Diagnosis Of Tuberculous Pleural Effusion Research Articles

Optimising the utility of pleural fluid adenosine deaminase for the diagnosis of adult tuberculous pleural effusion in Hong Kong.

Pleural fluid adenosine deaminase level can be applied to rapidly detect tuberculous pleural effusion. We aimed to establish a local diagnostic cut-off value for pleural fluid adenosine deaminase to identify patients with tuberculous pleural effusion, and optimise its utility. We retrospectively reviewed the medical records of consecutive adults with pleural fluid adenosine deaminase level measured by the Diazyme commercial kit (Diazyme Laboratories, San Diego [CA], United States) during 1 January to 31 December 2011 in a cluster of public hospitals in Hong Kong. We considered its level alongside early (within 2 weeks) findings in pleural fluid and pleural biopsy, with and without applying Light's criteria in multiple scenarios. For each scenario, we used the receiver operating characteristic curve to identify a diagnostic cut-off value for pleural fluid adenosine deaminase, and estimated its positive and negative predictive values. A total of 860 medical records were reviewed. Pleural effusion was caused by congestive heart failure, chronic renal failure, or hypoalbuminaemia caused by liver or kidney diseases in 246 (28.6%) patients, malignancy in 198 (23.0%), non-tuberculous infection in 168 (19.5%), tuberculous pleural effusion in 157 (18.3%), and miscellaneous causes in 91 (10.6%). All those with tuberculous pleural effusion had a pleural fluid adenosine deaminase level of ≤100 U/L. When analysis was restricted to 689 patients with pleural fluid adenosine deaminase level of ≤100 U/L and early negative findings for malignancy and non-tuberculous infection in pleural fluid, the positive predictive value was significantly increased and the negative predictive value non-significantly reduced. Using this approach, neither additionally restricting analysis to exudates by Light's criteria nor adding closed pleural biopsy would further enhance predictive values. As such, the diagnostic cut-off value for pleural fluid adenosine deaminase is 26.5 U/L, with a sensitivity of 87.3%, specificity of 93.2%, positive predictive value of 79.2%, negative predictive value of 96.1%, and accuracy of 91.9%. Sex, age, and co-morbidity did not significantly affect prediction of tuberculous pleural effusion using the cut-off value. We have established a diagnostic cut-off level for pleural fluid adenosine deaminase in the diagnosis of tuberculous pleural effusion by restricting analysis to a level of ≤100 U/L, and considering early pleural fluid findings for malignancy and non-tuberculous infection, but not Light's criteria.

CXCR3 ligands in pleural fluid as markers for the diagnosis of tuberculous pleural effusion.

A tertiary care academic medical centre. To evaluate the clinical usefulness of C-X-C motif chemokine receptor 3 (CXCR3) ligands in tuberculous pleural effusion (TPE). We recruited 336 patients with pleural effusion due to various causes. Concentrations of interferon-gamma (IFN-γ) and the CXCR3 ligands CXCL9 and CXCL11 were determined using enzyme immunoassays; adenosine deaminase (ADA) activity was measured in pleural fluid and serum. TPE was diagnosed in 106 patients. Non-TB conditions included lung cancer (n = 95), para-pneumonic effusion (n = 52), non-lung malignancy (n = 30), other exudate (n = 24) and transudate (n = 29) disorders. All marker levels in serum samples and pleural fluid were significantly higher in the TPE group. Analyses of receiver operating characteristic curves for differentiating TPE from non-TB effusions produced the following results for the area under the curve (AUC) for CXCL9, CXCL11, IFN-γ and ADA, respectively: 0.982, 0.952, 0.982, and 0.952. Marker AUCs in lymphocytic exudates were also high. Combining the levels of CXCL9, IFN-γ and ADA in pleural fluid improved the diagnostic performance. Serum levels of CXCL9 had the highest AUC (0.848) for diagnosing TPE. Levels of CXR3 ligands in pleural effusion are useful for diagnosing TPE.

