Pleural Biopsy Specimens Research Articles

Pleural Mesothelial Cells-Induced Monocytes to the Pleural Cavity through the Effect of C3 Lytic Products in Tuberculous Pleural Effusion

Background. The activation of complement is involved in monocyte recruitment in tuberculous pleural effusion (TPE), while the role of the cleavage product of complement C3 in this process needs further research. Methods. The expression of complement components in pleural biopsy specimens of TPE patients was measured. The concentration of cleavage products of complement was tested in TPE by ELISA. Moreover, the colocalizations of C3b and CR1, C3d and CR3, and CXCL12 and CXCR4 in monocytes and pleural mesothelial cells (PMCs) isolated from TPE were determined by an immunofluorescent assay. Monocyte chemotaxis assay was analyzed via transwell chambers. Results. Three pathways of the complement system were activated in tuberculous pleurisy. In patients with TPE, C3 lysis was more active than peripheral blood in pleural cavity. Tuberculous protein Mpt64 and anaphylatoxin C3a could significantly promote CXCL12 production in human PMCs isolated from TPE. C3b-CR1, C3d-CR3, and CXCL12-CXCR4 were colocalized in PMCs and monocytes from TPE. The recruitment of monocytes into TPE mediated by PMCs could be inhibited by anti-CR1, anti-CR3, and anti-CXCL12 monoclonal antibodies (mAbs). Conclusions. Complement activates strongly in TPE, and PMCs induced monocytes to the pleural cavity through C3a, C3b, and C3d.

Autofluorescence imaging-assisted medical thoracoscopy in the diagnosis of malignant pleural disease

BackgroundMedical thoracoscopy (MT) does not always provide a conclusive diagnosis of pleural diseases because the endoscopic appearance of pleural diseases can be misleading. Autofluorescence imaging (AFI) is an effective assistive diagnostic tool. However, its clinical application for pleural disease remains controversial. ObjectivesThis prospective study evaluated the clinical usefulness of AFI-assisted MT for diagnosis of malignant pleural diseases. MethodsPatients with unexplained pleural effusion admitted to our clinics between December 2018 and September 2021 were enrolled. We performed white-light thoracoscopy (WLT) first, and then AFI, during MT. Images of endoscopic real-time lesions were recorded under both modes. Pleural biopsy specimens were analyzed pathologically. Between-groups differences in diagnostic sensitivity, specificity, positive-predictive value (PPV), and negative-predictive value (NPV) were assessed using 95% confidence intervals (CI). Receiver operating characteristic curves and decision curve analyses were employed to analyze the diagnostic efficiency of these two modes. ResultsOf 126 eligible patients, 73 cases were diagnosed with malignant pleural disease. A total of 1292 biopsy specimens from 492 pleural sites were examined for pathological changes. The diagnostic sensitivity, PPV, and NPV of AFI were 99.7%, 58.2%, and 99.2%, respectively. AFI was significantly superior to WLT, which had a sensitivity of 79.7%, PPV of 50.7%, and NPV of 62.8%. Subgroup analysis showed that the AFI type III pattern was significantly more specific for pleural malignant disease than that of WLT. ConclusionsAFI could further improve the diagnostic efficacy of MT by providing better visualization, convenience, and safety.

AFB culture and adenosine deaminase levels in subjects with tubercular pleural effusion

Background: Tuberculosis is the communicable infectious disease usually caused by Mycobacterium Tuberculosis Bacteria (MTB). Tuberculosis generally affects lungs, but can also affect other parts of the body. ADA has been found to be useful parameter to conclude the tubercular etiology. Tuberculous Pleural effusion is diagnosed by demonstration of tubercular bacilli in pleural fluid or granuloma in pleural biopsy specimen. Objectives of this study: The objectives of this study were to estimate ADA levels and to study AFB culture in subjects with and without tubercular pleural effusion. Materials and Methods: Biochemical analysis for Protein and Glucose were performed on Automated Biochemistry Analyser and ADA was estimated by ADA-MTB kit method. Cytological examination and ADA Microbiological demonstration of AFB by ZN stain and AFB culture was done by conventional LJ method. Statistical Analysis: Data were expressed as mean ± SD. The Student t test was used for the comparison. Statistical analysis was done using Microsoft Excel spreadsheet, and statistical package for the social sciences (SPSS) version 20.0 software.

