Pleural TB Research Articles

Pleural TB Presenting as Acute Respiratory Distress in an HIV-Infected Patient

SESSION TITLE: Fungal Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Presented is an atypical case of pleural tuberculosis presenting as acute respiratory distress in an HIV-infected patient. CASE PRESENTATION: A 27 year-old African American male with known HIV presented with 2 days of fever, cough, pleuritic chest pain and worsening dyspnea. On exam, temperature 38.9°C, respiratory rate 30 and SpO2 85% room air which improved to 93% on 7L supplemental oxygen. Chest x-ray (CXR) revealed a large left pleural effusion [Figure 1]. Of note, a CXR 1 week prior was normal. Chest computed tomography was negative for intraparenchymal or cavitary findings. Sputum AFB were negative x3 and quantiFERON was negative. He underwent thoracentesis with removal of 2,300 mL with lymphocyte predominance and elevated total protein 5.1 g/dL. Pleural fluid adenosine deaminase was normal 8.7 U/L. Despite initial improvement symptoms worsened. Repeat CXR demonstrated reaccumulated large pleural effusion and worsening hypoxia. He underwent video-assisted thoroscopic surgery with pleural and lung biopsies. Histology revealed caseating granulomas [Figure 2] consistent with pleural tuberculosis and he was started on appropriate therapy. At the time of submission, mycobacterium cultures had not resulted. DISCUSSION: Incidence of pleural involvement in HIV-infected patients with tuberculosis is estimated at 11% and remains the second most common site of extrapulmonary tuberculosis. Most common symptoms include subacute onset fever, cough and pleuritic chest pain; less commonly dyspnea. The case presented is unique given the rapid onset, reaccumulation and large size of pleural effusion and severity of hypoxic respiratory distress. Pleural biopsy with histologic examination remains the most sensitive test for pleural tuberculosis (estimated 95% sensitivity) and histologic finding of caseating granuloma is virtually diagnostic of pleural disease. CONCLUSIONS: Extrapulmonary tuberculosis is more common in HIV-infected patients. Reference #1: Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017; 64(2):e1-e33. Reference #2: Xuwel G, Heping X. Diagnosis of tuberculosis pleurisy with adenosine deaminase (ADA): a systematic review and meta-analysis. Int J Clin Exp Med. 2014; 7(10):3126-3135. Reference #3: Gopi A, Madhavan S, Sharma S, et al. Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest. 2007; 131(3):880-9. DISCLOSURE: The following authors have nothing to disclose: Craig Schuring, Anthony Mattox, Matt Rudd, Julio Lanfranco No Product/Research Disclosure Information

Diagnostic Potential of Circulating Biomarkers in Adenosine Deaminase Diagnosed Pleural Tuberculosis Cases.

Pleural tuberculosis accounts for nearly 20% of Extra pulmonary tuberculosis. Adenosine deaminase, commonly used biomarker for the diagnosis, is non specific and there is paucity of literature on its correlation with conventional or newer methods for the diagnosis of extra pulmonary forms of TB. The aim of the study was to assess diagnostic potential of T cell function markers [interferon (IFN-γ), interleukin (IL-2) and IFN-γ/IL-2 ratio]; macrophage activation marker [neopterin]; and oxidative stress markers [protein carbonyl and malondialdehyde (MDA)] in pleural tuberculosis. 26 pleural TB cases diagnosed on the basis of suggestive chest X-ray and raised serum ADA levels and healthy controls were included in the study. Pleural fluid specimens were subjected to Zeihl Neelsen staining and culture on Lowenstein Jensen medium. Serum IFN-γ, IL-2, neopterin and protein carbonyl levels detection were done by ELISA and MDA levels were determined by measuring the thiobarbituric acid reactive substances. Median serum levels of IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly different between cases and controls. Levels of all biomarkers except IL-2 were significantly higher in cases with contact history. Mean levels of ADA and ESR were 46.27U/L and 46.62mm/hr in PTB cases. AUC for IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly discriminative for cases and controls. IFN-γ/IL-2 ratio was best discriminatory biomarker with highest area under ROC curve. Though no correlation was seen between ADA and any of the six biomarkers, ESR levels correlated significantly with all biomarkers except IL-2 by spearman's correlation coefficient. Though all the circulating biomarkers under study provide useful supportive evidence for the diagnosis of PTB, further studies involving diverse control groups particularly non-PTB effusion are needed to validate these results.