Diagnostic utility of QuantiFERON-TB Gold and Xpert MTB/RIF combined with adenosine deaminase in tuberculous pleural effusion: a prospective study

ObjectiveTuberculous pleural effusion remains difficult to diagnose despite numerous diagnostic tools. The aim of this study was to evaluate and compare the diagnostic efficiency of adenosine deaminase (ADA) analysis in the diagnosis of tuberculous pleural effusion when used alone or in combination with QuantiFERON-TB Gold (QFT-G) or Xpert MTB/RIF.Patients and methodsSeventy-one patients with unknown bilateral or unilateral pleural effusion were subjected to pleural tapping, and pleural fluid samples were subjected to total ADA, QFT-G, and Xpert MTB/RIF. Pleural biopsies (thoracoscopic or closed) were performed for 41 patients, sent for histopathology of tuberculosis culture and Xpert MTB/ RIF, and they were differentiated into tuberculous (TB) and non-TB effusions by culture for Myobacterium tuberculosis and/or histopathology of pleural biopsy.ADA results were further analyzed using receiver operating characteristic curve to determine the cutoff values to achieve the optimum sensitivity and specificity.ResultsForty-six patients had definite TB pleural effusion and 25 patients had non-TB pleural effusion. For ADA at a cutoff point of >40 IU/l, the sensitivity was 97.83% (n=45) [95% confidence interval (CI): 88.47–99.94%) and specificity was 76.00% (95% CI: 54.87–90.64%), but at a cutoff point of 70 U/l, the specificity was 96.00% (95% CI: 79.65–99.90%) and sensitivity was 84.78% (n=39) (95% CI: 71.13–93.66%). The sensitivity of QFT-G was 23.91% (95% CI: 12.59–38.77%) and specificity was 96.00% (95% CI: 79.65–99.90%). The sensitivity of Xpert MTB/RIF was 47.83% (95% CI: of 32.89–63.05%) and specificity was 100.00% (95% CI: 86.28–100.00%). Combined analysis of ADA at a cutoff value greater than 70 U/l with Xpert MTB/RIF showed a sensitivity of 85.64% (95% CI: 71.13–96.23%) and specificity of 98.50% (95% CI: 78.64–99.93%). ADA at a lower cutoff value greater than 40 U/l showed a sensitivity of 96.78% (95% CI: 77.13–99.66%) and specificity of 97.00% (95% CI: 79.65–99.90%).ConclusionADA is a useful marker in the diagnosis of TB pleural effusion. ADA specificity with low cutoff value can be improved by combining with Xpert MTB/RIF, resulting in an accurate test to identify patients with suspected TB pleural effusion.

Developing a new intelligent system for the diagnosis of tuberculous pleural effusion

Background and Objective: In countries with high prevalence of tuberculosis (TB), clinicians often diagnose tuberculous pleural effusion (TPE) by using diagnostic tests, which have not only poor sensitivity, but poor availability as well. The aim of our study is to develop a new artificial intelligence based diagnostic model that is accurate, fast, non-invasive and cost effective to diagnose TPE. It is expected that a tool derived based on the model be installed on simple computer devices (such as smart phones and tablets) and be used by clinicians widely.Methods: For this study, data of 140 patients whose clinical signs, routine blood test results, blood biochemistry markers, pleural fluid cell type and count, and pleural fluid biochemical tests’ results were prospectively collected into a database. An Artificial intelligence based diagnostic model, which employs moth flame optimization based support vector machine with feature selection (FS-MFO-SVM), is constructed to predict the diagnosis of TPE.Results: The optimal model results in an average of 95% accuracy (ACC), 0.9564 the area under the receiver operating characteristic curve (AUC), 93.35% sensitivity, and 97.57% specificity for FS-MFO-SVM.Conclusions: The proposed artificial intelligence based diagnostic model is found to be highly reliable for diagnosing TPE based on simple clinical signs, blood samples and pleural effusion samples. Therefore, the proposed model can be widely used in clinical practice and further evaluated for use as a substitute of invasive pleural biopsies.

