Diagnosis Of Pleural Tuberculosis Research Articles

The Diagnostic Challenges of Pleural Tuberculosis: A Case Report

Extra-pulmonary tuberculosis often presents atypically, resulting in a delay in diagnosis and treatment. We present a case of recurrent pleural effusion in an immunocompetent patient due to pleural tuberculosis. We also discuss the diagnostic challenges and the role of immunohistochemistry in the diagnosis of pleural tuberculosis.

The accuracy of gross medical thoracoscopy findings in the diagnosis of pleural tuberculosis: A hospital-based study from Qatar

Background: Pleural tuberculosis (TB) diagnosis is a challenging clinical entity. Medical thoracoscopy (MT) is quickly replacing other diagnostic methods as the preferred diagnostic method for exudative pleural effusions. This study aimed to describe the gross MT findings in pleural TB and to evaluate the accuracy of these findings in the diagnosis of pleural TB in terms of sensitivity and specificity. Methods: This is a retrospective descriptive study involving all patients who underwent MT in the pulmonary department of Hamad General Hospital, from January 2014 to December 2019 to determine the etiology of undiagnosed pleural effusions. Results: We studied 400 cases, 353 (88.3%) were male and 47 (11.7%) were female. Their mean age was 37.49±12.46 years. Gross MT findings included free fluid 400 (100%), nodules 307 (76.8%), adhesions 226 (56.5%), pleural thickening 382 (95.5%), and pleural hyperemia 366 (91.5%). Confirmed cases of pleural TB based on histomicrobiologic studies were 320 (80.0%). The specificities of pleural nodules, adhesions, thickening, and hyperemia were 52.50%, 11.25%, 50.00%, and 25.00%, respectively. While the sensitivities for pleural nodules, adhesions, thickening, and hyperemia were 58.75%, 97.19%, 83.44%, and 95.62%, respectively. Conclusion: Gross MT findings without pleural nodules, hyperemia, and thickening can be used to rule out pleural TB, thereby allowing the treating physician to postpone antitubercular therapy until the final diagnosis is confirmed. However, the presence of these gross findings has no significant association with pleural TB. On the other hand, pleural adhesions showed low sensitivity and specificity for pleural TB.

Scope of medical rigid thoracoscopy in patients with pleural effusion of unknown etiology: A prospective single center study

Background: Pleural diseases commonly encountered are pleural effusion, pneumothorax, pleural wall thickening, and pleural mass. Medical thoracoscopy is a minimally invasive procedure that allows diagnostic and therapeutic intervention. The medical diagnostic thoracoscopy in local anesthesia is a simple, low-cost investigation with relatively high diagnostic accuracy, no mortality, and low morbidity. A diagnosis of pleural tuberculosis (TB) could be achieved in 99% of patients as against 51% using closed pleural biopsy. Aims and Objectives: Assessment of the role of medical rigid thoracoscopy in patients with pleural effusion of unknown etiology in a tertiary health care setup. The primary objectives of the study were to evaluate the diagnostic yield of medical thoracoscopy in pleural effusion of unknown etiology. Materials and Methods: The study duration/time frame to address the study: November 2017–February 2019 sample size with Justification Sample size: Minimum 31 patients. It was a prospective observational study. All patients admitted in hospital/daycare at LHRC presenting with pleural effusion with unknown etiology. All patients had a medical thoracoscopy, and samples were sent for microbiological and histological analysis. Clinical, thoracoscopic results and histopathological data of the patients were collected prospectively and analyzed. Results: In this study, 28 patients out of 31 patients were diagnosed. The diagnostic yield of thoracoscopic pleural biopsy was 90.3% Out of 31 patients, the most common complication found was chest pain 48.4% (15/31), followed by 09.7% (03/31) of the cases had complications such as surgical emphysema, postoperative fever, and bleeding. There were no complications in 32.2% (10/31) patients. Conclusion: Medical thoracoscopy is a noble procedure that helps the pulmonologist/surgeon to inspect the pleural cavity. It is a safe and effective diagnostic as well as a therapeutic tool with a high diagnostic yield. The most common differentials of undiagnosed pleural effusion cases are TB and malignancy.

Use of Pleural Fluid Digital PCR Analysis to Improve the Diagnosis of Pleural Tuberculosis.