Seasonality of active tuberculosis notification from 2005 to 2014 in Xinjiang, China.

ObjectivesXinjiang is one of the highest TB-burdened provinces of China. A time-series analysis was conducted to evaluate the trend, seasonality of active TB in Xinjiang, and explore the underlying mechanism of TB seasonality by comparing the seasonal variations of different subgroups.MethodsMonthly active TB cases from 2005 to 2014 in Xinjiang were analyzed by the X-12-ARIMA seasonal adjustment program. Seasonal amplitude (SA) was calculated and compared within the subgroups.ResultsA total of 277,300 confirmed active TB cases were notified from 2005 to 2014 in Xinjiang, China, with a monthly average of 2311±577. The seasonality of active TB notification was peaked in March and troughed in October, with a decreasing SA trend. The annual 77.31% SA indicated an annual mean of additional TB cases diagnosed in March as compared to October. The 0–14-year-old group had significantly higher SA than 15–44-year-old group (P<0.05). Students had the highest SA, followed by herder and migrant workers (P<0.05). The pleural TB cases had significantly higher SA than the pulmonary cases (P <0.05). Significant associations were not observed between SA and sex, ethnic group, regions, the result of sputum smear microcopy, and treatment history (P>0.05).ConclusionTB notification in Xinjiang shows an apparent seasonal variation with a peak in March and trough in October. For the underlying mechanism of TB seasonality, our results hypothesize that winter indoor crowding increases the risk of TB transmission, and seasonality was mainly influenced by the recent exogenous infection rather than the endogenous reactivation.

Corticosteroids for tuberculous pleurisy.

BackgroundCorticosteroids used in addition to antituberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are inconsistent and raise doubt as to whether such treatment is worthwhile. There is also concern regarding the potential adverse effects of corticosteroids, especially in HIV‐positive people.ObjectivesTo evaluate the effects of adding corticosteroids to drug regimens for tuberculous pleural effusion.Search methodsIn April 2016, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, LILACS, Current Controlled Trials, and the reference lists of articles identified by the literature search.Selection criteriaRandomized controlled trials (RCTs) and quasi‐RCTs that compared any corticosteroid with no treatment, placebo, or other active treatment (both groups should have received the same antituberculous drug regimen) in people diagnosed with tuberculous pleurisy.Data collection and analysisTwo review authors independently screened the search results, extracted data from the included trials, and assessed trial methodological quality using the Cochrane 'Risk of bias' tool. We analysed the data using risk ratios (RR) with 95% confidence intervals (CIs). We applied the fixed‐effect model in the absence of statistically significant heterogeneity.Main resultsSix trials with 590 participants met the inclusion criteria, which were conducted in Asia (three trials), Africa (two trials), and Europe (one trial). Two trials were in HIV‐negative people, one trial was in HIV‐positive people, and three trials did not report HIV status.Corticosteroids may reduce the time to resolution of pleural effusion. Risk of residual pleural effusion on chest X‐ray was reduced by 45% at eight weeks (RR 0.54, 95% CI 0.37 to 0.78; 237 participants, 2 trials, low certainty evidence), and 65% at 24 weeks (RR 0.35, 95% CI 0.18 to 0.66; 237 participants, 2 trials, low certainty evidence).Compared with control, corticosteroids may reduce the risk of having pleural changes (such as pleural thickening or pleural adhesions), on chest X‐ray at the end of follow‐up by almost one third (RR 0.72, 95% CI 0.57 to 0.92; 393 participants, 5 trials,low certainty evidence), which translates to an absolute risk reduction of 16%.One trial reported deaths in people that were HIV‐positive, with no obvious difference between the groups; the trial authors' analysis suggests that the deaths observed in this trial were related to HIV disease rather than pleural TB (RR 0.91, 95% CI 0.64 to 1.31; 197 participants, 1 trial).We found limited data on long‐term functional respiratory impairment on 187 people in two trials, which reported that average percentage predicted forced vital capacity was similar in the group receiving prednisolone and in the control group (very low certainty evidence).The risk of adverse events that led to discontinuation of the trial drug was higher in people with pleural TB receiving corticosteroids (RR 2.78, 95% CI 1.11 to 6.94; 587 participants, 6 trials, low certainty evidence). The trial in HIV‐positive people reported on six different HIV‐related infections, with no obvious differences. However, cases of Kaposi's sarcoma were only seen in the corticosteroid group (with 6/99 cases in the steroid group compared to 0/98 in the control group) (very low certainty evidence).Authors' conclusionsLong‐term respiratory function is potentially the most important outcome for assessing the effects of adjunctive treatments for people with pleural TB. However, the information on the impact of pleural TB on long‐term respiratory function is unknown and could be eclipsed by other risk factors, such as concurrent pulmonary TB, smoking, and HIV. This probably needs to be quantified to help decide whether further trials of corticosteroids for pleural TB would be worthwhile.11 April 2019Up to dateAll studies incorporated from most recent searchAll eligible published studies found in the last search (18 Nov, 2016) were included and two ongoing studies have been identified (see 'Characteristics of ongoing studies' section)