Diagnostic Accuracy of Pleural Fluid Adenosine Deaminase Level Test in Tuberculous Pleural Effusion

Background: Tuberculous pleural effusion is a paucibacillary manifestation of tuberculosis, so isolation of Mycobacterium tuberculosis is difficult, biomarkers being an alternative for diagnosis. Adenosine deaminase has the potential to optimize the diagnostic approach of tuberculous pleural effusion.
 Methods: This study is a diagnostic test observational (cross-sectional), which included 35 inpatient samples that meet inclusion and exclusion criteria from H. Adam Malik Medan General Hospital. Research began on February 1st until July 31st 2016 to examine 10 cc of pleural fluid specimens for the levels of Adenosine deaminase.
 Results: There are significant differences in the levels of adenosine deaminase from tuberculous and non-tuberculous pleural effusion (P=0.001). In the cut-off point 36.55 IU/L, level of sensitivity 95.8%, specificity 90.99%, positive predictive value 95.8%, negative predictive value 90.99%, and accuracy 94.2% of pleural fluid adenosine deaminase level test in tuberculous pleural effusion. 
 Conclusion: Adenosine deaminase pleural fluid can be a diagnostic modality that is easy, fast, relatively affordable and applicable in the diagnosis of tuberculous pleural effusion. (J Respir Indo. 2017; 37(4): 278-82)

Calpain and Spectrin Breakdown Products (SBDP) as Potential Biomarkers in Tuberculous Pleural Effusion

SESSION TITLE: Tuberculosis SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Early diagnosis of tuberculous pleural effusion remains difficult. Calpain is a family of calcium-dependent endopeptidase that plays an important role in ECM remodeling and collagen synthesis. The aim of this study was to explore the diagnostic value of pleural fluid angiotensin-converting enzyme (ACE), Calpain-1, Spectrin breakdown products (SBDP) and matrix metalloproteinase-1 (MMP-1) measurement in tuberculous pleural effusion (TPE) and malignant pleural effusion (MP). METHODS: The study included 47 patients with TP, 28 patients with MP and 10 patients with transudate of non-tuberculous and non-malignant origin as controls. Calpain, ACE, SBDP and MMP-1 levels in pleural fluid were measured by ELISA method. RESULTS: ACE level, Calpain-1 level, SBDP level and MMP-1 level were higher in TPE than MPE and transudate (all, P value<0.05). By logistic regression analysis, ACE > 47.16 ng/mL, Calpain-1> 787 ng/mL, SBDP > 2.745 ng/mL and MMP-1 >7229 pg/mL were independent factors associated with TPE. The predicted probability based on the four predictors had an area under the ROC curve of 0.935, with 89.3% sensitivity and 89.4% specificity under the cut-off value 0.429. CONCLUSIONS: Our data suggest that ACE, Calpain-1, SBDP and MMP-1 levels could be useful biomarkers for diagnosing TPE. CLINICAL IMPLICATIONS: Early diagnpsos of tuberculous pleural effusion remains difficult. Measuring pleural effusion ACE, Calpain-1, SBDP and MMP-1 levels can improve the diagnosis and may give information about pleural fibrosis. DISCLOSURE: The following authors have nothing to disclose: Ji Young Hong, Myung Goo Lee, Chang Youl Lee No Product/Research Disclosure Information