The diagnosis of pleural tuberculosis (TB) remains difficult due to the paucity of Mycobacterium tuberculosis in pleural fluid (PF). This study aimed to improve pleural TB diagnosis using highly sensitive digital PCR (dPCR) technique. A total of 310 patients with evidence of PF were consecutively enrolled, 183 of whom suffered from pleural TB and 127 from non-TB. PF samples were prospectively collected and total DNA was extracted. The copy numbers of M. tuberculosis insertion sequence (IS) 6110 and IS1081 in DNA were quantified using dPCR. The overall area under the curve of IS6110-dPCR was greater than that of IS1081-dPCR (0.85 versus 0.79). PF IS6110 OR IS1081-dPCR (according to their cut-off values, "positive" was defined as either of them was positive, while "negative" was defined as both of them were negative) had higher sensitivity and equal specificity compared with single target-dPCR. The sensitivity of PF IS6110 OR IS1081-dPCR for total, definite, and probable pleural TB was 59.0% (95% CI = 51.5% to 66.2%), 72.8% (95% CI = 62.6% to 81.6%), and 45.1% (95% CI = 34.6% to 55.8%), respectively. Its specificity was 100% (95% CI = 97.1% to 100.0%). PF IS6110 OR IS1081-dPCR showed a higher sensitivity than smear microscopy (57.4% versus 7.1%), mycobacterial culture (55.3% versus 31.8%), and Xpert MTB/RIF (57.6% versus 23.0%). Long antituberculosis treatment time (>1 month) was found to be associated with negative dPCR results in pleural TB patients. This study indicates that PF IS6110 OR IS1081-dPCR is an accurate molecular assay, which is more sensitive than routine etiological tests and has the potential to enhance the definite diagnosis of pleural TB. IMPORTANCE Pleural TB is one of the most frequent causes of pleural effusion, especially in areas with high burden of TB. Due to the paucibacillary nature of the disease, the diagnostic sensitivities of all available bacteriological and molecular tests remain poor. There is an urgent need to develop new efficient methods. Digital PCR (dPCR) is the third generation of PCR that enables the exact quantification of trace nucleic acids in samples. This study evaluates the diagnostic performance of pleural fluid (PF) dPCR analysis for pleural TB, and shows that PF IS6110 OR IS1081-dPCR has a higher sensitivity than routine etiological tests such as smear microscopy, mycobacterial culture, and Xpert MTB/RIF. This work provides a new choice for improving the definite diagnosis of pleural TB.

Economic evaluation of microbiological and host biomarker-based tests for the diagnosis of pleural tuberculosis in a high burden setting.

BackgroundPleural tuberculosis (TB) remains difficult to diagnose. Tests measuring host biomarkers, such as adenosine deaminase (ADA) and unstimulated interferon-gamma, perform better than conventional microbiological tests for TB diagnosis using pleural fluid. However, there is no data on the cost-effectiveness of these diagnostic approaches.MethodsA cost-consequence analysis was performed from the South African healthcare provider perspective to determine the cost-effectiveness of the following strategies for the diagnosis of pleural TB: (I) Smear microscopy (SM); (II) Mycobacterial-Growth-In-Tube liquid culture (MGIT); (III) adenosine deaminase (ADA); (IV) Xpert ULTRA (Xpert); (V) unstimulated interferon-gamma using IRISA-TB™ (IRISA-TB). Costs (2019 USD) were derived from national sources and outcomes from published literature. Cost-effectiveness was expressed as the cost per pleural TB case diagnosed and initiated on treatment (per 1,000 patients screened). Sensitivity analyses were performed.ResultsTotal strategy costs ranged from $354,632 (SM) to $390,363 (ADA). Strategies incorporating highly specific tests, including IRISA-TB and Xpert, had the lowest costs associated with unnecessary treatment. In terms of outcomes (per 1,000 screened), IRISA-TB and ADA correctly identified the most pleural TB cases (8.4 and 8.0 cases, respectively), almost double that of MGIT (4.2 cases) and Xpert ULTRA (3.7 cases). IRISA-TB was the most cost-effective strategy, as the cost per pleural TB patient diagnosed and initiated on treatment was $44,084, ~$5,000 less than ADA (the second most cost-effective strategy; $49,065). These values were most sensitive to changes in pleural TB prevalence, treatment costs, and empirical treatment rates. The cost difference, compared to ADA, equated to a potential saving of ~US$45 million per year in South Africa.ConclusionsIRISA-TB offers good value for money and is a potentially more cost-effective alternative to ADA for pleural TB diagnosis.