Histomorphological Spectrum of Pleural Biopsy Specimen of Exudative Pleural Effusion in a Tertiary Care Hospital in Bangladesh

Background: The commonest manifestation of pleural pathology is pleural effusion. Most of the time, in spite of routine biochemical and cytological examination of pleural fluid we can’t evaluate the etiology of pleural effusion. Aim: Aim of present study was to make an etiological diagnosis of exudative pleural effusion by pleural biopsy and histopathological examination. Study design and setting: Fifty consecutive patients of pleural effusion were selected from the outpatient and indoor department of a tertiary medical college hospital in Sylhet. It was a prospective and observational study. It was conducted over a period of one and a halfyears. Material and method: In all the cases, cytological examination of pleural fluid (for malignant cell) and pleural biopsy by Abram’s needle were done. Subsequently, histopathological diagnoses were made to determine the etiology of effusion. Results: Out of 50 subjects, males outnumbered females, Age is ranged between 19 and 85 years. According to the histopathological examination of the submitted pleural biopsy specimen, granulomatous inflammation is the most common etiology (40%) followed by chronic inflammation of non-specific origin (38%) and malignancy (22%). Conclusion: This study represents the result of the experience acquired over one and half years in the histopathological interpretation of pleural biopsies and its correlation with cytology of the pleural fluid. Pleural biopsy is a useful, minimally invasive procedure with no or little complication and has more sensitivity and specificity than pleural fluid cytology smears.

Xanthomatous Pleuritis Associated With Pancreaticopleural Fistula.

Xanthomatous pleuritis is a very rare type of chronic inflammation, with only 3 reports to date.1–3 However, the exact etiology of this disease is unknown. Herein, we present a case of xanthomatous pleuritis that might have been associated with pancreatic pleural effusion. CASE REPORT A 62-year-old male who regularly consumed alcohol (<20 g/day), was a nonsmoker, and had no medical history was referred to our hospital for exertional dyspnea. Laboratory examination revealed leukocytosis (11,200/μL); however, all other findings were normal (C-reactive protein, 0.62 mg/dL; serum amylase, 171 IU/L; serum lipase, 30 IU/L; tumor markers, negative; interferon-gamma release assay, negative). The chest radiograph showed left pleural effusion. Moreover, chest computed tomography (CT) revealed left pleural effusion. We performed thoracoscopy under local anesthesia for drainage and pathologic diagnosis as pleural effusion because of malignancy was considered. Pleural fluid examination revealed bloody exudative (protein, 5.0 g/dL; lactate dehydrogenase, 1264 IU/L; Rivalta reaction, positive; serum total protein, 6.9 g/dL; serum, lactate dehydrogenase 212 IU/L) and high level of amylase (13,355 IU/L). Thoracoscopy of the left thorax revealed diffuse yellow plaque-like deposits in the pleura (Fig. 1). Histology of the left pleural biopsy specimen showed inflammation and foamy cells (Fig. 2). There was no evidence of malignancies and infections, including Mycobacterium. Therefore, we considered the presence of pancreaticopleural fistula and performed further abdominal examinations. An enhanced CT and endoscopic retrograde cholangiopancreatography revealed pancreatic stones, main pancreatic duct dilatation, meandering pancreatic duct, and left pancreaticopleural fistula (Fig. 3). Distal pancreatectomy was performed after thoracic drainage with a chest tube to treat the pancreatic pleural fistula for prevention of pleural effusion recurrence and rule out pancreatic cancer. The surgically resected specimen of the pancreas showed chronic pancreatitis with pancreatic stones and no findings of malignancies. On the basis of these results, xanthomatous pleuritis with pancreaticopleural fistula because of chronic pancreatitis was finally diagnosed. The patient has had an uneventful course without recurrence for more than 4 years.FIGURE 1: A and B, Thoracoscopic image shows diffuse yellow plaque-like deposits in the pleura of the left thorax.FIGURE 2: Biopsy specimen of the pleura with yellow plaque-like deposit shows foamy cells (×400 magnification).FIGURE 3: Endoscopic retrograde cholangiopancreatography reveals meandering pancreatic duct and contrast outflow to the left thoracic cavity (red arrow).DISCUSSION To the best of our knowledge, this is the first report of xanthomatous pleuritis with pancreatic pleural effusion. Xanthomatous pleuritis is a very rare benign type of chronic inflammation, and only 3 cases have been reported in the literature.1–3 Although the exact etiology is uncertain, previous reports2–4 suggested that chronic inflammation, defective lipid transport, and hemorrhage might be the causes of xanthomatous inflammation. In the present case, chronic inflammation because of pancreaticopleural fistula might have caused xanthomatous pleuritis. Furthermore, aberrance of the lipid component of the pancreas might also be a cause of defective lipid transport. In addition, we present the thoracoscopic findings of xanthomatous pleuritis. Thoracoscopy showed diffuse yellow plaque-like deposits in the pleura. This finding was similar to that in a previous report by Bateman et al.3 Xanthoma comprises yellow plaque-like lesions characterized by the presence of lipid-containing histocytes and is commonly found in the gastrointestinal tract.5 The endoscopic finding of xanthoma in the gastrointestinal tract includes yellow spots,6,7 which is very similar to the finding in our case and a previous report.3 Hence, the yellow plaque-like deposits might be the characteristic finding in xanthomatous pleuritis. Physicians should consider the possibility of xanthomatous pleuritis when such thoracoscopy findings are observed. Furthermore, the thoracoscopy finding of xanthomatous pleuritis may indicate the possibility of the presence of pancreatic disease, even though pancreatic disease is not initially considered as a differential diagnosis when physicians examine patients with pleural effusion. Therefore, abdominal examinations, such as abdominal CT, ultrasound, or endoscopic retrograde cholangiopancreatography, should be performed when physicians confirm this thoracoscopy finding. Treatments for xanthomatous pleuritis are yet to be established, although steroids have been used in the previous cases.1,3 Since xanthomatous pleuritis was considered to be associated with pancreaticopleural fistula in the present case, we performed distal pancreatectomy, which led to a favorable outcome. It may be important to find out the underlying causes, such as pancreaticopleural fistula, when physicians diagnose xanthomatous pleuritis. In conclusion, the present case suggests that pancreatic pleural effusion might be a cause of xanthomatous pleuritis, and the thoracoscopic finding of yellow plaque-like deposits in pleura might be the characteristic finding of xanthomatous pleuritis.

