Treatment Of Tuberculous Pleural Effusion Research Articles

Urokinase in the treatment of tuberculous pleurisy: a systematic review and meta-analysis

ObjectiveTo evaluate the efficacy of urokinase (UK) treatment for tuberculous pleural effusion (TPE).MethodsWe searched Chinese biomedical literature database, WanFang data, CNKI, PubMed, EMbase, Web of Science and The Cochrane Library for the randomized controlled trials (RCTs) of urokinase treatment for tuberculous pleurisy from January 2000 to February 2023. Pleural tuberculosis, urokinase and randomized controlled trial were used as keywords. The eligible studies were meta-analyzed by using Revman 5.4.1: risk of bias was assessed, mean difference (MD) and 95% CI were used for continuous variables, pooled studies were conducted using random-effects or fixed-effects models, forest plots were drawn to analyze efficacy, and funnel plots were drawn to discuss publication bias.ResultsTwenty-nine RCTs were included. The meta-analyzed results showed that, on the basis of routine anti-tuberculosis, comparison between the treatment group treated with urokinase and the control group treated with antituberculosis alone, the time of pleural effusion absorption [MD-5.82, 95%CI (− 7.77, − 3.87); P<0.00001] and the residual pleural thickness [MD-1.31, 95%CI (− 1.70, − 0.91); P<0.00001], pleural effusion drainage volume [MD 822.81, 95%CI (666.46,977.96); P<0.00001], FVC%pred [MD 7.95, 95%CI (4.51,11.40); P<0.00001], FEV1%pred [MD 12.67, 95%CI (10.09,15.24); P<0.00001] were significantly different.ConclusionThe clinical effect of urokinase is better than that of antituberculous therapy alone: it can increase total pleural effusion, decrease residual pleural thickness, improve the pulmonary function, and shorten the time of pleural effusion absorption.

Evaluation of Adenosine Deaminase as a Diagnostic Marker in Tuberculous Pleural Effusion

Abstract: Tuberculous pleural effusion (TPE) is a common medical condition more frequently encountered in poor countries. It is the second most common form of extra-pulmonary tuberculosis. The diagnosis of TPE is problematic because the clinical features are non-specific, and most laboratory tests are not diagnostic. An accurate diagnosis requires the detection of TB bacilli in the pleural fluid or tissue sample from the pleura, which is not an easy task due to the scarcity of bacilli in the pleural fluid and the need for invasive maneuvers to get pleural tissue for histopathological, bacteriological or molecular confirmation for the TB bacilli. : Different markers in pleural fluid have been evaluated to aid in diagnosing TPE. Among those biomarkers, Adenosine deaminase (ADA) was the most studied marker. It is an enzyme predominantly produced by T-lymphocytes and catalyzes the conversion of adenosine to inosine and deoxyadenosine. It is a hallmark of active cellular immunity. A high level of ADA can be found in exudative effusion of different etiologies such as parapneumonic, tuberculous and malignant effusions. : Although there is still a debate over the diagnostic accuracy of ADA as a marker for TPE, many studies recommend its use. A correct diagnosis is crucial for the start of treatment for TPE. Therefore, it is crucial to assess the diagnostic value of adenosine deaminase in diagnosing tuberculous pleural effusion. The ADA optimal cutoff value is still under investigation.

Efficacy of intrapleural instillation of streptokinase with pigtail catheter drainage in the treatment of tuberculous pleural effusion

