis of tuberculous pleurisy in the United States, 9.