Performance of Xpert MTB/RIF assay on thoracoscopic pleural biopsy in undiagnosed exudative pleural effusion

AimsThe aim of the study was to determine the performance of Xpert MTB/RIF assay in diagnosing tuberculosis on thoracoscopic pleural biopsies in exudative pleural effusion. MethodsPatients who underwent thoracoscopic pleural biopsy in the defined period were included in the study. Histopathology was done for all and Xpert MTB RIF assay and AFB culture of pleural biopsy specimen and pleural fluid were done as per the clinician's discretion. ResultsTotal of 110 patients underwent pleural biopsy and tissue Xpert MTB/RIF and MTB culture were done in 29 patients. XpertMTB/RIF assay and MTB culture had a sensitivity of 59% and 35% respectively and specificity of specificity of 100. ConclusionThe study described the ability of XPERT MTB/RIF in getting additional diagnostic information from thoracoscopic Pleural biopsy. Pleural biopsy Xpert MTB/RIF had sensitivity of 59% and specificity of 100% in diagnosing TPE. In addition to the diagnosis, Xpert MTB/RIF can also give valuable information about rifampicin resistance too. XPERT MTB/RIF assay also helped in getting diagnosis when histopathology alone was not able to confirm or rule out the diagnosis of TPE. Pleural fluid ADA of 38 IU/L had a sensitivity of 71% and a specificity of 86% for diagnosis of TPE in present study.

Diagnostic accuracy of semirigid thoracoscopy in exudative pleural effusions and relationship of thoracoscopic findings with probability of malignant diagnosis.

Semirigid thoracoscopy is increasingly becoming the procedure of choice for evaluation of undiagnosed exudative pleural effusions. Few studies have reported relationship of thoracoscopic appearances of pleural abnormalities and etiological diagnoses. We aimed our study to assess the diagnostic utility and safety of semirigid thoracoscopy for evaluation of patients with undiagnosed exudative pleural effusion. Further, we also pursued to find any relation of various thoracoscopic findings with the final diagnosis. We prospectively enrolled hospitalized patients with undiagnosed exudative pleural effusion who underwent semirigid thoracoscopy. Demographic, clinical and laboratory data along with data on thoracoscopic appearance of various pleural abnormalities and histopathological diagnosis of pleural biopsy specimens were collected and analysed. Semirigid thoracoscopy was diagnostic in 46 (N=55) patients (83.64%). Malignancy was diagnosed in 31 patients (56.36%), of which adenocarcinoma was the most common histopathological diagnosis (45.16%). Sensitivity, specificity, PPV, NPV LR+ and LR- of thoracoscopy were 93.87%, 100%, 100%, 66.67%, 40.30 and 0.06, respectively. Pleural nodules, masses and hemorrhagic pleural fluid significantly increased the diagnosis yield of malignancy [OR= 37.16 (95%CI = 3.61-382.65), =0.002]. The procedure related complications were mild and transient. Post- procedural pain (20%) was most commonly reported followed by dry cough (18.18%), sub-cutaneous emphysema (7.27%) and anaesthesia related complication (1.82%). Semirigid thoracoscopy is simple, safe and effective procedure in diagnosing exudative pleural effusion of unknown etiology with high diagnostic accuracy and minor procedure related complications. The likelihood of diagnosing malignancy is high if combination of pleural nodules, masses and hemorrhagic pleural fluid is present.