Diagnostic Accuracy of Bronchoalveolar Lavage in Diagnosis of Ple-ural Tuberculosis among Suspected Cases of Pleural TB

Aim: To determine the accuracy of bronchoalveolar lavage in diagnosis of pleural tuberculosis among suspected cases of pleural tuberculosis using biopsy. Study design: Descriptive, cross-sectional. Place and duration of study: Department of Chest Medicine, JPMC, Karachi from 1st August 2017 to 31st January 2018. Methodology: One hundred and thirty six patients with cases of pleural tuberculosis of age 18-55 years and both genders were included. Patients with anti-tuberculosis drugs, pneumonia, tonsillitis, pharyngitis, obstructive pulmonary disease and platelet function disorders, thrombocytopenia or coagulation factors disorder were excluded. 30-50 ml of bronchoalveolar fluid was carried out through fiberoptic bronchoscopy. Three milliliters of 4% lignocaine was used as pre-medication and 3 ml of 2% lignocaine was used during bronchoscopy. Results: In BAL positive patients, 73 (true positive) had pleural tuberculosis and 9 (false positive) had no pleural tuberculosis on biopsy. Among 54, BAL negative patients, 5 (false negative) had pleural tuberculosis on biopsy whereas 49 (true negative) had no pleural tuberculosis on biopsy. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of BAL in diagnosis of pleural tuberculosis among suspected cases of pleural tuberculosis using biopsy as gold standard was 93.59%, 84.48%, 89.02%, 90.74% and 89.71% respectively. Conclusion: The diagnostic accuracy of bronchoalveolar lavage in diagnosis of pleural tuberculosis among suspected cases of pleural tuberculosis is quite high. Keywords: Pleural tuberculosis, Bronchoalveolar lavage, Sensitivity

Rapid Detection of Mycobacterium tuberculosis in Pleural Fluid Using Resuscitation-Promoting Factor-Based Thin Layer Agar Culture Method.

BackgroundPleural tuberculous is difficult to diagnose. Culture is still considered the gold standard, especially in resource-limited settings where quick, cheap, and easy techniques are needed. The aim of the study was to evaluate resuscitation-promoting factors (Rpfs)-based thin layer agar (TLA) culture method for quick detection of Mycobacterium tuberculosis in pleural fluid.MethodsPatients with suspected pleural TB were enrolled prospectively in our hospital, pleural fluid of all patients were collected, stained with Ziehl–Neelsen for acid-fast bacilli (AFB), cultured on Rpfs-TLA, TLA, and Löwenstein–Jensen (LJ) medium, and identified according to recommended procedures.ResultsA total of 137 suspected pleural TB were enrolled and categorized, including 103 pleural TB (49 confirmed and 54 probable pleural TB) and 34 non-TBP patients. The sensitivity of Rpfs-TLA for total pleural TB was 43.7% (34.5∼53.3%), higher than that of TLA 29.1% (21.2∼38.5%) and LJ 26.2% (18.7∼35.5%) (p < 0.01), and all specificity was 100% in the diagnosis of pleural TB. Median time to detection of a positive culture was 11.8 days (95% CI 10.4∼13.4) for Rpfs-TLA, 21.0 days (95% CI 19.1∼22.9) for TLA, and 30.5 days (95% CI 28.5∼32.5) for LJ (p < 0.001).ConclusionRpfs-TLA is an accurate, rapid, cheap, and easy culture method, which makes it promising for use in clinical laboratories.

Performance of GeneXpert MTB/RIF in the diagnosis of extrapulmonary tuberculosis in Morocco

Tuberculosis (TB), a chronic bacterial disease caused by Mycobacterium tuberculosis, commonly affects the lung but can also affect other parts of the body (extrapulmonary tuberculosis, EPT). A rapid diagnosis is essential to initiate a specific and effective treatment. Although mycobacterial culture remains the gold standard for EPT diagnosis, molecular tools are attracting increasing interest. GeneXpert MTB/RIF, a rapid automated diagnostic test, allows the detection of Mycobacterium tuberculosis as well as mutations in the hot-spot region of the rpoB gene associated with Rifampicin resistance. The present study was performed to evaluate the performance of the GeneXpert MTB/RIF test for the diagnosis of EPT compared to the standard method. This prospective study was conducted on 304 clinical samples collected from 192 patients attending the Laboratory of Mycobacteria and Tuberculosis of Pasteur Institute of Morocco, between 2016 and 2017. Out of the 304 samples, 113 were pleural f luids decontaminated using the Petroff method and 191 were biopsies (78 lymph nodes and 113 pleural biopsies) decontaminated using the Löwenstein method. Mycobacterium tuberculosis detection and identification were performed on all samples using smear microscopy, Löwenstein–Jensen medium culture and the GeneXpert MTB/RIF test. Our results showed that 54.5 (103/189) were men and 45.5% (86/189) were women. The age of patients ranged from 2–78 years and the majority of patients was in the age group 25–45 years. Extrapulmonary samples were derived from lymph nodes, pleural f luids and pleural tissues, with a percentage of 25.66, 37.17 and 37.17%, respectively. Interestingly, the sensitivity of the GeneXpert was 51.4 for all samples and 83.3% for lymph nodes. In conclusion, the present study revealed that the performance of the GeneXpert test depends highly on the type of sample, with a high sensitivity observed for lymph nodes. Additionally, we clearly showed that the GeneXpert MTB/RIF test presents limitations in the diagnosis of pleural TB. Thus, we recommend the coupled use of the GeneXpert MTB/RIF and the conventional techniques for EPT diagnosis.