Radiological patterns of childhood thoracic tuberculosis in a developed country: a single institution's experience on 217/255 cases.

The incidence of tuberculosis is increasing in the developed world and children in particular represent a high-risk group for developing the disease. The aim of this review is to analyse the spectrum of radiological signs as reported in the recent literature, in light of our series over a 15-year period, to pinpoint the most common radiological patterns in a developed country and to determine the role played by the different chest imaging techniques in diagnosis improvement. Lung TB was present in 217 out of 255 patients (85%): 146 patients were under 5years of age (76 under 2years) and 71 over 5years (41 over 10years). We describe different patterns differentiating adolescents and young adults from infants and children. Adolescents and young adult tuberculosis are apical and cavitary. Thoracic TB in infants and children is characterized by lymph node and parenchymal disease. In 21 cases with lymphadenopathies without lymph-bronchial diffusion (age range 2months-7years), CT identified the Ghon focus in 16/21 cases; chest X-ray never identified the Ghon focus. In our series, pleural TB was present in 8 cases out of 146 under 5years of age, 5 cases out of 76 under 2years, and 18 cases out of 71 over 5years. Radiologists should be aware of typical patterns of tuberculosis, to provide an early diagnosis.

A Systematic Review of the Prevalence and Pattern of Imaging Defined Post-TB Lung Disease.

BackgroundTuberculosis is an important risk factor for chronic respiratory disease in resource poor settings. The persistence of abnormal spirometry and symptoms after treatment are well described, but the structural abnormalities underlying these changes remain poorly defined, limiting our ability to phenotype post-TB lung disease in to meaningful categories for clinical management, prognostication, and ongoing research. The relationship between post-TB lung damage and patient-centred outcomes including functional impairment, respiratory symptoms, and health related quality of life also remains unclear.MethodsWe performed a systematic literature review to determine the prevalence and pattern of imaging-defined lung pathology in adults after medical treatment for pleural, miliary, or pulmonary TB disease. Data were collected on study characteristics, and the modality, timing, and findings of thoracic imaging. The proportion of studies relating imaging findings to spirometry results and patient morbidity was recorded. Study quality was assessed using a modified Newcastle-Ottowa score. (Prospero Registration number CRD42015027958)ResultsWe identified 37 eligible studies. The principle features seen on CXR were cavitation (8.3–83.7%), bronchiectasis (4.3–11.2%), and fibrosis (25.0–70.4%), but prevalence was highly variable. CT imaging identified a wider range of residual abnormalities than CXR, including nodules (25.0–55.8%), consolidation (3.7–19.2%), and emphysema (15.0–45.0%). The prevalence of cavitation was generally lower (7.4–34.6%) and bronchiectasis higher (35.0–86.0%) on CT vs. CXR imaging. A paucity of prospective data, and data from HIV-infected adults and sub-Saharan Africa (sSA) was noted. Few studies related structural damage to physiological impairment, respiratory symptoms, or patient morbidity.ConclusionsPost-TB structural lung pathology is common. Prospective data are required to determine the evolution of this lung damage and its associated morbidity over time. Further data are required from HIV-infected groups and those living in sSA.