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.

Treatment of intestinal tuberculosis with small bowel perforation: a case report

BackgroundDiagnosis of intestinal tuberculosis poses a dilemma to physicians due to nonspecific symptoms like abdominal pain, fever, nausea, and a change in bowel habit. In particular, the distinction between inflammatory bowel disease and intestinal tuberculosis remains challenging.Case presentationA 27-year-old man from Colombia presented with fever, night sweats, and progressive lower abdominal pain. Computed tomography revealed a thickening of the bowel wall with a mesenterial lymphadenopathy, ascites ,and a pleural tumor mass. Histology of intestinal and pleural biopsy specimens showed a granulomatous inflammation. Although microscopy and polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MTB) were negative, empirical MTB treatment was initiated on suspicion. Due to a massive post-stenotic atrophied intestinal bowel, MTB medications were administered parenterally in the initial phase of treatment to guarantee adequate systemic resorption. The complicated and critical further course included an intra-abdominal abscess and bowel perforation requiring a split stoma, before the patient could be discharged in good condition after 3 months of in-hospital care.ConclusionsThis case highlights the clinical complexity and diagnostic challenges of intestinal MTB infection. A multidisciplinary team of physicians should be sensitized to a timely diagnosis of this disease, which often mimics inflammation similar to inflammatory bowel disease, other infections, or malignancies. In our case, radiological findings, histological results, and migratory background underpinned the suspected diagnosis and allowed early initiation of tuberculostatic treatment.

Diagnostic Outcome of Open Pleural Biopsy

Background: Pleural diseases involve the parietal and visceral pleura. They can be of inflammatory or malignant origin. Pleural biopsy is advised for assessment and excluding infectious causes as tuberculosis or malignant disease, particularly malignant mesothelioma. Connective tissue disorders such as rheumatoid disease can also present with involvement of pleura, requiring pleural biopsy for diagnosis. Objectives: The aim of my study was to find out diagnostic outcomes of open pleural biopsy or differentiation between benign (noncancerous) and malignant (cancerous) disease, to diagnose viral, fungal and parasitic diseases of pleura. Materials and Methods: Non-random sampling was used for data collection from Gulab Devi hospital. To find out the clinical value of nonspecific pleural biopsy specimen and fluid malignant neoplasm and tuberculosis. Data was collected from the patients undergoing procedure at Gulab Devi hospital. The collected data consists of 160 patients included females and males of all age groups. Results: 160 patients were undergone biopsies. Out of 160 patients a nonspecific or normal result was found in 53(33.3%). Diagnostic of malignant neoplasm in 18(10.9%) and granulomatous disease in 28(17%). Tuberculosis was found in 46 (28.9%). Histopathologically, pnemonitis was found in 16 (10.1%). Conclusion: Open pleural biopsy is precise and gold standard investigative method for malignancy. Pleural biopsy is safe easily performed and useful in diagnoses of tuberculosis or malignancy.

A multidisciplinary approach for the diagnosis of benign asbestos pleural effusion: a single-center experience.

BackgroundThere is little detailed information regarding benign asbestos pleural effusion (BAPE). It is frequently misdiagnosed because of lack of a standardized diagnostic approach and criteria. The present study aimed to better characterize BAPE and outline a diagnostic approach for this disease.MethodsComplete clinical data of 11 consecutive patients with BAPE were prospectively collected and analysed. A multidisciplinary team (MDT) was involved in discussing the suspected cases of BAPE. The team was comprised of thoracic physicians, radiologists and pathologists. A multidisciplinary practical diagnostic approach for BAPE was introduced.ResultsSix patients had respiratory symptoms, but another 5 were asymptomatic. All the patients had an asbestos exposure and the median duration was 23.9 years (rang, 12–36 years). The median level of lactate dehydrogenase (LDH), adenosine deaminase (ADA), proteins and carcinoembryonic antigen (CEA) in the pleural fluid (PF) were 221.4 U/L (range, 189.8–11,325 U/L), 21 U/L (rang, 14–247 U/L), 48.3 g/dL (range, 35.2–53.2 g/dL) and 3.46 mg/mL (range, 0.84–4.54 mg/mL), respectively. Five patients had pleural plaques, 2 had diffuse pleural thickening (DPT), 1 had asbestosis, and 1 had round atelectasis. The pleural biopsy specimens showed a benign fibrotic pleura in all case. The symptoms and pleural pulmonary radiologic findings remained stable during the follow-up.ConclusionsBAPE is diagnosed by exclusion. A suspected diagnosis of BAPE with an asbestos exposure should be considered, especially with the presence of pleural plaques, and/or DPT, and rounded atelectasis. The MDT-based diagnostic approach may reduce misdiagnosis.