Diagnostic dilemma in tuberculous pleural effusion

AimTo evaluate the clinical use of interferon gamma release assays (QuantiFERON-TB Gold (In-Tube Method)) for the diagnosis of pleural tuberculosis and comparing it with ADA as a method for diagnosis TB effusion. Patients and methods40 patients presenting with pleural effusions were classified according to their final diagnosis in two groups.Group I: Include 20 cases with tuberculous pleural effusions, group II: Control group: 20 cases divided into 2 subgroups: Subgroup11a: para pneumonic pleural effusions: 8 cases, Subgroup11b: malignant pleural effusions: 12 cases. ResultsTuberculous pleural effusion showed statistically significantly lower mean age than non-tuberculous effusion. Tuberculous group showed statistically significantly highest mean ADA. This was followed by para pneumonic group then malignant group. ADA showed sensitivity (98%), specificity (55%), diagnostic accuracy (75%), negative predictive value (PV−) (67.9%) and positive predictive value (PV+) (91.7%) in diagnosing tuberculous effusion QuantiFERON-TB Gold showed sensitivity 65%, specificity 70%, PPV (68.4%), NPPV (66.7%) and diagnostic accuracy (67.5%) in diagnosing tuberculous effusion. ConclusionIt was concluded that ADA measurement in the pleural fluid is an appropriate, fast diagnostic tool for the diagnosis of tuberculous pleural effusion, with higher sensitivity (98%) and diagnostic accuracy (75%). QuantiFERON-TB Gold which is technically more complicated, expensive and has lower sensitivity (65%) and diagnostic accuracy (67.5%) than ADA.

Developing a Scoring System in the Diagnosis of Tuberculous Pleural Effusion

Developing a Scoring System in the Diagnosis of Tuberculous Pleural Effusion

Utility of pleural fluid routine and microscopy examination plus adenosine deaminase levels in the diagnosis of tuberculous pleural effusion

Background: Tuberculous pleural effusion is the second most common site of extrapulmonary tuberculosis. Not all centers have access to advanced and invasive tests and affordability is also an issue. Hence, diagnosis is largely based on history, clinical examination, and pleural fluid analysis. Objectives: Our aim was to evaluate the utility of pleural fluid routine micro examination along with adenosine deaminase (ADA) levels in diagnosis of tuberculous pleural effusion. Materials and Methods: A retrospective analysis was done of the 100 adult patients with pleural effusion predefined criteria were adopted to label a case as tuberculous. Using MS Excel 2007 sensitivity, specificity, positive and negative likelihood ratio, accuracy, etc., were derived and various parameters in pleural fluid were also studied. Result: The sensitivity, specificity, positive, and negative predictive values, positive and negative likelihood ratios, accuracy, and discordance were 95.74%, 94.33%, 93.75%, 96.15%, 16.88%, 4.51%, 95%, and 5%, respectively. Conclusion: Pleural fluid routine micro examination along with ADA levels has an acceptable sensitivity, specificity, and accuracy for the diagnosis of tuberculous pleural effusion.

Biological markers in the diagnosis of tuberculous pleural effusion.

Tuberculosis is one of the main etiologies to evoke in the context of lymphocyte pleurisy. However, diagnosis is difficult and is based on mycobacteriology that is not enough sensitive and time-consuming, or on histology that requires invasive biopsy gesture. This literature review, carried out from Medline, summarizes the main meta-analyzes, reviews, and originator publications in English on biomarkers, classic and more innovative, studied for the diagnosis of tuberculous pleurisy. Among the immuno-biochemical markers, interferon-γ (IFN-γ), isoenzyme of adenosine deaminase 2 (ADA2) and total adenosine deaminase (ADA) seem the most relevant with respective sensitivities of 89% (87-91), 97.2% (95 to 98.7) and 92% (90-93) and specificities of 97% (96-98), 94.2% (91.8 to 96) and 90% (89-91). About molecular biology, PCR Xpert MTB/RIF has a sensitivity of 46.4% (26.3 to 67.8), which is much higher than the direct examination, while providing rapid diagnostic confirmation, with a specificity of 99.1% (95.2 to 99.8), and a resistance to rifampicin screening. The release assay of interferon-γ (IGRA) is less effective with a sensitivity of 75% (69-81) and a specificity of 82% (75-88) in blood and a sensitivity of 80% (74-86%) and a specificity of 72% (64-80) in pleural fluid. Other biomarkers (including several cytokines) might have an interest but are still under evaluation. These innovative methods, particularly the determination of ADA and the use of PCR Xpert MTB/RIF should find their place in the diagnostic algorithm of TB pleurisy.

