Cases Of Tuberculous Pleural Effusion Research Articles

Different characteristics of pleural abnormalities on computed tomography between tuberculous and malignant pleural effusions

BackgroundComputed tomography (CT) is the mainstay imaging modality for suspected pleural malignancy. Tuberculous pleural effusion (TPE) can present with various pleural abnormalities. However, few studies have evaluated the different characteristics of pleural abnormalities on chest CT between TPE and malignant pleural effusion (MPE). MethodsPleural abnormalities on contrast-enhanced CT in 277 and 289 patients with confirmed TPE and MPE diagnoses, respectively, were retrospectively assessed and compared between the two groups. Discriminating factors and diagnostic performance for MPE were evaluated using multivariate analysis and receiver operating characteristic curves. ResultsFocal pleural thickening was present in 44 (16%) cases of TPEs and 202 (70%) of MPEs. Further characterization of focal pleural thickening showed that MPEs had a significantly greater number, larger maximal thickness, and more nodular contour form, compared to TPEs. On the other hand, diffuse and circumferential pleural thickening were significantly more common in TPEs. In multivariate analysis, independent predictors for MPE included focally thickened pleurae ≥7, maximum thickness ≥6 mm, nodular contour pattern, and the absence of diffuse pleural thickening. Out of all the individual or combined predictors for MPE, the presence of any one of the three sub-parameters of focal pleural thickening provided the best diagnostic yield with 66% sensitivity and 92% specificity. ConclusionAlthough focal pleural thickening in TPE mimics that in MPE, the features of MPE are significantly different from those of TPE in terms of size, number, and contour. These different characteristics may help differentiate MPE from TPE in patients with suspected MPE.

Evaluation of Gene Xpert versus Pleural Biopsy in Diagnosis of Suspected Cases of Tuberculous Pleural Effusion.

Evaluation of Gene Xpert versus Pleural Biopsy in Diagnosis of Suspected Cases of Tuberculous Pleural Effusion.

FluoroType® MTB in pleural fluid for diagnosing tuberculosis

ObjectivesThis work aims to investigate the diagnostic accuracy of a nucleic acid amplification test (FluoroType MTB®) in pleural fluid (PF) and sputum to diagnose tuberculous pleural effusion (TPE). We also analyzed the increase in diagnostic accuracy of a second FluoroType MTB® test on a second thoracentesis sample when the first was negative. MethodsWe conducted a prospective single-center study that included 207 patients with pleural effusion (31 tuberculous and 176 due to other causes). Of the 31 cases of TPE, 21 (68%) were confirmed histologically or microbiologically; the other cases were considered probable. ResultsThe operational characteristics of FluoroType MTB® in PF for identifying tuberculosis were a sensitivity of 13%, a specificity of 99%, a positive likelihood ratio of 11, and a negative likelihood ratio of 0.9. The diagnostic efficacy data for sputum samples were 21%, 91%, 2.4, and 0.9, respectively. PF and sputum cultures in solid and liquid media had greater sensitivity (36% and 31%, respectively). A second FluoroType MTB® test in PF was negative for 24 patients who had TPE and for whom the first FluoroType MTB® test was also negative. Only two (6.5%) patients with TPE had a confirmed diagnosis based exclusively on the positive results of the FluoroType MTB® in PF. ConclusionDue to its low sensitivity, the FluoroType MTB® test in PF has a limited role in diagnosing tuberculous pleurisy.

FluoroType® MTB en líquido pleural para el diagnóstico de tuberculosis

ObjectivesThis work aims to investigate the diagnostic accuracy of a nucleic acid amplification test (FluoroType MTB®) in pleural fluid (PF) and sputum to diagnose tuberculous pleural effusion (TPE). We also analyzed the increase in diagnostic accuracy of a second FluoroType MTB® test on a second thoracentesis sample when the first was negative. MethodsWe conducted a prospective single-center study that included 207 patients with pleural effusion (31 tuberculous and 176 due to other causes). Of the 31 cases of TPE, 21 (68%) were confirmed histologically or microbiologically; the other cases were considered probable. ResultsThe operational characteristics of FluoroType MTB® in PF for identifying tuberculosis were a sensitivity of 13%, a specificity of 99%, a positive likelihood ratio of 11, and a negative likelihood ratio of 0.9. The diagnostic efficacy data for sputum samples were 21%, 91%, 2.4, and 0.9, respectively. PF and sputum cultures in solid and liquid media had greater sensitivity (36% and 31%, respectively). A second FluoroType MTB® test in PF was negative for 24 patients who had TPE and for whom the first FluoroType MTB® test was also negative. Only two (6.5%) patients with TPE had a confirmed diagnosis based exclusively on the positive results of the FluoroType MTB® in PF. ConclusionDue to its low sensitivity, the FluoroType MTB® test in PF has a limited role in diagnosing tuberculous pleurisy.