Tuberculous pleural effusion – relapse or re-infection? Follow up of a case report and review of the literature

IntroductionThis is a case report of pleural effusion with acute drug reactions to anti-tubercular drugs. Case presentationA 45year old female patient had the typical signs and symptoms of tuberculosis with continuous coughing, breathlessness and protruded abdomen. The USG abdomen showed fluid in the left pleural space. Thoracocentesis was carried out thrice at an interval of 15days and about 5.15L were aspirated. The symptoms of dyspnea and cough were relieved. There was acute drug reaction after starting the ATT. The blood pressure was very high requiring hospital admission. The patient was monitored during the entire course of treatment. No fluid in the bilateral pleural spaces was observed in USG after 6months of treatment.This patient had spinal tuberculosis 8years ago and had recovered following ATT. Therefore, it is difficult to say whether pleural effusion was due to relapse of a previous infection or a re-infection. It is also not known whether TB patients remain susceptible to yet another infection in some other extra-pulmonary site. ConclusionAbdominal TB should be suspected in patients with fever, abdominal pain and ascites. Sputum induction (in addition to pleural fluid) for acid-fast bacilli and culture is a recommended procedure in all patients with TB pleurisy.This condition carries good prognosis, if promptly diagnosed and treated. A reasonable management strategy for pleural TB would be to initiate a four-drug regimen and perform a therapeutic thoracocentesis in patients with large, symptomatic effusions. Prolonged follow-up is essential in cases of pleural effusion, as in the presented case.

Factors associated with mortality in extrapulmonary tuberculosis patients at a teaching hospital in Ghana

Objectives : To investigate the clinical manifestations and factors associated with mortality in patients with extrapulmonary tuberculosis (EPTB) at the Korle-Bu Teaching Hospital Chest Clinic in Accra, Ghana. Design : We conducted a retrospective chart review of patients treated for EPTB at the Chest Clinic between January 1, 2009 and December 31, 2011. Patients with a new diagnosis of EPTB without concomitant pulmonary disease, aged 18 years or older, and who were treated at the Chest Clinic were eligible for participation in the study. Relevant data were abstracted from medical records and entered into a database. The factors associated with mortality were examined using bivariate and multivariate analysis. Results : Of the 157 patients in the study, the most affected age group was 25-34 years old (33.1%), 57.3% were male, and 71 (55.5%) of the 128 patients tested for HIV were sero-positive. Overall, 62 (39.5%) died during EPTB treatment. Mortality was associated with disseminated TB (AOR 149.85; P < 0.001), TB meningitis (AOR 79.14; P < 0.001), abdominal TB (AOR 23.59; P = 0.011), pleural effusion (AOR 12.6; P = 0.021) and age (AOR 1.05; P = 0.021). Among HIV co-infected patients, early initiation of ART reduced mortality rate. Conclusions : The site of EPTB was a key determinant of mortality. Given that death occurs soon after diagnosis, patients with suspected TB meningitis, disseminated, abdominal and pleural TB should be targeted for early diagnosis and treatment to reduce the high EPTB mortality in our setting. Key words: Extrapulmonary TB, HIV coinfection, Treatment outcomes, Mortality, Adults, Ghana

Safety and Complications of Medical Thoracoscopy.