Factors associated with negative pleural adenosine deaminase results in the diagnosis of childhood pleural tuberculosis

BackgroundUntil now, the influential factors associated with pleural adenosine deaminase (ADA) activity among children remain unclear. This retrospective study was therefore conducted aiming to investigate the factors associated with negative pleural ADA results in the diagnosis of childhood pleural tuberculosis (TB).MethodsBetween January 2006 and December 2019, children patients with definite or possible pleural TB were recruited for potential analysis. Then, patients were stratified into two categories: negative pleural ADA results group (experimental group, ≤40 U/L) and positive pleural ADA results group (control group, > 40 U/L). Univariate and multivariate logistic regression analyses were performed to estimate risk factors for negative pleural ADA results.ResultsA total of 84 patients with pleural TB were recruited and subsequently classified as experimental (n = 17) and control groups (n = 67). Multivariate analysis (Hosmer–Lemeshow goodness-of-fit test: χ2 = 1.881, df = 6, P = 0.930) revealed that variables, such as chest pain (age-adjusted OR = 0.0510, 95% CI: 0.004, 0.583), pleural total protein (≤45.3 g/L, age-adjusted OR = 27.7, 95% CI: 2.5, 307.7), pleural lactate dehydrogenase (LDH, ≤505 U/L, age-adjusted OR = 59.9, 95% CI: 4.2, 857.2) and blood urea nitrogen (≤3.2 mmol/L, age-adjusted OR = 32.0, 95% CI: 2.4, 426.9), were associated with negative pleural ADA results when diagnosing childhood pleural TB.ConclusionOur findings demonstrated that chest pain, pleural total protein, pleural LDH, and blood urea nitrogen were associated with a negative pleural ADA result for the diagnosis of pleural TB among children. When interpreting pleural ADA levels in children with these characteristics, a careful clinical assessment is required for the pleural TB diagnosis.

Diagnostic yield of Xpert MTB/RIF on contrast-enhanced ultrasound-guided pleural biopsy specimens for pleural tuberculosis

BackgroundA 3-year prospective study was conducted to evaluate the efficacy of Xpert MTB/RIF (Xpert) in the diagnosis of pleural tuberculosis (pTB) on contrast -enhanced ultrasound (CEUS)-guided pleural biopsy specimens. MethodPatients suspected with pTB were prospectively enrolled to receive CEUS-guided biopsy. Specimens (pleural tissue and fluid) were submitted for Xpert and other routine examinations. Surgical thoracoscopy was performed on undiagnosed cases. ResultA total of 316 patients were enrolled, including 280 cases of pTB (definite 195, possible 85) and 36 cases of non-pTB. The sensitivity of Xpert was 69.64% (195/280) in biopsy specimens, which was significantly higher than that in pleural effusion specimens (p < 0.01). In 195 definite cases, the highest sensitivity of 100% (195/195) and NPV of 29.75% (36/121) were achieved by Xpert on biopsy specimens. Xpert-positive results were obtained in 149 culture-negative cases and 90 histopathological MTB PCR-negative cases. The incidence of necrosis by CEUS in Xpert-positive pTB was significantly higher than that in Xpert-negative pTB (χ2 = 72.41; p < 0.01). No serious complications occurred. ConclusionXpert achieved highly diagnostic sensitivity in pTB through CEUS-guided biopsy sampling, especially on necrotic lesions, which was proven to be efficient, minimally invasive and safe.