Study of serum interferon gamma in tubercular pleural effusions

Background: Pleural effusions (PEs) are a common reason for admission in Acharya Vinoba Bhave Rural Hospital, and in developing countries like India, tuberculosis (TB) is the most common cause of exudative PE. The diagnosis of tuberculous PE with standard analysis of pleural fluid is often inaccurate. Pleural tissue histopathology and culture for Mycobacterium tuberculosis are considered the gold standard, but the procedure is invasive, requires skilled clinicians, and does not provide immediate results. To address these limitations, we evaluated whether serum interferon gamma (IFN-γ) can be used as a diagnostic aid for tubercular PEs and to compare its efficacy with adenosine deaminase (ADA) and cytology of pleural fluid. Materials and Methods: The sample size was 86 patients aged 16 years and above and who were diagnosed having tubercular PE either on the basis of ADA or cytology or by both methods, and serum IFN-γ levels were evaluated in these patients. Results: Serum IFN-γ was significantly raised in patients with tubercular PE. Conclusion: Pleural fluid ADA and IFN-γ are almost equally sensitive in diagnosing tubercular effusion; however, in cases where obtaining pleural fluid or other diagnostic material is difficult, serum IFN-γ can be considered as aid in diagnosing TB.

Pleural Fluid Adenosine Deaminase Values in Diagnosis of Tuberculous Pleural Effusion in South Khorasan Province

Background: Due to variability of pleural fluid ADA measures in pleural tuberculosis, researchers have recommended the necessity of regional studies for determination of specific regional values. Objectives: The purpose of the present study was to evaluate the values of pleural fluid ADA in diagnosis of Tuberculous pleural effusion in South Khorasan province. Methods: A cross-sectional study was conducted on patients > 12 years old with exudative pleural effusion in South Khorasan province (east of Iran). Light criteria were used to define exudative effusion. Total ADA was determined calorimetrically by Diazyme ADA assay. The data were analyzed using t test, ANOVA and χ2 tests through Spss 16 version software. Results: We studied 255 cases including 139 (54.5%) males and 116 (45.5%) females with mean age of 63.8 ± 18 years. There were 36 (14.1%) cases with Tuberculous pleural effusion and 219 (85.9%) cases of non-Tuberculous pleural effusion. Malignant and acute bacterial infection comprise 106 (41.6%) and 29 cases (11.4%), respectively. The mean levels and optimal cut off point of ADA in Tuberculous pleural effusion were40.2 ± 24.7 and 30 IU/L respectively. ADA in Tuberculous pleural effusion showed negative correlation with age (r = -0.40, p = 0.01), but weak positive correlation with fluid protein(r = 0.44, P = 0.007) and LDH (r = 0.32, P = 05). Conclusions: Mean and cut off point of ADA was relatively low in patients with Tuberculous pleural effusion in South Khorasan province. The age of patients and fluid levels of protein, and LDH must be considered in interpretation of pleural fluid ADA levels.