Background: Tuberculosis is the most common cause of exudative lymphocytic pleural effusion in India. The present study was undertaken to evaluate the efficacy of intrapleural instillation of streptokinase with pigtail catheter drainage in the treatment of tuberculous pleural effusion.Methods: Clinical profile, hospital course and outcome of tuberculous pleural effusion patients at the end of six months of anti-tubercular treatment of 50 patients from January 2009 to June 2010 were analyzed. These patients were randomly divided into two groups. One group (n=25) received intrapleural streptokinase via pigtail catheter and the other group (n=25) received intercostal drainage without intrapleural streptokinase instillation. All the patients received standard daily anti TB regimen of 2HERZ/4HR for a total duration of six months.Results: Majority of the patients were above 40 years of age (60%). The male to female ratio was 2.3:1. The major symptoms of the patients were, fever in 44 patients (88%), cough in 42 patients (84%), breathlessness in 33 patients (66%), loss of appetite in 25 patients (50%) and chest pain in 25 patients (50%). Most of the patients had ADA levels between 40-70 IU/L (48%) and only 6% had ADA levels below 40 IU/L. The mean pleural drainage was 2615±126.1 ml in the study group (intrapleural streptokinase) and 1858 ± 93.3 ml in the control group (p &lt;0.0001). Mean duration of intercostal drainage in the study group was 3.76 ± 0.144 days and it was 5.08±0.199 days in the control group (p &lt;0.0001). The mean duration of hospitalization in the study group was 6.60±0.91 days and it was 8.60 ± 0.57 days in the control group (p=0.06). Conclusion: Intrapleural streptokinase instillation is successful in increasing the total drainage of pleural fluid and results in effective drainage of tuberculous pleural effusion. It is also associated with increased amount of pleural fluid drainage, decreased duration of intercostal drainage, decreased length of hospital stay.

Pleural fluid cytology, biochemistry and adenosine deminase level study in differentiating tubercular and non tubercular causes of pleural effusion

Background: Adenosine deaminase (ADA) level in pleural fluid study has gained popularity for quick diagnosis and treatment of tuberculous pleural effusion in tuberculosis burden countries. Studies have confirmed high sensitivity and specificity across the world. Pleural fluid cytology, biochemistry and malignant cell examinations are already in use and widely available.Objectives: Diagnostic approach to quickly differentiate between tubercular and non tubercular pleural effusions by analyzing cytology, biochemistry and ADA level.Materials &amp; Methods: This study was carried out on 85 patients who were admitted or visited outpatient department with pleural effusion. The pleural fluid study was including measurement of ADA level was done.Results: 41 cases were diagnosed as tubercular pleural effusion. Among the low ADA group, 9 cases were diagnosed as malignant pleural effusion with positive malignant cell and 13 cases were transudative effusion.7 cases were diagnosed as parapneumonic effusion with exudative fluid, neutrophilic cell distribution and mixed ADA activity.Conclusion: ADA was found positive with a mean value of 88.3 U/L in tubercular pleural effusions. Non tubercular pleural effusion showed low ADA level. However the cytological and biochemical examination of pleural fluid was also found to be important in differentiating tubercular from non tubercular causes.KYAMC Journal Vol. 9, No.-1, April 2018, Page 28-31

I Went to New York City and All I Got Was a Heimlich Valve: Conservative Management of TB Empyema With a Bronchopleural Fistula

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tuberculous (TB) empyema with a bronchopleural fistula (BPF) is a late-stage presentation of active infection within the pleural space that is rare and difficult to treat. We report a case of a patient with TB empyema complicated by a BPF, which was managed conservatively with anti-TB medications and nonsurgical intervention. CASE PRESENTATION: A 45 year old male from Guyana with hypertension presented with shortness of breath and dyspnea on exertion. He denied fevers, chills, night sweats and cough but endorsed an unintentional weight loss of 20 lbs over the past month. He had a large left sided pleural effusion which drained a purulent fluid with a pH of 6.9, WBC 63120 Polys85%, RBC 1400. A chest tube was placed and he was started on broad spectrum antibiotics for empiric coverage. However, when AFB stains returned positive, he was given isoniazid, rifampin, pyrazinamide and ethambutol. Pleural fluid cultures grew mycobacterium tuberculosis. Multiple attempts were made to remove the chest tube by weaning suction and with clamp trials but an air leak persisted. A chest CT showed a thickened pleura and a clear BPF track which explained our findings at the bedside. The decision was made to manage the BPF conservatively with low suction and the eventual placement of a Heimlich valve. A follow-up CT scan was performed and the BPF was still present but the fistula track appeared to have diminished. Patient tolerated the Heimlich valve and was discharged from the hospital with recommendations for close follow-up with pulmonary and cardiothoracic surgery. DISCUSSION: In patients with difficult-to-treat TB empyema complicated by BPF, surgical interventions such as decortication, pneumonectomy and thoracoplasty can be attempted, but these are invasive procedures with variable outcomes. Conservative management with a Heimlich valve will likely not fully re-expand the lung given the thickened visceral pleura but may allow enough time for the fistula track to begin to heal, as seen in our patient, and hopefully close completely. CONCLUSIONS: A conservative approach may allow a patient with TB empyema and BPF to avoid more invasive procedures and may allow for an improved quality of life. Reference #1: Subotic, D.,Yablonskiy, P., Sulis, G., Cordos., Petrov, D., Centis R. et al, Surgery and pleura-pulmonary tuberculosis: a scientific literature review. J Thorac Dis. 2016;8:E474-E485 Reference #2: Xiong, Y.,Gao, X., Zhu, H., et al. Role of medical thoracoscopy in the treatment of tuberculous pleural effusion. J Thorac Dis 2016;8:52-60 DISCLOSURE: The following authors have nothing to disclose: Jason Lam, Angeliki Kazeros No Product/Research Disclosure Information