Improved early diagnosis of difficult cases of tuberculous pleural effusion by combination of thoracoscopy with immunological tests

IntroductionAlthough pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. The aim of this study was to evaluate the performance of commonly used laboratory tests for the early diagnosis of difficult cases of pleural effusion. MethodsPatients with undiagnosed pleural effusion were enrolled and subjected to five laboratory tests including thoracoscopy, pleural fluid adenosine deaminase assay (ADA), serum tuberculosis antibody test (TB-antibody), tuberculin skin test (TST), and T-SPOT.TB assay. The diagnosis of TP was established based on pleural histology and mycobacterial culture. The different tests were compared for diagnostic performance. ResultsA total of 106 patients were enrolled; their mean age was 53 years and 70.8% were male. Seventy-two (68%) of them were confirmed to have TP. When used individually, the five laboratory tests showed highly variable performance parameters, including sensitivity ranging from 46% to 92% and specificity ranging from 33% to 82%. When used in different combinations, thoracoscopy combined with TST or TB-antibody showed the optimal performance parameters, with a sensitivity of 80.8% and a specificity of 85.7%. ConclusionsThe results of this study suggest that the combination of thoracoscopy with TST or TB-antibody test is the best choice for the early diagnosis of difficult cases of TP in high TB burden countries.

Predictive Factors and Treatment Outcomes of Tuberculous Pleural Effusion in Patients With Cancer and Pleural Effusion

BackgroundPatients with cancer are at an increased risk of tuberculosis. As pleural effusion has great clinical significance in patients with cancer, the differential diagnosis between tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE) is important. However, the predictive factors and treatment outcomes of TPE in patients with cancer have rarely been studied. Materials and MethodsConfirmed TPE cases identified at cancer diagnosis and during anticancer management from 2008-2015 were retrospectively investigated. Patients in the study included coexisting TPE and cancer (n = 20), MPE (n = 40) and TPE without cancer (n = 40). Control groups were patients with MPE, and patients with TPE without cancer. Clinical, laboratory and pleural fluid characteristics were compared among groups. Treatment outcomes were compared between patients with TPE with and without cancer. ResultsIn the final analysis, serum C-reactive protein (S-CRP) ≥3.0mg/dL and pleural fluid adenosine deaminase (ADA) ≥40U/L were independent predictors for identifying TPE in patients with cancer having pleural effusion. The combination of S-CRP with pleural fluid ADA using an “or” rule achieved a sensitivity of 100%, whereas both parameters combined in an “and” rule had a specificity of 98%. Treatment outcomes were not different between the TPE groups with and without cancer. ConclusionsS-CRP and pleural fluid ADA levels may be helpful for predicting TPE in patients with cancer with pleural effusion. The combination of these biomarkers provides better information for distinguishing between TPE and MPE in these patients. Treatment outcomes of TPE in patients with cancer are comparable to those in patients without cancer.

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

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

Atypical Pleural Fluid Profiles in Tuberculous Pleural Effusion: Sequential Changes Compared with Parapneumonic and Malignant Pleural Effusions.