STUDY OF EXUDATIVE PLEURAL EFFUSION IN THE AGE GROUP OF 15-40 YEARS WITH SPECIAL REFERENCE TO ADENOSINE DEAMINASE AND TUBERCULIN SKIN TEST IN THE DIAGNOSIS OF TUBERCULOUS ETIOLOGY

Background: A tubercular pleural effusion can either be a sequel to a primary infection acquired 3 to 6 month previously or represent reactivation tuberculousis.&#x0D; Two different pathogenic mechanism can lead to tuberculous pleural effusion. By far the more common is the entry of only a few M. tuberculosis into the pleural space; in the presence of specific cell mediated immunity, tubercle bacilli provoke an intense hypersensitivity reaction and outpouring of fluid. Chest radiograph may or may not reveal associated parenchymal involvement. In the second variety, a subpleural caseous focus or cavity rupture into the pleural space and results in a pleural effusion. In this case chest radiograph nearly always shows parenchymal abnormalities.&#x0D; A definitive diagnosis of TBPE can be difficult to make because of the low sensitivity and / or specificity of noninvasive traditional diagnostic tools.&#x0D; In most series of patients with TBPE the result of pleural fluid staining for acid fast bacilli are virtually always negative and pleural fluid cultures are positive for mycobacteria in &lt;35% of cases. Without underlying lung parenchymal lesion sputum examination may be positive in 4% to 11% of patient with TBPE. On the other hand, pleural biopsy specimen will demonstrate granulomatous pleuritis in 50% to 80% of patients.&#x0D; This study was taken whether pleural fluid ADA and tuberculin skin test has any role in the diagnosis of tubercular pleural effusion.&#x0D; Methods and Materials: In the present study 120 cases of exudative pleural effusion in the age group of 15-40 years of varying etiology are taken who attended the pulmonary medicine department of Burdwan Medical College and Hospital.&#x0D; The study was conducted the period of March 2017 to February 2018 apart from relevant history taking a detail clinical examination, full investigation were done to reach a complete and final diagnosis.&#x0D; Result: In our study 120 patient of aged 15-40 years were taken. Different aetiological groups and there frequency as diagnosed by various mean were Tuberculous – 85%, Paraneumonic effusion – 10 %, Malignant effusion – 10%.&#x0D; There was male preponderance in all groups of pleural effusion. History of contact was present in 34 % cases of tuberculous effusion. Sputum for AFB was found 10.78% cases of tuberculous effusion. These patients also had pulmonary lesions. 80.39% cases of tuberculous effusion had pale yellow coloured effusion but 13.72 % cases had haemorrhagic fluid. 66.66% malignant effusion had haemorrhagic fluid and 33.37% of malignant effusion had pale yellow coloured fluid. Pleural fluid for malignant cell was positively 66.67% of malignant effusion. Pleural fluid for Z-N stain detect 1.96% cases tubercle bacilli in TBPE group. Plural biopsy was found positive in 68.18% cases of TBPE and 60% cases of MPE.&#x0D; Pleural fluid ADA level was significantly higher (P&lt;0.001) in patients of tuberculous effusion than non-tuberculous effusion. Taking a cut off value of 70 U/L sensitivity and specificity is 95.09% and 33.33%. But when parapneumonic effusion was excluded, the specificity increases. Lymphocytic pleural effusion below the age group of 40 years with cut off value of ADA &lt;40 U/L can be used as a screening test for malignant effusion.&#x0D; In TBPE tuberculin skin test was positive in 74.50% cases. Taking a cut off value of 10 mm or more induration of tuberculin skin test, "P" value is less than 0.001. Sensitivity and specificity of tuberculin skin test in tuberculous pleural effusion is 74.50% and 50%.&#x0D; If we compare the efficacy of ADA &gt; 70 U/L and tuberculin skin test positivity to diagnose tuberculous pleural effusion the former is superior statistically to the later (P value is less than 0.01) specificity of tuberculin skin test is low because it may be positive with infection with NTM and prior BCG vaccination.&#x0D; Conclusion: Maximum incidence of tuberculous pleural effusion occurs in the age group of 20-30 years. Malignant pleural effusion is less likely below the age group of 30 years.&#x0D; Increased ADA level &gt;70 U/L in pleural fluid is a sensitive, minimally invasive, cost effective, easy method for diagnosis of tuberculous pleural effusion.&#x0D; Lower level of pleural fluid ADA level (&lt;40 U /L) is a sensitive, specific, minimally invasive, cost effective easy method for suspecting malignant effusion. Its value is much more important when younger patients (&lt;40 years of age) present with malignant effusion, especially so when the pleural fluid is also appeared pale yellow. A low ADA level will guide us to look for malignancy in this age group.&#x0D; Tuberculin skin testing with intermediate strength PPD has a high sensitivity in patients with pleural tuberculosis. It was seen negative in 1/3rd cases of TBPE. This negative tuberculin skin test in TBPE may be due to recent tuberculous infection or may be due to sequestration of PPD reactive T-lymphocytes in the pleural space or patient may be anergic. Our study is insufficient to comment this negative result. More precise study need to comment.

