Clinical value of pleural biopsy in the diagnosis of children with tuberculous pleurisy

Abstract

To explore the value of pleural biopsy in the diagnosis of tuberculous pleurisy in children. Fifty-one cases with tuberculous pleurisy, whose diagnosis was established according to the clinical diagnostic criteria of the child pulmonary tuberculosis formulated by the Chinese Medical Association (CMA) in 2006, after pleural biopsy hospitalized in Children's Hospital of Chongqing Medical University from Jan. 1, 2007 to Jan. 1, 2013 were enrolled into this study. Clinical symptoms, history traits, laboratory examination, imaging tests, pleural fluid characteristics and the results of pleural biopsy were retrospectively analyzed. Medical records of the cases who were diagnosed with tuberculous pleurisy by histological examination were reviewed to assess tuberculosis detection rate of pleural biopsy and to get the percentage of cases with a preoperative diagnosis inconsistent with the final diagnosis. There were 35 boys and 16 girls, and the mean age was (9.7 ± 3.5) years. The common symptoms included fever (82%), cough (71%) , chest pain (23%), weakness (10%) and shortness of breath (10%); 27% (14/51) children had shown tuberculosis toxic symptoms; 76% (39/51) patients had BCG vaccination history; 12% (6/51) cases had a history of contact with tuberculosis patients. The positive rates of the tuberculin skin test, serum tuberculosis antibody detection, detection of Mycobacterium tuberculosis DNA by polymerase chain reaction, acid-fast bacillus test of sputum (or gastric juice) smear, acid-fast bacilli (AFB) smear and culture of pleural effusion were respectively 61% (20/33), 6% (3/46), 0 (0/12), 4% (1/27), 22% (7/32). Pleural effusion was found by using imaging tests in 50 cases, among whom 28 cases (55%) with encapsulated effusion, and the multilocular cysts separated by fibrous tissue in 12 patients (23%) . Other features included pleural thickening (53%) , hilar and mediastinal lymph-nodes enlargement (14%) and white nodules of calcification (10%) . Thoracocentesis was performed in 31 cases, and pleural effusion obtained from which were exudative. The cell count, mainly mononuclear cells, increased in 28 patients (90%) . Among the 51 children investigated, 47 (92%) were histologically diagnosed to be tuberculous pleurisy. The typical pathologic changes of tuberculosis (caseous necrosis, granulomas, Langhans' giant cells and inflammatory cell infiltration) were observed in 40 cases, granulomatous inflammation without caseous necrosis were the main manifestations in 7 other patients. The pathological changes of the remaining 4 cases were not consistent with the pathological characteristics of tuberculosis. All 47 cases were given a preoperative diagnosis of tuberculous pleurisy (32%), purulent pleurisy (51%) and pleural effusion of unknown origin (17%) respectively before pleural biopsy. Therefore, the tuberculosis detection rate of pleural biopsy was 92%, and the preoperative misdiagnosis rate was 68%. Pleural biopsy was of great diagnostic value for children with tuberculous pleurisy.