Risk factors associated with surgical intervention in childhood pleural tuberculosis

Surgical intervention use is common in the management of childhood pleural tuberculosis (TB), however, its associated risk factors remain unclear. Between January 2006 and December 2019, consecutive children patients (≤ 15 years old) who had a diagnosis of pleural TB were included for the analysis. Surgical intervention was defined as debridement (such as breaking loculations), decortication, and thoracic surgery (such as lobectomy or segmental resection). Patients undergoing surgery were included as surgical group, without surgery were classified as non-surgical group, surgical risk factors were then estimated. Univariate and multivariate logistic regression analysis were performed to evaluate the risk factors for surgical interventions. A total of 154 children diagnosed as pleural TB (definite, 123 cases; possible, 31 cases) were included in our study. Of them, 29 patients (18.8%) were classified as surgical group and 125 patients (81.2%) were classified as non-surgical group. Surgical treatments were analyzed in 29 (18.8%) patients, including debridement (n = 4), decortication (n = 21), and thoracic surgery (n = 4). Further multivariate analysis revealed that empyema (age- and sex-adjusted OR = 27.3, 95% CI 8.6, 87.1; P < 0.001) and frequency of hospitalization (age- and sex-adjusted OR = 1.53, 95% CI 1.11, 2.11; P < 0.01) were associated with the use of surgical interventions in children with pleural TB. In China, surgical interventions are still required in a significant proportion of children with pleural TB, and the surgical risk is found to be associated with the frequency of hospitalization and empyema. These findings may be helpful to improve the management of children with pleural TB and minimize the risk of poor outcomes.

Improving the yield of diagnostic medical thoracoscopy for undiagnosed exudative pleural effusions using a rigid diagnostic algorithm.

Establishing the etiology of exudative pleural effusions in the setting of an unrewarding pleural fluid analysis often requires biopsies from the parietal pleura. However, it may be noted that diagnosis such as pulmonary embolism and connective tissue diseases can result in an exudative pleural effusion where a pleural biopsy can yield nonspecific results. Medical thoracoscopy (MT) is a minimally invasive procedure performed under local anesthesia or moderate sedation with excellent yield and favorable safety profile. We analyzed the diagnostic yield of MT for exudative pleural effusions after employing a rigid diagnostic algorithm. The study was undertaken to ascertain the yield of MT in establishing the diagnosis in diagnosis of exudative pleural effusions, to find out the relative contribution of pleural tuberculosis (TB) as a cause of undiagnosed exudative pleural effusion, to describe the etiology of undiagnosed exudative pleural effusion in patients undergoing MT and to determine the correlation between pleural fluid adenosine deaminase (ADA) levels and TB pleuritis in patients undergoing MT. This was a retrospective study. Patients with undiagnosed exudative pleural effusion were included in the study. MT was performed with semirigid thoracoscope (Olympus LTF 160) under local anesthesia and conscious sedation. Gross appearance and ADA level of pleural fluid were noted. Pleural biopsy material was subjected to histopathology examination and culture for mycobacteria along with cartridge-based nucleic acid amplification test for TB. The yield of MT for establishing the etiology of pleural effusion and the relative contribution of tuberculous pleuritis as a cause of undiagnosed pleural effusion was ascertained. Correlation of pleural fluid ADA levels was done with a final diagnosis of TB pleuritis in patients undergoing MT. Twenty-five patients with undiagnosed exudative pleural effusion underwent thoracoscopy of which 16 were male and 9 were female. MT was able to establish the diagnosis in all cases, providing a diagnostic yield of 100%. Histopathological examination of biopsy specimens yielded a diagnosis of malignant involvement of pleura in 10 patients and granulomatous pleuritis consistent with TB in 14 patients. Pleural TB contributed to 60% of undiagnosed pleural effusions in the present study. The mean ADA value among those who turned positive was 56.338 and 35.300 among those who turned negative using genexpert, which was found to be statistically significant. A value of 31 IU/L showed a sensitivity of 93.3% and specificity of 99.8% and hence can be taken as a cut off value for the diagnosis of pleural TB based on receiver-operating characteristic analysis. TB contributed to 60% of undiagnosed exudative pleural effusions in the present study. MT had 100% yield in the diagnosis of undiagnosed exudative effusions. Pleural fluid ADA levels may help in differentiating TB versus malignant effusion.

Diagnostic incremental value of sputum in patients with pleural tuberculosis

Background Pleural effusion (PE) Xpert has limited use in the diagnosis of pleural tuberculosis (TB). However, the diagnostic incremental value of sputum Xpert for pleural TB diagnosis remains unclear. Materials and methods Between March 2018 and October 2019, patients with certain causes (such as TB, malignancy, and pneumonia) of PE were enrolled in our study. Sputum and PE were collected from all patients and sent for acid-fast bacilli smear (Auramine O staining), mycobacterial culture (Lowenstein-Jensen media), and Xpert. The differences in the sensitivities of these TB assays between different groups were examined with the chi-square test. Results One hundred and twenty-seven PE patients were enrolled in the study and then were divided into pleural TB (n = 104) and other causes of PE (excluding TB, referred as non-pleural TB; n = 23). Compared with PE Xpert (11.5%, 12/104), sputum Xpert has a higher sensitivity of 25.0% (26/104, p = .012 < .05). The combination of sputum and PE has a non-significant higher sensitivity of 31.7% (33/104) than Xpert on sputum (p > .05). Culture using both sputum and PE combined has a high sensitivity of 43.3% (45/104). Conclusion Compared to PE Xpert, sputum Xpert showed an incremental diagnostic yield in the diagnosis of pleural TB and is expected to speed up the diagnosis of pleural TB.