Expressions and diagnostic value of the cytokines in tuberculous and malignant pleural effusion

Objective To analyze the levels of pro-inflammatory cytokines, anti-inflammatory cytokines and chemokines in tuberculous and malignant pleural effusion using Luminex method, and to evaluate their diagnostic value in tuberculous pleural effusion. Methods Fifty-three patients with tuberculous pleural effusion and 28 patient with malignant pleural effusion were included in this study. Luminex method was applied to detect the levels of pro-inflammatory cytokines (interleukin [IL]-1β, IL-6, IL-12, interferon [IFN]-γ and tumor necrosis factor [TNF]-α), anti-inflammatory cytokines (IL-1 receptor antagonist [IL-1ra], IL-4, and IL-10), and chemokines (IFN-γ inducible protein [IP]-10, macrophage inflammatory protein [MIP]-1α, MIP-1β, and monocyte chemo-attractant protein [MCP]-1) in all patients. The levels of cytokines were compared using Mann-Whitney test. Results The levels of IFN-γ (1 064.33 pg/mL vs 294.78 pg/mL, U=130.5, P<0.01) and IP-10 (39 179.86 pg/mL vs 9 411.73 pg/mL, U=98.0, P<0.01) in tuberculous pleural effusion were significantly higher than those in malignant pleural effusion, while the IL-10 level (11.52 pg/mL vs 17.77 pg/mL, U=565.5, P=0.017) was significantly lower than that in malignant pleural effusion. Furthermore, IFN-γ/IL-10 (100.07 vs 16.19, U=116.0, P<0.01) and IP-10/IL-10 (2 930.91 vs 591.18, U=75.0, P<0.01) in tuberculous pleural effusion were significantly higher than those in malignant pleural effusion. Area under the curve of receiver operating characteristic of IFN-γ, IP-10, IFN-γ/IL-10, and IP-10/IL-10 were 0.91, 0.93, 0.92 and 0.95, respectively, with the cut-off value of 483.5 pg/mL, 20 340 pg/mL, 41.11 and 1 614. For the diagnosis of tuberculous pleural effusion, the sensitivities and specificities of IFN-γ≥483.5 pg/mL, IP-10≥20 340 pg/mL, IFN-γ/IL-10≥41.11, and IP-10/IL-10≥1 614 were 0.830(95%CI: 0.702-0.920) and 0.962(95%CI: 0.804-0.999), 0.906(95%CI: 0.793-0.969) and 0.923(95%CI: 0.749-0.991), 0.811(95%CI: 0.680-0.906) and 0.923(95%CI: 0.749-0.991), 0.868(95%CI: 0.747-0.945) and 0.923(95%CI: 0.749-0.991), respectively. Conclusions The expression levels of IFN-γ, IP-10 and IL-10 in pleural effusion detected by Luminex method is convenient, rapid, noninvasive, sensitive and specific, which is helpful for the diagnosis of tuberculous pleural effusion. Key words: Cytokines; Tuberculosis, pleural; Pleural effusion, malignant; Diagnosis, differential

Tuberculous pleural effusion.

Although it is curable, tuberculosis remains one of the most frequent causes of pleural effusions on a global scale, especially in developing countries. Tuberculous pleural effusion (TPE) is one of the most common forms of extrapulmonary tuberculosis. TPE usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. The gold standard for the diagnosis of TPE remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli, Although adenosine deaminase and interferon-γ in pleural fluid have been documented to be useful tests for the diagnosis of TPE. It can be accepted that in areas with high tuberculosis prevalence, the easiest way to establish the diagnosis of TPE in a patient with a lymphocytic pleural effusion is to generally demonstrate a adenosine deaminase level above 40 U/L. The recommended treatment for TPE is a regimen with isoniazid, rifampin, and pyrazinamide for two months followed by four months of two drugs, isoniazid and rifampin.

Application of in-house nested polymerase chain reaction for rapid diagnosis of tuberculous pleural effusion