Diagnostic value of polymerase chain reaction/acid-fast bacilli in conjunction with computed tomography-guided pleural biopsy in tuberculous pleurisy: A diagnostic accuracy study.

Patients with tuberculous pleurisy often remain undiagnosed even after blind thoracentesis and closed pleural biopsy (PB). In this study, we assessed the value of computed tomography (CT)-guided core needle biopsy of pleural lesion and evaluated the diagnostic accuracy of polymerase chain reaction (PCR)/staining for acid-fast bacilli (AFB) in suspicious tuberculous pleurisy undiagnosed in blind thoracentesis.Patients with exudative pleural effusion (PE) without specific etiology after blind thoracentesis and closed PB were enrolled in this study. PB specimens were obtained through CT-guided core needle biopsy of pleural lesion, then underwent PCR, AFB, histopathological examination, and some routine tests. Diagnostic values were evaluated through sensitivity, specificity, negative predictive value, positive predictive value, and accuracy.A total of 261 participants (TB group: 241, non-TB group: 20) were recruited. In this cohort, the sensitivity, specificity, and accuracy were 56.0%, 95.0%, and 59.0%, respectively for PCR, whereas 57.3%, 95.0%, and 60.2%, respectively for AFB. Their parallel test achieved an improved sensitivity (76.8%) and accuracy (77.8%), with a slight decrease in specificity (90.0%). In histopathological examination, granuloma was the most common finding in TB group (88.4%, 213/241), but also observed in non-TB group (10.0%, 2/20). In addition, pleural lymphocyte percentage in TB group was significantly higher than that of non-TB group (92% vs 61%, respectively; P = .003). However, no significant differences were found for other biomarkers.CT-guided core needle PB is essential for patients with exudative PE but undiagnosed after blind thoracentesis. Combining with PCR and AFB, it strongly improves the diagnosis of tuberculous pleurisy.

Pleural effusion related to IgG4.

Purpose of reviewThe causes of exudative pleural effusions are diverse and frequently remain unclear despite exhaustive examinations. Recently recognized IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder that can affect nearly any organ including the lungs. This review will focus on the involvement of IgG4 in exudative pleural effusion of unknown cause.Recent findingsIgG4 is found to be involved in a proportion of patients with undiagnosed pleural effusions. Pleural involvement in IgG4-RD can be seen in isolation or association with other organ disease. Pleural thickening and/or effusion are common clinical features of IgG4-related pleural lesions, and this condition is histologically characterized by a lymphoplasmacytic infiltrate enriched in IgG4-positive plasma cells in the pleura. Although the pathogenesis of IgG4-RD is poorly understood, there is a growing body of evidence that indicates an antigen-driven process requiring T-cell and B-cell interaction in which autoantibodies, plasmablasts, follicular helper T cells and CD4+ cytotoxic T lymphocytes participate.SummaryThe possibility of IgG4-related pleural lesion should be considered in patients with pleural effusion of unexplained cause when lymphoplasmacytic infiltration is seen in a pleural biopsy specimen. This condition is responsive to systemic steroid therapy.

Medical thoracoscopy for tuberculous pleurisy: A retrospective analysis of 575 cases.