Phlegmonous Appearance in the Ipsilateral Paracardiac Fat without Paracardiac Lymph Node Enlargement on Chest CT Favors the Diagnosis of Pleural Tuberculosis over Malignant Pleural Effusion.

This study investigated the potential role of paracardiac fat stranding (FS) interspersed with multiple fluid collections (FC) as a clue to differentiate between pleural tuberculosis (pleural TB) and malignant pleural effusion (MPE). The authors retrospectively analyzed chest computed tomography (CT) findings of 428 patients, 351 with pleural TB and 77 with MPE, focusing on the paracardiac fat, and level of pleural adenosine deaminase (ADA) and blood C-reactive protein (CRP). Two radiologists independently evaluated the chest CT findings regarding the paracardiac fat pad ipsilateral to the effusion, including FS, FC, phlegmonous appearance (a combination of the FS and multiple FC), and the presence of lymph node enlargement (>1 cm in short axis diameter). There were significant differences between patients with pleural TB and those with MPE with respect to the prevalence of phlegmonous appearance in the ipsilateral paracardiac fat (47.6% and 10.4%, p < 0.001, OR = 7.8; 95% CI 3.7–16.8) and paracardiac lymph node enlargement (1.4% and 19.5%, p < 0.001, OR = 0.06; 95% CI 0.02–0.2) on CT. In contrast, there was no difference in the prevalence of isolated FS or multiple FC within the ipsilateral paracardiac fat between the two groups. Median pleural ADA and serum CRP level were higher in patients with pleural TB accompanied by phlegmonous appearance in paracardiac fat compared to those without that appearance (ADA: median 104 IU/L versus 90 IU/L, p < 0.001; CRP: 6.5 mg/dL versus 4.2 mg/dL, p < 0.001). In conclusion, phlegmonous appearance in the ipsilateral paracardiac fat without paracardiac lymph node enlargement on chest CT favors a diagnosis of pleural TB over MPE.

“ROLE OF TB PCR IN CLINICALLY DIAGNOSED AND TREATED CASES OF TUBERCULAR PLEURAL EFFUSION”.

Background: Tuberculosis is still a major health problem worldwide. It is estimated that about one-third of the world's population is infected with mycobacterium tuberculosis. While pulmonary tuberculosis is most common presentation; pleural effusion is one of the common complications of primary tuberculosis or in conjunction with pulmonary infiltrate typical of post primary tuberculosis. Diagnosis of pleural tuberculosis (TB) remains a challenge due to its nonspecific clinical presentation and paucibacillary nature.TB PCR is a self-automated method from Roche for the detection of mycobacterium tuberculosis. This test allows for detection and identification of MTB from direct specimens within 24 – 48 hours of the receipt in the laboratory. We determined the role of TB PCR in diagnosis of tubercular etiology in pleural effusion in our study. Materials and methods: Prospective and analytical studyin a tertiary care centre of the study area was conducted after Ethics Committee permission. The study period was from June 2018 to December 2019.Data of 36tubercular pleural effusion patients was retrieved. Role of TB PCR in the diagnosis of tubercular etiology was assessed. Results: Pleural fluid samples collectedwere sent for various investigations like Routine microscopy, cytology, Pleural fluid pH, protein, LDH and TB PCR. Serum protein and serum LDH were also done.The diagnosis of Tubercular Pleural Effusion was made by clinical examination, radiological presentation, results of pleural fluid investigations and response to Anti Tubercular treatment collectively. Out of the 36 patients diagnosed to have tubercular pleural effusion, 8(22%) patient’s pleural fluid TB PCR report was positive. Conclusion:TB PCR is not a useful test in the diagnosis of tubercular etiology in pleural effusion.