Tuberculous pleural effusion (TPE) is a common manifestation of extrapulmonary tuberculosis and is the most common cause of pleural effusion in many countries. Conventional diagnostic tests for detection of Mycobacterium tuberculosis in pleural fluid or pleural tissue, have known limitations. Hence, there is need for a newer, rapid diagnostic tests. Molecular techniques, detecting DNA of M. tuberculosis in pleural fluid have better sensitivity and could be a potent tool for rapid diagnosis of tuberculous pleural effusion. Objective: To evaluate Nested PCR protocol targeting 38 kDa gene for rapid detection of M. tuberculosis complex in clinically suspected cases of TPE. Material and methods: A cross-sectional, prospective study was carried out at the tertiary care institute in a rural setup at western U.P. A total of 155 subjects with clinical suspicion of TPE enrolled during February 2015 to January 2016. About 10-20 ml of pleural fluid was collected and analysed for presence of M .tuberculosis by Z.N staining, culture on Lowenstein Medium (LJ), BacT/Alert 3D culture bottle and by Nested PCR targeting 38kDa gene of M. tuberculosis. Result: Off the 155 patients enrolled, M. tuberculosis was detected by AFB staining, LJ culture and BacT/Alert 3D system staining in 13 (8.4%), 45 (29%) and 72 (46.5%) respectively. Diagnostic sensitivity of nested PCR (nPCR) was 60.6% and among smear positive and culture negative samples, sensitivity was 100% while in smear negative, culture negative it was 29.2%. Conclusion: 38 kDa based nested PCR offers alternative robust approach for rapid and accurate detection of M .tuberculosis in paucibacillary tuberculous pleural effusion specimens.

Determination of Interleukin 27-Producing CD4(+) and CD8(+) T Cells for The Differentiation Between Tuberculous and Malignant Pleural Effusions.

The numbers of IL-27+ CD4+ and IL-27+ CD8+ T cells have been found to be increased in tuberculous pleural effusion (TPE) as compared with malignant pleural effusion (MPE). The objective of the present study was to investigate whether pleural IL-27+ CD4+ and IL-27+ CD8+ T cells can distinguish patients with TPE from those with MPE. Paired specimen of pleural fluid and peripheral blood were collected from 35 patients with TPE and 46 MPE. The numbers of IL-27+ CD4+ and IL-27+ CD8+ T cells were simultaneously determined by flow cytometry. Receiver operating characteristic curve analysis was used to evaluate the capacity of IL-27+ CD4+ and IL-27+ CD8+ T cells to differentiate TPE from MPE. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), and negative predictive value (NPV) of IL-27+ CD4+ T cells were 94.3%, 93.5%, 14.46, 0.06, 91.7%, and 95.6%, respectively. The sensitivity, specificity, PLR, NLR, PPV and NPV of IL-27+ CD8+ T cells were 80.0%, 93.5%, 12.27, 0.21, 90.3% and 86.0%, respectively. The number of IL-27+ CD4+ in pleural fluid is a helpful diagnostic biomarker for the diagnosis of TPE, which performs better than that of IL-27+ CD8+ T cells.

A combination of the QuantiFERON-TB Gold In-Tube assay and the detection of adenosine deaminase improves the diagnosis of tuberculous pleural effusion

The differential diagnosis of tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE) remains difficult despite the availability of numerous diagnostic tools. The current study aimed to evaluate the performance of the whole blood QuantiFERON-TB Gold In-Tube (QFT-GIT) assay and conventional laboratory biomarkers in differential diagnosis of TPE and MPE in high tuberculosis prevalence areas. A total of 117 patients with pleural effusions were recruited, including 91 with TPE and 26 with MPE. All of the patients were tested with QFT-GIT, and the conventional biomarkers in both blood and pleural effusion were detected. The level of antigen-stimulated QFT-GIT in the whole blood of TPE patients was significantly higher than that of MPE (2.89 vs 0.33 IU/mL, P<0.0001). The sensitivity and specificity of QFT-GIT for the diagnosis of TPE were 93.0% and 60.0%, respectively. Among the biomarkers in blood and pleural effusion, pleural adenosine deaminase (ADA) was the most prominent biomarker, with a cutoff value of 15.35 IU/L. The sensitivity and specificity for the diagnosis of TPE were 93.4% and 96.2%, respectively. The diagnostic classification tree from the combination of these two biomarkers was 97.8% sensitive and 92.3% specific. Ultimately, the combination of whole blood QFT-GIT with pleural ADA improved both the specificity and positive predictive value to 100%. Thus, QFT-GIT is not superior to pleural ADA in the differential diagnosis of TPE and MPE. Combined whole blood QFT-GIT and pleural ADA detection can improve the diagnosis of TPE.