Objectives. To highlight the possible complications of medical thoracoscopy (MT) and how to avoid them. Methods. A retrospective and prospective analysis of 127 patients undergoing MT in Nagoya Medical Center (NMC) and Toyota Kosei Hospital. The data about complications was obtained from the patients, notes on the computer system, and radiographs. Results. The median age was 71.0 (range, 33.0–92.0) years and 101 (79.5%) were males. The median time with chest drain after procedure was 7.0 (range, 0.0–47.0) days and cases with talc poudrage were 30 (23.6%). Malignant histology was reported in 69 (54.3%), including primary lung cancer in 35 (27.5), mesothelioma in 18 (14.2), and metastasis in 16 (12.6). 58 (45.7%) revealed benign pleural diseases and TB was diagnosed in 15 (11.8%). 21 (16.5%) patients suffered from complications including lung laceration in 3 (2.4%), fever in 5 (3.9%) (due to hospital acquired infection (HAI) in 2, talc poudrage in 2, and malignancy in 1), HAI in 2 (1.6%), prolonged air-leak in 14 (11.0%), and subcutaneous emphysema in 1 (0.8%). Conclusions. MT is generally a safe procedure. Lung laceration is the most serious complication and should be managed well. HAI is of low risk and can be controlled by medical treatment.

Extrapulmonary TB in North Eastern Nigeria: A 10-Year Retrospective Review

Background: Information on extrapulmonary TB is scarce in Nigeria despite being one of the 22 countries with highest burden of tuberculosis in the world and the most populous country in sub-Saharan Africa where the dual epidemics of TB and HIV/AIDS mutually co-exist. Objective: The purpose of this study was to document the burden of extrapulmonary TB in North-eastern Nigeria. Methodology: A retrospective cross-sectional study was conducted at a DOTS treatment centre in a tertiary hospital in North-eastern Nigeria. TB treatment registers and case records of 1240 patients were reviewed over a 10-year period. Results: Out of the 1240 TB cases who received treatment at the facility; 179 (14.4%) had extra-pulmonary TB. Skeletal TB and TB lymphadenitis were the predominant forms of extra-pulmonary TB in the study i.e. 51 (28.5%) and 50 (28.0%), respectively. This was closely followed by abdominal TB (38 (21.2%), tuberculous pleural effusion (23 (12.8%), miliary TB (9 (5.0%), TB meningitis (3 (1.7%) and others (5 (2.8%): viz; 1 (0.6%) each of- TB of the breast, TB of the skin, adrenal TB, genitourinary TB and TB pericarditis respectively. Only 101 (56.4%) of the study subjects had information on their HIV status; of whom 52 (51.5%) were HIV positive and 49 (48.5%) HIV negative. Conclusion: The study has shown that extrapulmonary TB was relatively common among TB patients receiving care at the facility despite its diagnostic challenges particularly in a resource poor setting like ours.

Medical thoracoscopic versus ultrasound guided transthoracic pleural needle biopsy in diagnosis of pleural lesions

BackgroundMedical thoracoscopy increases the diagnostic yield in patients with undiagnosed pleural effusion. Ultrasound guided pleural biopsies are safe procedures with high diagnostic yields. ObjectiveTo compare safety and efficacy of medical thoracoscopic versus ultrasound guided transthoracic needle biopsy in the diagnosis of pleural lesions. Patients and methods40 patients with undiagnosed pleural lesions were divided into 2 groups. After clinical, radiological examination and laboratory investigations; pleural biopsies were taken by ultrasound guided needle biopsy and medical thoracoscopy in group I and II respectively. ResultsComplications in group I were in the form of pain in 2 patients (10%), hemoptysis in 1 (5%), while complications in group II were pain in 4 (20%), failure of the lung to expand in 5 (25%), pneumothorax in 5 (25%) and wound infection in 3 patients (15%).Final histopathological diagnosis in group I was parapneumonic effusion in 3 patients (15%), inflammatory lung lesion in 1 (5%), pleural fibroma in 2 (10%), malignant mesothelioma in 4 (20%), sarcoma in 1 (5%), adenocarcinoma in 1 (5%), squamous cell carcinoma in 4 (20%), and metastatic adenocarcinoma in 1 (5%). Final histopathological diagnosis in group II was pleural TB in 4 patients (20%), inflammatory lung lesions in 2 (10%), malignant mesothelioma in 6 (30%), adenocarcinoma in 5 (25%), and metastatic adenocarcinoma in 2 (10%). The diagnosed cases were 17 (85%) and 19 (95%) in groups I and II respectively. ConclusionsMedical thoracoscopy is an important diagnostic method for the diagnosis of undiagnosed pleural effusion while it is concluded that US guided pleural biopsy is more useful in cases of pleural lesions without effusion.