Mycobacterial antigens in pleural fluid mononuclear cells to diagnose pleural tuberculosis in HIV co-infected patients

BackgroundExtra pulmonary manifestation of tuberculosis (TB) accounts for approximately one-half of TB cases in HIV-infected individuals with pleural TB as the second most common location. Even though mycobacteria are cleared, mycobacterial antigens may persist in infected tissues, causing sustained inflammation and chronicity of the disease. The aim of this study was to explore various mycobacterial antigens in pleural effusions, the impact of HIV infection and CD4+ T-cell depletion on the presence of antigens, and the diagnostic potential of antigens for improved and rapid diagnosis of pleural TB.MethodsPleural fluid specimens were collected from patients presenting with clinically suspected pleural TB, and processed routinely for culture, cytology, and adenosine deaminase activity analysis. HIV status and CD4+ T-cell counts were recorded. Pleural fluid mononuclear cells (PFMC) were isolated, and cell smears were stained with acid-fast staining and immunocytochemistry for various mycobacterial antigens. Real-time and nested-PCR were performed. Patients were categorized as pleural TB or non-TB cases using a composite reference standard. Performance of the mycobacterial antigens as diagnostic test was assessed.ResultsA total of 41 patients were enrolled, of which 32 were classified as pleural TB and 9 as non-TB. Thirteen patients had culture confirmed pleural TB, 26 (81%) were HIV-TB co-infected, and 64% had < 100 CD4+ T-cells/microL. Both secreted and cell-wall mycobacterial antigens were detected in PFMC. Lipoarabinomannan (LAM) was the most frequently detected antigen. There was no direct correlation between positive culture and antigens. Cases with low CD4+ T-cell counts had higher bacterial and antigen burden. By combining detection of secreted antigen or LAM, the sensitivity and specificity to diagnose pleural TB was 56 and 78%, respectively, as compared to 41 and 100% for culture, 53 and 89% for nested PCR, and 6 and 100% for real-time PCR.ConclusionMycobacterial antigens were detectable in PFMC from tuberculous pleural effusions, even in cases where viable mycobacteria or bacterial DNA were not always detected. Thus, a combination of secreted antigen and LAM detection by immunocytochemistry may be a complement to acid-fast staining and contribute to rapid and accurate diagnosis of pleural TB.

Chylothorax with Transudate: An Unusual Presentation of Tuberculosis.

IntroductionTwenty-five per cent of tuberculosis patients have pleural tuberculosis, which is the third most common form of presentation. Most cases present as an exudative pleural effusion with just few cases reported as chylothorax in the literature. All pleural effusions from confirmed cases, including tuberculous chylothorax, had exudate features.AimTo describe a patient with Mycobacterium tuberculosis affecting the lungs and pleura, which laboratory testing demonstrated had features of transudate chylothorax.Patient and methodsA 70-year-old man presented with constitutional symptoms, progressive exertional dyspnoea and right pleural effusion with fibrocavitary changes on chest imaging. Thoracentesis and pleural fluid analysis revealed chylous fluid with transudate features, high triglycerides, low cholesterol content and mononuclear cell predominance. Acid-fast sputum stains and pleural fluid were negative for Mycobacterium tuberculosis as was an adenosine deaminase test for pleural effusion. Tomography-directed lung biopsy sampling of a lung nodule revealed a chronic granulomatous inflammatory process associated with the presence of acid-fast bacilli.DiscussionTuberculosis-associated chylothorax is an uncommon presentation of the disease. A recent review found only 37 cases of confirmed tuberculous chylothorax had been reported in the literature. All cases had exudate characteristics. The diagnosis of pleural tuberculosis was made through culture or testing of sputum, pleural fluid or biopsy samples in 72.2% of cases, with the rest identified by histopathology.LEARNING POINTSThe main cause of non-traumatic chylothorax is malignancy, which is found in 39–72% of cases.Few cases of transudative chylothorax have been reported in the literature; the main aetiology is chronic hepatopathy.Tuberculosis-associated chylothorax is a rare presentation of infection caused by Mycobacterium tuberculosis, an uncommon aetiology.

Epidemiology and clinical characteristics of tuberculosis in leon bernard tuberculosis unit in algeria.