Objective Although tuberculous pleural effusion (TPE) is commonly characterized by lymphocytic predominance and high adenosine deaminase (ADA) levels, it may present with neutrophilic predominance or low ADA levels, which are more commonly found in parapneumonic effusion (PPE) or malignant pleural effusion (MPE), respectively. A few studies have observed that the atypical pleural fluid profiles of these cases of TPE may resolve at follow-up thoracentesis. However, these observations were incompletely analyzed and lacked comparison with proper control groups. Thus, limited data are available comparing the sequential pleural fluid changes between TPE and PPE or MPE with similar pleural fluid profiles. Methods TPE, PPE, and MPE patients who underwent sequential thoracentesis were retrospectively reviewed. The sequential changes in the pleural fluid profiles were compared between neutrophilic TPE and PPE, and lymphocytic TPE and MPE with low ADA levels. Results Twenty-three TPE patients (16 with neutrophilic exudates, seven with lymphocytic exudates), 72 cases of PPE with neutrophilic exudates, and 18 cases of MPE with lymphocytic exudates were included in the analysis. A sequential shift to lymphocytic exudates occurred significantly more often in TPE than in PPE cases. The initial and follow-up ADA levels in TPE cases with a lymphocytic shift were significantly higher than those in PPE cases with a lymphocytic shift. The ADA levels in the TPE cases with initial lymphocytic exudates and low ADA levels significantly increased at follow-up thoracentesis. For the TPE and MPE cases with initial lymphocytic exudates and ADA levels <40 U/L, the frequency of effusion with ADA levels ≥40 U/L at the second thoracentesis was significantly higher in the TPE cases. Conclusion Follow-up thoracentesis may provide useful information for clinical decision-making in suspected atypical TPE cases with neutrophilic exudates or low ADA levels.

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.

Expressions and diagnostic value of interleukin-31 in tuberculous pleural effusion

Objective To analyze the expression of interleukin (IL)-31 in tuberculous pleural effusion, and to evaluate its diagnostic value of tuberculous effusion. Methods Seventy-one patients with pleural effusion were enrolled, including 40 cases of tuberculous pleural effusion and 31 cases of malignant pleural effusion. Luminex method was applied to detect the IL-31 expression in pleural effusion. IL-31 levels were compared using non-parametric Mann-Whitney U test, and the receiver operator characteristic (ROC) curve was used to elvaluate the diagnostic value of IL-31. Results IL-31 expression in tuberculous pleural effusion was significantly higher than that in malignant pleural effusion with statistical significance (529.4 ng/L vs 13.8 ng/L, U=62, P<0.01). Based on the level of IL-31 expression, area under the ROC curve was 0.95 with the optimum cut-off value of 67.5 ng/L. Thus, the sensitivity and specificity of IL-31≥67.5 ng/L for diagnosis of tuberculous pleurisy were 82.5% (95%CI: 73.3%-94.2%) and 100.0% (95%CI: 91.4%-100.0%), respectively. Conclusion IL-31 is highly sensitive and specific for the diagnosis of tuberculous pleural effusion, which favors the differentiation of tuberculosis from malignance. Key words: Interleukin-31; Pleural effusion, malignant; Tuberculosis, pleural; Differential diagnosis

Factors Influencing Pleural Adenosine Deaminase Level in Patients With Tuberculous Pleurisy

BackgroundAdenosine deaminase (ADA) activity is useful for diagnosing tuberculous (TB) pleurisy in regions with a high prevalence of tuberculosis. However, some cases of TB pleural effusion show decreased ADA activity. Therefore, we evaluated factors influencing pleural ADA levels in patients with TB pleurisy. MethodsWe retrospectively evaluated 182 patients with TB pleural effusion who were admitted to Gyeongsang National University Hospital from January 2004 to September 2008. Patients were dichotomized into 2 groups: a low-ADA (<40 IU/L) group (n = 22) and a high-ADA (≥40 IU/L) group (n = 160). Age, sex, ADA level of pleural effusion, smoking status, history of tuberculosis and comorbid diseases were evaluated in each group. ResultsThe median age of the patients was 50.5 years, with a male to female ratio of 1.72:1. Patients with a low-ADA level were significantly older than those with a high ADA level (66.9 ± 12.0 versus 49.4 ± 21.2 years, P < 0.001). A history of tuberculosis and hypertension was more common in the low-ADA group than in the high-ADA group (31.8% versus 15.0%, P = 0.049 and 36.4% versus 16.9%, P = 0.03, respectively). A multivariate analysis revealed that older age and current smoking were predictive of TB pleurisy with a low ADA level (odds ratios, 1.053 and 4.848; P = 0.002 and 0.028, respectively). ConclusionsPhysicians should be careful when interpreting pleural ADA levels in elderly patients and/or current smokers for the diagnosis of TB pleurisy.