OBJECTIVE:The objective of this retrospective study was to assess the efficacy of medical thoracoscopy in diagnosing of tuberculous pleurisy and characterize tuberculous pleurisy with medical thoracoscopy.METHODS:A total of 575 patients with tuberculous pleurisy who underwent medical thoracoscopy were included in the study. Demographic data, clinical manifestations, and routine and biochemical tests on pleural fluid, cultures of pleural fluid, sputum, and pleural biopsy for the detection of Mycobacterium tuberculosis and pathological findings were evaluated.RESULTS:Sputum, pleural fluid, and pleural biopsy cultures were positive for M. tuberculosis in 12.5%, 19.2%, and 41.9% of patients, respectively. Furthermore, there were significant differences in total positive tuberculosis (TB) tests in the pleural cavity according to patient's age (<18 years old, 50.0%; 18–34 years old, 50.2%; 35–59 years old, 34.8%; >60 years old, 18.6%; and all groups vs. >60 years old, P < 0.001). Patients with 18–34 years old were more likely to have granuloma in pleural biopsy specimens when compared to patients >60 years old (77.0% vs. 37.9%). The percentage of patients with high adenosine deaminase (ADA) levels in pleural fluid (>40 U/L), who were <18, 18–34, 35–59, and > 60 years old, was 83.3% (15/18), 72.8% (193/265), 51.2% (88/172), and 34.7% (17/49), respectively (all groups vs. >60 years old, P < 0.001).CONCLUSION:Medical thoracoscopy is effective for diagnosing tuberculous pleurisy. Younger patients with tuberculous pleurisy have a higher number of positive TB tests in the pleural cavity, are more likely to have granuloma in pleural biopsy specimens, and have higher ADA levels in the pleural fluid.

Tuberkulozni pleuralni izliv kod prethodno zdravog pacijenta - prikaz slučaja i pregled literature

Introduction: Although pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of the pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. Case report: We present a previously healthy man who had no contagious or TB contact but developed massive tuberculous pleural effusion which eventually was unexpected tuberculous. He started with therapy per protocol and feeling well. The purpose of this case and review of literature was to remind the physicians that tuberculosis is not a sickening illness, but on the contrary, it is in the expansion. Discussion: When a patient presents with new pleural effusion, the diagnosis of tuberculous pleuritis should be considered. The patient is at great risk for developing pulmonary or extra pulmonary TB if the diagnosis is not made properly. Between 3% and 25% of patients with TB will have TB pleuritic or more in immunocompromised patients. The treatment for TB pleuritis is the same as that for pulmonary TB. Conclusion: The gold standard for the diagnosis of tuberculous pleural effusion 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.

Histopathological diagnoses on pleural biopsy specimens over a 15-year period at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa: A retrospective review.

Pleural effusions are a common reason for presentation to healthcare facilities. Blind closed pleural biopsy can be a useful tool to diagnose their cause, especially in resource-limited settings. To determine the aetiology, frequency and change in profile of histopathological diagnoses made at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, South Africa, over the period 1 January 2001 - 31 December 2015. Pleural biopsies performed at CHBAH and analysed by histopathologists from the National Health Laboratory Service at the hospital over the study period were retrospectively reviewed by accessing reports from two databases (DISA and TrakCare). The subjects' ages, genders, HIV status and histopathological diagnoses as well as adenosine deaminase and Ziehl-Neelsen results were recorded. A total of 1 013 samples were included in the study, with 780 considered adequate for assessment. The most common diagnosis was granulomatous inflammation (48.1%, n=375), with the most common type being necrotising granulomatous inflammation (73.6%, n=276). Ten percent of biopsies (n=78) showed malignancy, most commonly adenocarcinoma, with 46.2% (n=36) metastatic and 23.1% (n=18) primary lung adenocarcinoma. The odds of being diagnosed with malignancy showed increasing statistical significance above the age of 40 years: 40 - 49 years odds ratio (OR) 8.7, 95% confidence interval (CI) 1.1 - 66.9 (p=0.038); 50 - 59 years OR 12.4, 95% CI 1.6 - 95.0 (p=0.015); ≥60 years OR 23.0, 95% CI 3.1 - 171.3 (p=0.002). HIV seropositivity was associated with lower odds of being diagnosed with malignancy compared with HIV-negative patients (OR 0.5, 95% CI 0.2 - 0.9; p=0.040), with greater odds of a 'non-cancer' diagnosis in HIV-positive patients (including granulomatous inflammation and pleuritis (OR 2.16, 95% CI 1.03 - 4.51; p=0.040)). Blind closed pleural biopsy has a role to play in the diagnosis of exudative pleural effusions in resource-limited settings, particularly for patients suspected to have tuberculosis (TB) or malignancy. TB remains a common cause of exudative pleural effusions. Patients aged &gt;40 years presenting with an exudative pleural effusion should routinely have pleural biopsy performed. However, this study showed a high frequency of inadequate specimens from closed pleural biopsy. Training in the performance of this procedure to increase diagnostic rates is recommended.