Efficacy and Safety of Diagnostic Thoracoscopy in Undiagnosed Pleural Effusions

Background: The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied. Objective: This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population. Methods: Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed. Results: During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube. Conclusions: MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion.

Evaluating the value of detecting cytokines for diagnosis of tuberculous pleural effusion by liquid array technology

Objective To establish a diagnostic model of multiple cytokines for differential diagnosis of tuberculous pleural effusion, and compare its diagnostic accuracy with tuberculosis infected T cells detection (T-SPOT.TB) in order to evaluate its diagnostic performance. Methods Case-control study.Totally 147 patients with pleural fluid in Tianjin Haihe Hospital were enrolled and categorized as tuberculous pleural effusion group (n=95) and malignant pleural effusion group (n=52) from December 2011 to June 2013. Pleural effusion cytokines including interferon-γ (IFN-γ), C-X-C motif chemokine 10 (CXCL-10), tumor necrosis factor-α (TNF-α), vascular endothelial growth factor (VEGF), IL-2, IL-16, IL-17, IL-27 and IL-33 were tested by liquid chip technology and analyzed by Binary Logistic regression and receiver operating characteristic curve(ROC), and the pleural effusion was also detected by tuberculosis infected T cells detection (T-SPOT.TB) as a control. Results The comparison of the AUC of cytokines is: CXCL-10> IL-27> IFN-γ> IL-33 > IL-17> IL-16> TNF-α> VEGF> IL-2; After that, CXCL-10, IFN-γ, IL-27 and IL-33 were included the Binary Logistic regression model. The regression equation is P=1/1+ e-(-16.851+ 0.390×IFN-γ+ 0.006×IL-27+ 0.020×IL-33). The AUC, sensitivity and specificity of the diagnostic model were 99.5%, 96.84%, and 98.08%, respectively. Both AUC and sensitivity of the diagnostic model were superior to those of any single index. Compared with T-SPOT.TB (0.995±0.003), the AUC of the diagnostic model (0.921±0.023) was significantly greater (Z=3.235, P 0.05). The Kappa of the two methods was 0.795, which meant fine agreement of the evaluations of the two raters. Conclusion The application of liquid array technology of high sensitivity and repeatability with high throughput provided a novel insight and method in the clinical diagnosis, treatment and prevention for tuberculous pleural effusion scientifically and accurately.(Chin J Lab Med, 2015, 38: 562-566) Key words: Tuberculosis, pleural; Pleural effusion; Cytokines; Interferon-gamma; Chemokine CXCL10; Interleukins

Tuberculous Pleural Effusion Presenting with Prevertebral and Cervical Emphysema: An Unusual Presentation

ABSTRACT We present a case of a 45-year-old male presenting with acute onset swelling on anterior aspect of neck, dysphagia and dyspnea. Clinical examination revealed bilateral submandibular space emphysema and retropharyngeal bulge. The preliminary diagnosis was made of an evolving deep neck space infection. Further, computed tomography (CT) of chest and neck was done which showed heterogenous collection in retropharyngeal space with air pockets and right-sided pleural effusion. Pleural tap was sent for cytology and adenosine deaminase (ADA) levels, which were found to be significantly raised. Thus, a final diagnosis of tuberculous pleural effusion was made and patient was started on anti-tubercular treatment. How to cite this article Chauhan A, Rajan S, Singh I. Tuberculous Pleural Effusion Presenting with Prevertebral and Cervical Emphysema: An Unusual Presentation. Int J Otorhinolaryngol Clin 2015;7(2):83-84.