Can tuberculous pleural effusions be diagnosed by pleural fluid analysis alone?

To assess whether pleural fluid analysis (PFA) can confidently diagnose tuberculous pleural effusion (TPE). PFA of 548 TPEs was performed between January 1991 and December 2011. The control group consisted of patients with malignant PE (MPE), complicated parapneumonic/empyema (infectious) PE (IPE), miscellaneous PE (MisPE) and transudative PE (TrPE). The PFA of 548 histologically or culture-positive consecutive cases of TPE was compared with that of 158 consecutive cases of MPE, 113 cases of IPE, 37 cases of MisPE and 115 cases of TrPE. Statistically significant differences were noted in pleural fluid glucose, pH, cholesterol, triglycerides, adenosine deaminase (ADA), and total percentages of lymphocytes, neutrophils and macrophages when TPEs were compared to all other groups. Of the TPEs, 99.1% were exudates. Pleural fluid protein ≥ 5.0 g/dl, lymphocytes > 80% and ADA > 45 U/l were diagnostic of TPE, with a specificity of 100%, a sensitivity of 34.9% and an area under the curve of 0.975. PFA alone was diagnostic in one third of the TPE cases, with a high probability in nearly 60%.

Evaluation of adenosine deaminase activity for diagnosis of tuberculous pleural effusion

Background: Tuberculosis is a leading cause of worldwide preventable morbidity and mortality from an infectious agent. A defi nite diagnosis of tubercular pleural effusion can be diffi cult to make because of low sensitivity and/or specifi city of noninvasive traditional diagnostic tools. This study is done to fi nd out a sensitive and specifi c marker for early diagnosis of tuberculous pleural effusion. Materials and Methods: One hundred and three pleural effusion cases were enrolled in the study, out of which 62 were tuberculous pleural effusion cases and 49 were non-tuberculous cases. Results: Considering 40 U/L as a cut off value for Adenosine deaminase assay level, the test result was positive in 58 out of 62 patients of tuberculosis indicating sensitivity of the test as 94%; however, among 41 non-tuberculous patients, 5 presented ADA activity level more than 40U/L, which lowers the specifi city of the test to 88%. ADA levels were signifi cantly higher in tuberculous than in non tuberculous cases (P value &lt;0.001). Conclusion: It may be concluded that ADA levels are signifi cantly high in patients with tuberculous pleural effusion compared to that in non tuberculous group. Sensitivity (94%) and specifi city (88%) of the test in tuberculous pleural effusions are very high, when cut off value set at 40U/L. The result indicated that the analysis of ADA levels in pleural effusion constitute a very useful marker for the diagnosis of TPE which, in addition, can be made quickly in a non- invasive way. Journal of Pathology of Nepal (2013) Vol. 3, No.1, Issue 5, 367-373 DOI: http://dx.doi.org/10.3126/jpn.v3i5.7860

A clinicopathological study of tuberculous pleural effusion in a tertiary care hospital

Context: Tuberculosis is a major contributor of exudative pleural effusion which is the second most common extra-pulmonary manifestation of tuberculosis following tubercular lymphadenitis. Aims: To re-evaluate the time tested and easily available investigation of closed pleural biopsy and its relation with pleural fluid adenosine deaminase (ADA) level and cytological findings in the clinically suspected cases of tuberculous pleural effusion. Materials and Methods: A total of 44 cases of suspected tubercular pleural effusion were selected from the indoor ward of a tertiary care hospital, over a period of 13 months. Apart from the relevant history taking and clinical examination, thorough investigations were done in each case to prove the etiological diagnosis, which comprised of routine hemogram, bleeding time, clotting time, Mantoux test, sputum microscopy, enzyme-linked immunosorbent assay (ELISA) for HIV, chest X-ray, examination of pleural fluid including ADA estimation, culture for Mycobacterium tuberculosis (BACTEC), and finally, pleural biopsy by Abram's needle. Results: A total of 65.8% cases of tuberculous pleural effusion were diagnosed by pleural biopsy results. Second biopsy attempts improved the diagnostic ability by 18.4%. The highest incidence was observed in the 11-20 years age group (36.8%). Chest pain (86.8%) was the predominant symptom. Positive Tuberculin skin test was observed in 89.5% cases. Pleural fluid analysis showed a predominance of lymphocytes in all the cases, with 97.3% patients having ADA levels > 70 U/L. There was no major complication of pleural biopsy. Conclusions: Pleural biopsy is a very important tool for diagnosing tuberculous pleural effusion without any major complication. ADA values > 70 U/L are highly suggestive of tubercular etiology and correlated well with histopathological findings of pleural biopsy.