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

Increased soluble and membrane-bound PD-L1 contributes to immune regulation and disease progression in patients with tuberculous pleural effusion.

Soluble and membrane-bound programmed death ligand-1 (sPD-L1 and mPD-L1, respectively) have been demonstrated to participate in the immune suppression of non-small cell lung cancer. However, the contribution of sPD-L1 and mPD-L1 to immune regulation and disease progression in patients with pleural effusions remains unknown. The present study evaluated the levels of sPD-L1 and membrane-bound PD-1/PD-L1 in the peripheral blood and pleural effusions of patients with tuberculous pleural effusion (TPE), malignant pleural effusion (MPE) and non-tuberculous non-malignant pleural effusion (n-TB n-M). Furthermore, selected T lymphocytes and cluster of differentiation (CD)14+ monocytes were co-cultured to investigate the potential effect of the PD-1/PD-L1 pathway in TPE. Levels of sPD-L1 and PD-L1 on CD14+ monocytes were increased in the TPE group, as compared with the MPE and n-TB n-M groups. Furthermore, sPD-L1 levels and the expression levels of PD-L1 on CD14+ monocytes were demonstrated to be positively correlated with interferon (IFN)-γ concentration in pleural effusions. Therefore, IFN-γ may increase the expression of PD-L1 on CD14+ monocytes in vitro. Cell counting kit-8 analysis demonstrated that anti-PD-L1 antibody was able to partially reverse the proliferation of T lymphocytes in the co-culture system. The results of the present study indicated that sPD-L1 or mPD-L1 are associated with the immune regulation and disease progression of TPE, and may serve as possible biomarkers of TPE. Furthermore, sPD-L1 and the PD-1/PD-L1 pathway of TPE may be associated with the Th1 immune response; therefore, an anti-PD-1/PD-L1 pathway suggests a potential immune therapy strategy for the treatment of TPE.

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.

Role of medical thoracoscopy in the treatment of tuberculous pleural effusion.

Fibrous tuberculous pleural effusion (TPE) represents common disease in tuberculous clinic. Medical thoracoscopy has been used to treat pleural empyema and shown promising outcomes, but data of its use in multiloculated and organized TPE remains limited to know. The study was performed on 430 cases with TPE. The cases were divided into free-flowing, multiloculated effusion and organized effusion group. Each group was subdivided into two or three types of therapeutic approaches: ultrasound guided pigtail catheter, large-bore tube chest drainage and medical thoracoscopy. Patients with multiloculated or organized effusions received streptokinase, introduced into the pleural cavity via chest tubes. The successful effectiveness of the study was defined as duration of chest drainage, time from treatment to discharge days and no further managements. Patients with organized effusion were older than those with free-flowing effusion and incidence of organized effusion combined with pulmonary tuberculosis (PTB) was higher than those of multiloculated effusion and free-flowing effusion respectively. Positive tuberculosis of pleural fluid culture was higher in organized effusion than that in free-flowing effusion. Sputum positive for acid-fast bacillus (AFB) in organized effusion was higher than that in multiloculated effusion and free-flowing effusion. Medical thoracoscopy showed significant efficacy in the group of multiloculated effusion and organized effusion but free-flowing effusion. No chronic morbidity and mortality related to complications was observed. Medical thoracoscopy was a safe and successful method in treating multiloculated and organized TPE.