The comparative value of pleural fluid adenosine deaminase and neopterin levels in diagnostic utility of pleural tuberculosis.

The aim of the present study was to evaluate and compare the diagnostic accuracy of pleura levels of adenosine deaminase (ADA) and neopterin for the differential diagnosis of pleural tuberculosis (TP). The study included 50 patients with TB, 27 patients with malignancies, and 24 patients with pleural effusion of non-tuberculous and non-malignant origin as controls. ADA and neopterin levels in pleural fluid were measured by spectrofotometric and ELISA method, respectively. Pleural neopterin levels were significantly higher in patients with pleural TB than patients with malignancy (p< 0.001). Pleural ADA levels were significantly higher in patients with pleural TB than patients with malignancy (p< 0.001) and patients with benign non-tuberculosis effusions (p< 0.001). The mean levels of ADA and neopterin in pleural effusion were evaluated according to their underlying diseases for the diagnostic accuracy. As for pleural TB receiving operating characteristic curves identified the following results; The best cut-off value for pleural neopterin was 4.7 U/L and yielded a sensitivity and specificity of 86% and 72.55%, respectively. Taking a cut-off value of 42 U/L for pleural ADA, the sensitivity and the specificity were found to be 88% and 68.63%, respectively. In the diagnosis of pleural TB pleural neopterin level has a comparable sensitivity to pleural ADA activity. Both markers may find a place as a routine investigation in the coming days for early detection of TB. However, these tests should not be considered an alternative to biopsy and culture.

Modified TB rapid test by proteinase K for rapid diagnosis of pleural tuberculosis.

The diagnosis of pleural tuberculosis continues to be a challenge due to the low sensitivity of traditional diagnostic methods. Better and more rapid tests are needed for diagnosis of pleural TB. In this study, pleural fluids were tested with rapid test to determine Mycobacterium tuberculosis (MTB antigen). Affinity chromatography was used to purify specific polyclonal antibodies against MTB antigen. Pleural samples after decontamination were treated with proteinase K. Rapid test for pleural fluids was prepared by specific antibody. Rapid test was performed on 85 pleural fluid patients. The patients had a mean age of 46.55 ± 15.96 years and 38 were men. The performance of rapid test, using proteinase K, was found to be the most impressive: sensitivity 93%, specificity 94%, PPV 90%, and NPV 96% compared with adenosine deaminase test (ADA), PCR, smear, and culture. The present study did demonstrate that modified TB rapid test can substantially improve the diagnosis of extrapulmonary TB.

Use of lateral flow assays to determine IP-10 and CCL4 levels in pleural effusions and whole blood for TB diagnosis

One of the key problems in combating TB is the lack of fast and accurate diagnostic tests that are affordable and easy to use in resource-limited settings. We have used a field-friendly up-converting phosphor (UCP) reporter technology in a lateral flow (LF) based test for the diagnosis of respiratory infections. In this study we analysed samples obtained from patients presenting with symptoms suggestive of TB but prior to confirmation by microbiology in The Gambia. Following clinical and microbiological evaluation they were classified as either having TB or other respiratory disorder (ORD). Analysis of blood was performed for those with pulmonary TB and pleural fluid for those with pleural TB. UCP-LF test for detection and quantitation of IP-10 and CCL4 were used being the two chemokine markers that have been shown to increase in active TB disease. UCP-LF test accurately determined concentrations of both markers as compared to ELISA and multiplex cytokine array. However, only IP-10 could discriminate between TB and ORD, and this was significantly enhanced by analysing the site of infection (pleural fluid), which showed 92% correct classification. Future work will assess the use of multiple markers to increase diagnostic accuracy.