Histomorphological and Immunohistochemical Analysis of Pleural Neoplasms

Primary pleural neoplasms are rare entities compared with the pleural involvement by metastatic carcinoma.The current study aimed at investigating the complete spectrum of pleural neoplasms and differentiating between them with the aid of immunohistochemistry (IHC). Consecutive pleural biopsy specimens positive for a neoplasm, both primary and metastatic, were included in the study. Diagnosis or a differential diagnosis was suggested on histopathology confirmed by a panel of IHC markers such ascytokeratin(AE1/AE3), epithelial membrane antigen (EMA),vimentin, calretinin, CD34, CD99, SMA,bcl2, S100, CK7,CK20,TTF1,GCDFP, HMB45, LCA, synapto-physin, chromogranin, and naspsin. A total of 35 cases of pleural neoplasms included 15 (42.9%) primary pleural neoplasms and 20 (57.1%) metastatic carcinoma. Synovial sarcoma, malignant mesothelioma (MM), and solitary fibrous tumor (SFT) accounted for 14.2%,11.4%, and 8.5% of metastatic cases, respectively. Epithelioid sarcoma(ES), neuroendocrine carcinoma, and inflammatory myofibroblastic tumor were less common, each contributing to 2.9% of pleural neoplasms. Among the 20 cases of metastatic carcinoma, 13 were from the lung and 7 from the breast. Lung neoplasms metastasizing to the pleura were adenocarcinoma (n=12) and atypical carcinoid (n=1). Analysis of histopathological pattern along with a panel of appropriate IHC markers distinguished the rare entities of pleural neoplasms essential to determine the prognosis and treatment modality.

Development of a clinical prediction rule for the diagnosis of pleural tuberculosis in Peru

ObjectivesTo develop a clinical prediction rule (CPR) for the diagnosis of pleural tuberculosis (PT) in patients with pleural exudates in Peru. MethodsClinical and laboratory information was collected from patients with exudative pleural effusion attending two reference hospitals in Lima, Peru. Predictive findings associated with PT in a multiple logistic regression model were used to develop the CPR. A definite diagnosis of PT was based on a composite reference standard including bacteriological and/or histological analysis of pleural fluid and pleural biopsy specimens. ResultsA total of 238 patients were included in the analysis, of whom 176 had PT. Age, sex, previous contact with a TB patient, presence of lymphadenopathy, and pleural adenosine deaminase (ADA) levels were found to be independently associated with PT. These predictive findings were used to construct a CPR, for which the area under the receiver operating characteristics curve (AUC) was 0.92. The single best cut-off point was a score of ≥60 points, which had a sensitivity of 88%, specificity of 92%, a positive likelihood ratio of 10.9, and a negative likelihood ratio of 0.13. ConclusionsThe CPR is accurate for the diagnosis of PT and could be useful for treatment initiation while avoiding pleural biopsy. A prospective evaluation is needed before its implementation in different settings.

Diagnostic Utility of Sago-Like Nodules on Gross Thoracoscopic Appearance in Tuberculous Pleural Effusion and Their Correlation with Final Histo-Microbiologic Findings

Background: Distinguishing tuberculous pleural effusion (TPE) from other causes of exudative effusion is often challenging. Delay in treatment initiation can occur while awaiting histo-microbiologic confirmation owing to the paucibacillary nature of the disease. Sago-like nodules are the most common visual finding on gross thoracoscopic appearance. The primary objective was to determine the diagnostic utility of the presence of sago-like nodules on gross thoracoscopic appearance in TPE to help justify early initiation of tuberculosis (TB) treatment based on their finding while awaiting final histo-microbiologic confirmation. Secondary objective was to study the correlation between the presence of sago-like nodules and the final histo-microbiologic findings in pleural biopsy specimens. Methods: This was a retrospective-descriptive study of all patients with exudative pleural effusion who underwent diagnostic medical thoracoscopy (MT) at Hamad General Hospital during an eight-year period (from January, 2008 to December, 2015). Results: The presence of sago-like nodules on gross thoracoscopic appearance of the pleural surface had a sensitivity of 58%, a specificity of 89% and a positive predictive value of 97% for TPE with a diagnostic accuracy of 62%. There is significant association between the presence of sago-like nodules and demonstration of granulomatous inflammation in pleural biopsy specimens (P = 0.000). There is no association between sago-like nodules and positive TB smear and culture in biopsy specimens. Conclusion: The presence of sago-like nodules on gross thoracoscopic appearance has a high specificity and positive predictive value for TPE and significantly correlates with the presence of granulomatous inflammation. Patients from TB prevalent areas with exudative pleural effusion and sago-like nodules on gross thoracoscopic appearance may be commenced on TB chemotherapy while awaiting final histologic confirmation.