Clinical outcome of tubercular pleural effusion in patients treated under revised national tuberculosis control programme

Background: 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. The recommended treatment for TPE was regimen developed by revised national tuberculosis control programme- directly observed treatment-short course (RNTCP-DOTS). Methods: The present study was conducted at Sri Siddhartha medical college hospital and research centre, Tumkur (Tumakuru), Karnataka, India for one and half year during the period of October 2010 to April 2012. 50 patients were included in the study after meeting inclusion criteria. Detailed history and clinical examination of patients were done including chest X-ray. Treatment was given with RNTCP-DOTS regimen. After complete treatment the recovery of patients was evaluated by chest X-ray. Results: A total of 50 patients were included in the study. The mean age group was 41 years. Male (62%) preponderance was seen compared to females (38%). Chest pain and fever are the common clinical symptoms observed in all the patients. Moderate amount of pleural fluid accumulation was seen in 41 (82%) cases. Presence of lymphocytes was noted in all the samples. Out of 50 patients, 4 (8%) of them are detected as HIV positive and 6 (12%) are noticed as diabetic. 48 (96%) patients were having pleural fluid protein value more than 2.9 g/dl and 49 (98%) patients had pleural fluid sugar more than 60 mg/dl. 14 (43%) were reported of having ADA (elaborate the abbreviation- Adenosine deaminase) in the ranges 100-150 U/L. 30 (60%) patients were reported of having >10 g/dl of hemoglobin, 36 (72%) with total leucocyte count 4000-11000 cells/cumm and 45 (90%) with ESR >20 mm/hr. After completion of treatment out of 50, 40 patients were analyzed with chest X-ray and the outcome observed was normal appearance. Conclusions: Early detection of tuberculosis was done by pleural fluid analysis and chest X-ray. After complete treatment with RNTCP-DOTS regimen all TPE cases produced significant cure rate when examined by chest X-ray.

Comparison of the clinical effects of three different methods in treatment of tuberculous pleural effusion

Objective To compare the clinical efficacy of three different methods in treatment of tuberculous pleural effusion.Methods 108 patients with tuberculous pleural effusion were divided into three groups by randomized single blind methods,and each group had 36 cases.Group A was given Chinese medicine formulations and central venous catheter pleural drainage for injection,group B was given minimally invasive thoracic closed drainage,while group C was given conventional pleural puncture.The clinical efficacy,complications and hospitalization corresponding cost were compared in three groups.Results The clinical effective rates of the three groups were 97.2％,83.3％,61.1％ (x2 =12.90,14.17,15.28,all P ＜ 0.05).In group A,the tuberculous pleural effusion disappearedfastest,hospitalization corresponding cost was lowest and less complications,followed by group B,and group C was the worst,there were statistically significant differences (all P ＜ 0.05).Conclusion Chinese medicine formulations combined with central venous catheter drainage in the treatment of tuberculous pleural effusion has good clinical effecacy,and it is an effective treatment method,which is worth to be further promoted in clinical. Key words: Pleural effusion; Drainage

Current Concepts in the Management of Tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.

Application of closed thoracic drainage with micro-catheter in treatment of tuberculous pleural effusion

Objective To observe the effect and safety of pleural effusion treated by closed thoracic drainage with micro-catheter. Methods A total of 64 cases with pleural effusion were randomly divided into conventional therapy group ( control group ) and closed thoracic drainage with micro-catheter group ( treatment group) , each group including( 32 cases ). Control group were treated with drainage of thoracic puncture interruptedly while treatment group treated by closed thoracic drainage with micro-catheter. Results Both two therapeutic methods could reduce pleural effusion, but obvious effective rate of treatment group was higher than that of control group( P ＜ 0.05 ). Meanwhile, the rate of pleural reaction and treatment cost in treatment group were lower than that in control group. Conclusion Closed thoracic drainage with micro-catheter was effective, lower treatment cost and lower complications. Moreover, it could reduce medical risk. Key words: Micro-catheter; Closed thoracic drainage; Pleural effusion; Clinical effect

Corticosteroids in the Treatment of Tuberculous Pleural Effusion in Children: Report of One Case

Pleural effusion is a common feature of primary pulmonary tuberculosis (TB) in adolescents and adults rather than in young children. Multiple studies in adult support the use of corticosteroids as adjuvant therapy to provide a prompt relief of the symptoms， to hasten absorption of fluid, and to prevent long-term pleural sequela. However, the experience in children is rare. We report a 9 year-old girl of tuberculous pleural effusion who responsed well after receiving the combined regimen of corticosteroids-antituberculous therapy.

Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006

Tuberculous (TB) pleural effusion occurs in approximately 5% of patients withMycobacterium tuberculosisinfection. The HIV pandemic has been associated with a doubling of the incidence of extrapulmonary TB, which has resulted in increased recognition of TB pleural effusions even in developed nations. Recent studies have provided insights into the immunopathogenesis of pleural TB, including memory T-cell homing and chemokine activation. The definitive diagnosis of TB pleural effusions depends on the demonstration of acid-fast bacilli in the sputum, pleural fluid, or pleural biopsy specimens. The diagnosis can be established in a majority of patients from the clinical features, pleural fluid examination, including cytology, biochemistry, and bacteriology, and pleural biopsy. Measurement of adenosine deaminase and interferon-γ in the pleural fluid and polymerase chain reaction forM tuberculosishas gained wide acceptance in the diagnosis of TB pleural effusions. Although promising, these tests require further evaluation before their routine use can be recommended. The treatment of TB pleural effusions in patients with HIV/AIDS is essentially similar to that in HIV-negative patients. At present, evidence regarding the use of corticosteroids in the treatment of TB pleural effusion is not clear-cut.

Pigtail drainage in the treatment of tuberculous pleural effusion: a randomized study

Thorax 2003;58:149–52. Lai Y-F, Chao Y-H, Wang Y-H, Lin A-S. Comments: The authors performed a randomized, controlled trial to study whether placement of a pigtail catheter is beneficial in the management of patients with tubercular pleural effusion. All patients had closed-needle pleural biopsy and diagnostic thoracentesis. The biopsies showed caseating granuloma with or without acid-fast bacilli in every patient. Chest roentgenograms were performed on a monthly basis. A visual analog score (VAS) was used to grade dyspnea, cough, night sweats, appetite, and sense of well-being, and so on. The outcome measures in this study were duration of fever and dyspnea after starting treatment, improvement in VAS, forced vital capacity, and residual pleural thickening (RPT) 6 months after treatment. Initially, 65 patients were enrolled into the study, but 5 patients were excluded from final analysis because they were either noncompliant with the medications or were lost to follow up. Of the remaining 61 patients, 30 received pigtail catheter and antitubercular treatment, and 31 patients received only antitubercular treatment. The authors do not provide information on how long the pigtail catheter was kept in the pleural space. The baseline characteristics were similar in both groups. The only difference in outcome was a more rapid resolution of dyspnea in those who had received the pigtail catheter and antitubercular treatment (median duration, 4 days) compared with antitubercular treatment only (median duration, 8 days; P <0.001). Both groups showed similar improvement in VAS score after initiating the treatment. The forced vital capacity (FVC) was similar in both groups (85.5% of predicted in the drainage group and 88% in the nondrainage group) after the completion of therapy. The incidence of RPT was also similar at 6 months (53% in the drainage group and 51% in the nondrainage group). The authors concluded that the addition of a pigtail catheter to effective antitubercular treatment is not warranted and does not reduce the incidence of RPT. Residual pleural thickening develops in 40% to 50% of patients after treatment of tubercular pleural effusion (Chest 1991;100:1264–7, Chest 1997;112:1293–7). The role of pleural drainage to reduce the chances of residual pleural thickening has been a controversial subject. This well-conducted study by Lai and coworkers shows that there are no benefits from pleural drainage in patients with tubercular pleural effusion. Although nearly one half of all patients developed some degree of RPT in this study, its functional consequences were minimal. The majority of patients did not develop a significant restrictive pulmonary defect. Based on this study, it can be concluded that drainage of the pleural cavity on a routine basis is not helpful in patients with tubercular pleural effusion.

Tuberculous pleural effusion: new pulmonary lesions during treatment.