This study aimed at highlighting some demographic and clinical features of tuberculosis (TB) at Leon Bernard TB unit, Algeria. This was a retrospective and descriptive study based on TB data extracted from TB patient records during 2009-2019 at Leon Bernard TB unit. Of the total 1375 TB patients, 602 (43.8%) had extrapulmonary TB (EPTB), 482 (35.1%) had new sputum smear-positive pulmonary TB (PTB), 42 (3.1%) had sputum smear-negative with culture-positive PTB, and 97 (7%) EPTB patients had concomitant pulmonary involvement. The male-to-female ratio was 1.07. A total of 116 (8.4%) TB relapses were reported with predominance among ETPB cases (54.3%). Lymphadenitis TB was the most common manifestation of EPTB with 301 cases (39.6%), followed by pleural TB with 237 cases (31.2%). The number of bacteriologically not confirmed EPTB was 22.6% more than half (53.3%) of whom were pleural TB. Among patients with new sputum smear-positive PTB, 71.2% were males, whereas the reverse was observed among patients with EPTB where 62.3% were female. Two-third of recorded cases were between 15 and 45 years old. Nearly all children had EPTB (64/69). The results revealed that most of the patients who passed away were affected by PTB (15/18), and the most frequent cmorbidities were diabetes (9/18) and high blood pressure (6/18). Specific attention needs to be given to an examination of the risk factors of PTB among male population and of EPTB among female population and children and to diagnosis of pleural TB and primary PTB.

Accuracy of genotype MTBDRplus line probe assay in patients with tuberculous pleural effusion: comparison with clinical and culture based diagnosis

Background: Pleural tuberculosis (TB) diagnosis is challenging due to paucibacillary disease. Diagnostic accuracy of GenoType MTBDRplus Line Probe Assay (MTBDRplus) has been evaluated in this study for pleural TB diagnosis.Objective: To evaluate diagnostic accuracy of MTBDRplus for pleural TB diagnosis compared to clinical and microbiological diagnosis.Methods: This prospective study was conducted at the Aga Khan University, Pakistan. Pleural fluid from 203 suspected pleural TB patients was collected and tested for smear, culture and MTBDRplus. Diagnostic accuracy of MTBDRplus was determined using clinical diagnosis and culture as the gold standard.Results: Out of 203 TB suspect patients, MTBDRplus, culture and smear were positive in 14 (6. 9%), 27 (13.3%) and 4 (1.9%) cases, respectively. A total of 106/203 patients (27 culture positive and 79 culture negative) successfully completed TB treatment. Considering clinical diagnosis as gold standard, sensitivity of MTBDRplus was 13.2%; 95% CI (7.4–21.2%) and specificity was 100%; 95% CI (96.1–100%). The sensitivity and specificity of MTBDRplus in culture positive samples were 44.4%; 95% CI (25.5–64.7%) and 98.9%; 95% CI (95.9–99.9%), respectively. Excluding indeterminate results, MTBDRplus accurately detected isoniazid sensitivity in 5/6 and rifampicin sensitivity in 6/6 cases.Conclusion: MTBDRplus had a low sensitivity of 13.2% in clinically diagnosed and 44% in culture-confirmed pleural TB patients and therefore could not be included in most diagnostic algorithms. Due to a higher sensitivity than smear, MTBDRplus may have a role in tuberculous pleural effusion diagnosis if it is positive pending culture results and pleural biopsy.

Accuracy of Xpert MTB/RIF Ultra for the Diagnosis of Pleural TB in a Multicenter Cohort Study

The Xpert MTB/RIF (Xpert) assay has greatly improved the diagnosis of TB and identification of resistance to rifampicin (RIF). However, sensitivity of Xpert remains poor for pleural fluid detection. This study evaluated the performance of the novel next-generation Xpert MTB/RIF Ultra (Xpert Ultra) in comparison with Xpert for pleural TB diagnosis. Patients with suspected pleural TB were enrolled consecutively in four hospitals, and pleural fluids were subjected to smear, culture, and Xpert. Defrosted pleural fluid (-80°C) was examined using Xpert Ultra. Drug susceptibility testing (DST) was conducted for all of the recovered isolates. In total, 317 individuals with suspected pleural TB were recruited; 208 of them were diagnosed with pleural TB according to the composite reference standard, which was composed of clinical, laboratory, histopathologic, and radiologic examination features and≥12months of follow-up data. The direct head-to-head comparison for Mycobacterium tuberculosis detection showed that Xpert Ultra (44.23%, 92 of 208) produced a higher sensitivity than culture (26.44%, 55 of 208, P< .001), Xpert (19.23%, 40 of 208, P< .001), and smear (1.44%, three of 208, P< .001). When Xpert Ultra outcomes were integrated, the percentage of definite pleural TB cases increased from 56.25%(117 of 208) to 64.90%(135 of 208). The specificities of smear, culture, Xpert, and Xpert Ultra were 100%(84 of 84), 100%(84 of 84), 98.67%(83 of 84), and 98.67%(83 of 84), respectively. Xpert Ultra was 100%concordant with phenotype DST for the detection of RIF resistance. Xpert Ultra has great potential in diagnosis of pleural TB and its RIF resistance, which could speed up the initiation of appropriate treatment.