Pleural effusions in children from Southern Brazil

Parapneumonic pleural effusions (PPE) are a relatively common (5-40%) complication of paediatric pneumonia. However, in clinical practice the majority of the effusions are small and do not need any further investigation or specific treatment apart from antibiotic therapy. A small number require drainage or surgical intervention. Rarely, significant effusions are associated with non-bacterial pneumonia in the paediatric population. Pleural tuberculosis in our hospital is the second highest cause of pleural effusions related to the high incidence of TB in our city. In the last 3 years we have had around 50 cases of pleural TB in children.

Epidemiological Survey of Extrapulmonary Tuberculosis in Baghmalek City of Khuzestan Province in Iran (2007-2011)

Results: Among 145 patients with TB, 67 patients (12.25%) were diagnosed with extrapulmonary TB including 39 males and 28 females with the age range of 15 to 64 years. Most common organ involved in the extrapulmonary TB was the lymph nodes (29%) followed by TB meningitis (17%), urinary tract TB (17% each), bone TB (13%), and pleural TB (13% each). Conclusions: The findings suggest that the prevalence of extrapulmonary TB was significant. Therefore, it is necessary to perform tests for extrapulmonary TB besides tests for TB.

Evaluation of adenosine deaminase (ADA) and ADA1 and ADA2 isoenzyme activities in patients with pulmonary tuberculosis and tuberculous pleurisy

ObjectivesTuberculosis (TB) still remains an important medical problem due to high levels of morbidity and mortality worldwide. Tuberculous pleurisy is the most common form of extrapulmonary TB. Since tuberculous pleural effusion usually contains a low number of mycobacteria, the diagnostic sensitivity of both direct microscopy and pleural fluid cultures is relatively low.Adenosine deaminase (ADA) is an essential enzyme in the metabolism of purine nucleosides. For an adequate interpretation of ADA, it is important to highlight the fact that ADA is represented by two isoenzymes: ADA1 and ADA2. The ADA1 isoenzymes are found in all cells, with the highest activity in lymphocytes, whereas ADA2 isoenzymes appear to be found only in antigen-presenting cells.The aim of this study is to evaluate the ADA and ADA1 and ADA2 isoenzyme activity in patients with pulmonary TB and tuberculous pleurisy. MethodsThis study included 25 patients with pleural effusions (11 with pleural TB and 14 with nontuberculous etiologies), 35 patients with pulmonary tuberculosis (PTB) and 42 healthy subjects.Total ADA activity level in pleural fluid and blood plasma was measured by the “ADA-test kit” developed in the Republican Scientific and Practical Center for Epidemiology & Microbiology (Minsk, Belarus). The principle “ADA-test” is a colorimetric method in which adenosine is deaminated by ADA and the free ammonia is estimated. Estimated ADA2 activity was calculated from the ADA and 2′-deoxyadenosine deaminase activities using the affinity of ADA2 for the two substrates. ResultsThe mean plasma ADA level in patients with PTB was 19.2±3.3U/L that was significantly higher than the control group (10.4±0.6U/L). The difference between patients with pleural TB and the controls is also significant (18.2±2.5U/L versus 10.4±0.6U/L, p<0.05). A significantly higher activity of ADA1 and ADA2 in the blood plasma was observed in patients with PTB and pleural TB than those of the corresponding controls (p<0.05).With diagnostic thresholds of 12.5 and 16U/L respectively, the sensitivities of plasma ADA for PTB and pleural TB were 54% and 64%; their specificities 68% and 78%; AUC – 0.67 and 0.73, respectively.The ADA level in the pleural fluid was significantly higher in patients with TB pleural effusion. It was found that the mean ADA level in the pleural fluid was 74.6±7.9U/L in cases of pleural TB, as compared with 21.9±4.3U/L in non-tuberculosis effusion (p<0.05). These results indicate that pleural fluid ADA1 and ADA2 levels were higher in patients with pleural TB as compared with non-tuberculosis effusion.An analysis of the ROC curve for pleural fluid ADA activity showed that at the most accurate cut-off level of 53.4U/L, the sensitivity of the test for tuberculous pleurisy was 91% and the specificity was 93%. ConclusionThis study concluded that pleural fluid ADA analysis could be an easy, cheap and highly sensitive and specific test for the diagnosis of pleural TB.