To evaluate patients who have a paradoxical response (development of new opacities) to treatment for tuberculous pleural effusion not related to acquired immunodeficiency syndrome. In 16 patients, follow-up chest radiographs (n = 16) and initial (n = 2) and follow-up (n = 9) computed tomographic (CT) scans of the chest were retrospectively reviewed by two radiologists. Patient records (n = 16) and results of percutaneous needle aspiration and/or biopsy (n = 6) were reviewed by one radiologist. Eighteen episodes of new lesion development were identified on radiographs in 16 patients. Each episode showed single (nine of 18 episodes, 50%) or multiple (nine of 18 episodes, 50%) nodules, most of which were in the peripheral lung (16 of 18 episodes, 89%) ipsilateral to the side of previous effusion (17 of 18 episodes, 94%). On CT scans, all lesions were peripheral pulmonary nodules, not round atelectasis. Needle aspiration and/or biopsy of the lesions showed findings consistent with tuberculosis in all six patients. Lesions usually evolved within 3 months after the start of medication (13 of 18 episodes) and finally disappeared (15 episodes) or left residual opacities (three episodes) 3-18 months later, with continuation of medication. New lung lesions that develop during medication for tuberculous pleural effusion should be considered a transient worsening that ultimately improves with continuation of medication.

6-Month Short-Course Chemotherapy for Tuberculous Pleural Effusion

Background: Short-course chemotherapy for 6 months is well established for pulmonary tuberculosis. However, little is known about the efficacy of the short-course chemotherapy for tuberculous pleural effusion. Tuberculous pleural effusion itself may be self-limiting without any treatment, but about two thirds of the patients with tuberculous pleural effusion may subsequently develop pulmonary tuberculosis within 5 years. After completing treatment for tuberculous pleural effusion. prolonged follow-up is necessary for evaluating the efficacy of the treatment There is still no report on the efficacy of 6-month regimens for tuberculous pleural effusion in Korea, where the incidence of tuberculous disease and drug resistance is high. We studied the efficacy of 6 month short-course chemotherapy comparing with 9 month chemotherapy. Method : Retrospective study was done through medical record review in 238 patients with tuberculous pleural effusion who admitted to Asan Medical Center during May 1989-May 1993. The diagnosis of tuberculous pleural effusion was made by bacteriologic or histopathologic study. Results: Among 238 patients, 38 patients were dropped out during follow-up period. In 2 patients, second line drugs were prescribed according to known drug resistance results. And, in 23 patients, treatment longer than 9 months was done due to accompanying extrapulmonary tuberculosis or durg resistance. In 8 patients, treatment regimen was changed due to hepatotoxicity. Remaining 167 cases (70.2%) completed the treatment as scheduled ; 6 month chemotherapy in 88 cases and 9 month chemotherapy in 79 cases. In 60 patients (35.9%) with pleural effusion only in chest X-ray finding, sputum smear or culture for M.tuberculosis was positive in 6 cases (10.0%), and in 63 patients (37.7%) with radiologically inactive pulmonary tuberculosis, sputum smear or culture was positive in 18 cases (28.6%). In 44 patients (26.3%) with radiologically active pulmonary tuberculosis, the sputum smear or culture was positive in 24 cases (54.5%). In 6-month chemotherapy group (n=88), during mean 23 months (range; 1~61months) follow-up period, pulmonary tuberculosis developed in 1 case (1.4%). In 9-month chemotherapy group(n=79), during mean 23 months (range; 3~70months) follow-up period, pulmonary tuberculosis developed in 2 cases (2.5%). All the cases who developed pulmonary tuberculosis also showed active pulmonary tuberculosis on initial chest X-ray before treatment Conclusion: In patients with tuberculous pleural effusion, the incidence of pulmonary tuberculosis after 6 month chemotherapy showed no difference from that after 9 month chemotherapy. Thus, 6 month short-course chemotherapy seems to be an effective treatment for tuberculous pleural effusion.

Unusual radiographic abnormalities observed during treatment of tuberculous pleural effusion

Three young patients with tuberculous pleural effusions are reported in whom peripheral x-ray opacities developed during treatment. Two patients also had radiographic evidence of mediastinal node enlargement. There was no factor common to the 3 cases to explain why the abnormalities developed, but it is suggested that enlargement of lymph nodes was the most likely cause of the radiographic lesions.

Treatment of Tuberculous Pleural Effusion with Local Instillation of Hydrocortisone

Treatment of Tuberculous Pleural Effusion with Local Instillation of Hydrocortisone