Adapted T Cell Interferon-Gamma Release Assay for the Diagnosis of Pleural Tuberculosis

Background: Better and more rapid tests are needed for the diagnosis of tuberculous pleural effusion (TPE), given the known limitations of conventional diagnostic tests. Objectives: To estimate diagnostic accuracy of the QuantiFERON-TB Gold In-Tube (QFT-GIT) test (and its components) using data-derived cutoffs in pleural fluid. Methods: The QFT-GIT test was performed on whole blood and pleural fluid from 43 patients with TPE and 29 control subjects (non-TPE). To achieve the objective, QFT-GIT test, estimating likelihood ratios and receiver operating curve analysis were performed. Results: The sensitivity and specificity using the QFT-GIT for the diagnosis of TPE were 48.8% and 79.3%, respectively, in pleural fluid. The best cutoff points for tuberculosis (TB) antigen, nil and TB antigen minus nil results were estimated at 0.70, 0.90 and 0.30 IU/ml, respectively. Area under the curve of TB antigen IFN-γ response was 0.86 (CI: 0.76–0.93), nil tube was 0.80 (CI: 0.69–0.89) and TB antigen minus nil tube was 0.82 (CI: 0.72–0.90). When the best cutoff scores of the nil tubes were set at this value, the results of a likelihood ratio of a positive and a negative test were 9.44 (7.4–12.0) and 0.37 (0.09–1.5), respectively. The percentages of indeterminate results in pleural fluid among the TPE cases were 42% (most of them caused by high nil IFN-γ values) using the QFT-GIT test. Conclusion: QFT-GIT test or its components have poor accuracy in the diagnosis of TPE, largely because of a high number of indeterminate results due to high background IFN-γ production in the TPE.

Clinical value of vascular endothelial growth factor combined with interferon-γ in diagnosing malignant pleural effusion and tuberculous pleural effusion

In order to investigate the clinical value of vascular endothelial growth factor (VEGF) combined with interferon-gamma (IFN-gamma) in diagnosing malignant pleural effusion and tuberculous pleural effusion, 42 cases of malignant pleural effusion and 45 cases of tuberculous pleural effusion in Tongji Hospital, from March 2004 to May 2005, were included. The carcinoembryonic antigen (CEA), VEGF and IFN-gamma levels of pleural effusion were detected by using ELISA, and adenosine deaminase (ADA) activity was determined by using enzyme kinetic analytical method. The sensitivity, specificity, accuracy and area under the curve (AUC(ROC)) of CEA and VEGF, VEGF/IFN-gamma ratio, ADA and IFN-gamma were measured by receiver operating characteristic curve (ROC). The results showed that CEA, VEGF levels and VEGF/IFN-gamma ratio were significantly higher and the ADA and IFN-gamma levels were significantly lower in malignant group than those in tuberculous group (P<0.01). The sensitivity, specificity, accuracy and AUC(ROC) of VEGF/IFN-gamma ratio (88.7%, 99.8%, 94.4%, 0.96 respectively) were higher than those of CEA (67.8%, 96.1%, 82.4%, 0.78 respectively) and VEGF (81.5%, 84.3%, 82.9%, 0.79 respectively). The sensitivity, specificity, accuracy and AUC(ROC) of IFN-gamma (85.7%, 96.4%, 90.9%, 0.94 respectively) were higher than those of ADA (80.2%, 87.6%, 83.8%, 0.81 respectively). It was concluded that VEGF/IFN-gamma ratio and IFN-gamma could be used as valuable parameters for the differential diagnosis of malignant pleural effusion and tuberculous pleural effusion.

Immunodiagnosis of childhood pulmonary and extrapulmonary tuberculosis using Mycobacterium tuberculosis ES antigen by penicillinase ELISA.