Pulmonary changes of pleural TB: Up-to-date CT imaging

Pulmonary changes of pleural TB: Up-to-date CT imaging

Pulmonary Changes of Pleural TB: Up-to-Date CT Imaging

BACKGROUND:The objective of this study was to evaluate pulmonary abnormalities of pleural TB by CT scanning and to determine CT scan findings for the development of the paradoxical response (PR).METHODS:CT scans were performed for 349 patients with pleural TB (between 2008 and 2013). We excluded 34 patients with coexisting pulmonary disease (n = 13) or a totally collapsed lung (n = 21). We analyzed CT scans focusing on pulmonary abnormalities such as the presence of consolidation, cavitation, interlobular septal thickening, and micronodules and their distribution. In addition, we recorded the development of PR during follow-up and statistically analyzed differences in clinical and CT scan findings between patients with and without PR.RESULTS:A total of 270 of 315 patients (86%) had pulmonary abnormalities. Common CT scan findings were micronodules (n = 209 [77%]), interlobular septal thickening (n = 202 [75%]), and consolidation (n = 120 [44%]). Cavitation was seen in 49 patients (18%). Among 209 with micronodules, the nodules were in the subpleural region (n = 146 [70%]), peribronchovascular interstitium (n = 113 [54%]), and centrilobular region (n = 64 [31%]). PR occurred in 81 patients (26%), and patients with PR tended to be young, male, and without underlying disease (P< .05 byttest, Pearson χ2test). Subpleural micronodules were more common in patients with PR than in those without PR (Pearson χ2,P= .025).CONCLUSIONS:Pulmonary abnormalities are very common in pleural TB. The most common CT scan findings were micronodules in the subpleural and peribronchovascular interstitium and interlobular septal thickening, suggesting the lymphatic spread of TB. In addition, PR is not rare in patients with pleural TB, especially in young, previously healthy, male patients who show subpleural nodules on initial CT scans.

Physician-Based Ultrasound-Guided Biopsy for Diagnosing Pleural Disease

Definitive diagnosis of pleural disease (particularly malignancy) depends upon histologic proof obtained via pleural biopsy or positive pleural fluid cytology. Image-guided sampling is now standard practice. Local anesthetic thoracoscopy has a high diagnostic yield for malignant and nonmalignant disease, but is not always possible in frail patients, if pleural fluid is heavily loculated, or where the lung is adherent to the chest wall. Such cases can be converted during the same procedure as attempted thoracoscopy to cutting-needle biopsy. This study aimed to determine the diagnostic yield of a physician-led service in both planned biopsies and cases of failed thoracoscopy. This study was a retrospective review of all ultrasound-guided, cutting-needle biopsies performed at the Oxford Centre for Respiratory Medicine between January 2010 and July 2013. Histologic results were assessed for the yield of pleural tissue, final diagnosis, and clinical follow-up in nonmalignant cases. Fifty ultrasound-guided biopsies were undertaken. Overall, 47 (94.0%) successfully obtained sufficient tissue for histologic diagnosis. Of the 50 biopsy procedures, 13 were conducted after failed thoracoscopy (5.2% of 252 attempted thoracoscopies over the same time period); of these 13, 11 (84.6%) obtained sufficient tissue. Thirteen of 50 biopsy specimens (26.0%) demonstrated pleural malignancy on histology (despite previous negative pleural fluid cytology), while 34 specimens (68.0%) were diagnosed as benign. Of the benign cases, 10 were pleural TB, two were sarcoidosis, and 22 were benign pleural thickening. There was one "false negative" of mesothelioma (median follow-up, 16 months). Within this population, physician-based, ultrasound-guided, cutting-needle pleural biopsy obtained pleural tissue successfully in a high proportion of cases, including those of failed thoracoscopy.