Chest
Volume 131, Issue 3, March 2007, Pages 880-889
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Special Feature
Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006

https://doi.org/10.1378/chest.06-2063Get rights and content

Abstract

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.

Section snippets

Epidemiology

A total of nine million new cases and approximately two million deaths from TB were reported in 2004.1Although the African region has the highest estimated incidence (356 per 100,000 population per year), the majority of patients with TB live in the most populous countries of the Asian subcontinent, which accounts for nearly half of the new cases that arise yearly.5The frequency of pleural involvement in TB has been variably reported (4% in United States to 23% in Spain).6, 7

TB pleural effusion

Pathogenesis

TB pleural effusions can manifest as primary or reactivated disease. Rupture of a subpleural caseous focus in the lung into the pleural space is considered the initial event in the pathogenesis of primary TB pleural effusions.12The entry of mycobacterial antigens into the pleural space is followed by an interaction with predominantly CD4+ T-lymphocytes resulting in a delayed hypersensitivity reaction.13The accumulation of fluid in pleural cavity results predominantly from increased capillary

Clinical Features

In contrast to pulmonary TB, most TB pleural effusions manifest as an acute illness, with approximately one third of patients being symptomatic for < 1 week and two thirds for < 1 month.18The most common presenting symptoms are pleuritic chest pain (75%) and nonproductive cough (70%).19TB pleural effusion was considered a disease of the young, with a mean age of 28 years, compared to 54 years for parenchymal tuberculosis.20However, Epstein and colleagues21demonstrated a rise in the median age

Diagnosis

The definitive diagnosis of TB pleural effusions depends on the demonstration ofM tuberculosisin sputum, pleural fluid, or pleural biopsy specimens. Supportive evidence includes demonstration of classical TB granulomas in the pleura and elevated adenosine deaminase (ADA) and IFN-γ levels in pleural fluid.14

Pleural Fluid Examination

A TB pleural effusion is typically clear and straw colored; however, it can be turbid or serosanguinous but is virtually never grossly bloody. The effusion is virtually always an exudate.14Pleural fluid pH is usually between 7.30 and 7.40 (rarely ever > 7.40),2although it can be < 7.30 in approximately 20% of cases.32Pleural fluid glucose concentration is > 60 mg/dL in 80 to 85% of cases.22Pleural fluid glucose is < 30 mg/dL in approximately 15% of cases.21Although in the initial stage of

Antituberculosis Drugs

The natural history of an untreated tuberculous pleural effusion is characterized by spontaneous resolution in 4 to 16 weeks with subsequent development of active pulmonary TB or EPTB in 43 to 65% of cases over the next several years.102, 103These data emphasize the importance of proper diagnosis and treatment of tuberculous pleural effusions. According to the directly observed treatment short-course guidelines, severely ill patients with extensive or bilateral pleural effusions and sputum

Unresolved Issues and Conclusions

There have been significant advances in the understanding of pathophysiology of TB pleural effusions. The more frequent use of imaging modalities, such as CT, and bronchoscopic techniques, such as BAL, has lead to detection of underlying pulmonary TB in a larger proportion of patients. However, the implication of these findings in the treatment of patients with TB pleural effusion is unclear. Likewise, the estimation of ADA and IFN-γ in pleural fluid has gained wide acceptance in the diagnosis

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