The diagnostic potential for detection of IgG to Mycobacterium tuberculosis excretory secretory (ES) antigen in childhood pulmonary and extrapulmonary tuberculosis was explored. IgG antibody to M. tuberculosis ES antigen was detected by indirect penicillinase ELISA. Twenty (80%) out of 25 pulmonary tuberculosis cases (clinically diagnosed and/or AFB-positive), five of nine tuberculous pleural effusion cases and only six of 69 cases in the control group were positive for IgG antibody to M. tuberculosis ES antigen. All CSF and sera were positive for IgG antibody in 12 cases of clinically diagnosed tuberculous meningitis (TBM). Out of 35 cases in the control group for TBM, all five cases of pyogenic meningitis but none of the 13 cases of viral encephalitis, five cases of enteric encephalopathy and 12 cases with no CNS infection were positive for anti-tubercular IgG antibody in CSF samples. Only two of them, i.e. one case of pyogenic meningitis and the other with no CNS infection, were positive for antibody in sera. The study demonstrated the potential of this assay in the diagnosis of tuberculosis in children where bacteriological confirmation is very difficult.

Tuberculous Pleural Effusion: Twenty-Year Experience

We reviewed the records of 1,738 cases of tuberculosis seen during the period from 1968 to 1988 in Mobile, Alabama. Seventy cases of tuberculous pleural effusion were identified and constituted 4.9 percent of all disease due to Mycobacterium tuberculosis during this period. Tuberculous pleural effusion was diagnosed if the patient had M tuberculosis cultured from sputum, pleura, or pleural fluid and had a roentgenographic pleural effusion without an alternative explanation for the presence of the effusion. The diagnosis of tuberculous pleural effusion was made in the absence of a positive culture if the patient had an undiagnosed lymphocytic exudative pleural effusion and all clinical and roentgenographic abnormalities resolved on antimycobacterial chemotherapy. The mean age of all patients was 47 +/- 18.4 years. The 70 cases were evenly divided between 35 that were accompanied by roentgenographic pulmonary parenchymal infiltrates and 35 that occurred in the absence of parenchymal infiltrates. We conclude that cultures of all potentially diagnostic specimens (sputum, pleural fluid, and pleura) and an intermediate-strength skin test, are sensitive tests for the diagnosis of tuberculous pleural effusion. In addition, the age of patients with tuberculous pleural effusion appears to be increasing.

Clinical and Pathological Features of Tuberculous Pleural Effusion and Its Long-Term Consequences

A retrospective study of 83 cases of tuberculous pleural effusion showed that the mean age of the patients was 44 years and 10 patients (12%) were over the age of 70. Pleural fluid was smear positive for tubercle bacilli in none but culture positive in 23% of the cases. Pleural biopsy was a more sensitive method of diagnosis with granulomatous inflammation seen in 97% of cases. Five patients developed significant pleural thickening during chemotherapy requiring decortication. Twenty-two patients with tuberculous effusion diagnosed and treated over 2 years previously were traced for reassessment. None of them had significant pleural thickening and lung function tests did not show significant impairment compared to matched control subjects.

Diagnostic Value of Simultaneous Determination of Pleural Adenosine Deaminase and Pleural Lysozyme/Serum Lysozyme Ratio in Pleural Effusions

We have determined simultaneously the ADAp and Lp/Ls ratio in 138 pleural effusions: 61 tuberculous; 42 malignant; 14 transudates; five parapneumonic uncomplicated; six empyematous; and ten cases belonging to a miscellaneous group which included two disseminated lupus erythematosus; two posttraumatic; one pancreatitis; one pleuropericarditis by Mycoplasma; one viral pleuropericarditis; and three pulmonary embolisms. This has allowed us to clear the overlapping for the ADAp activity among tuberculous patients (two cases of lupus and three cases of malignant effusions) in our series. The overlap in the Lp/Ls ratio among tuberculous patients, two malignant, and two parapneumonic uncomplicated cases was also cleared. Fixing the ADAp values at 33 U and the Lp/Ls ratio at 1.2, the tuberculous pleural effusion cases were differentiated from the nontuberculous with a sensibility, positive predictive value, negative predictive value, and safety diagnosis of 100 percent. It has been proven that there is a good correlation between ADAp and Lp/Ls ratio (r = 0.717) and the ADAp and Lp (r = 0.660).