Tuberculous Pleural Effusion

AM Report 8/11/08 Maggie Davis Hovda, MD

Epidemiology

Pleural TB is second most common extrapulmonary TB site behind lymph node involvement In NC in 2006, there were 24 pleural TB cases which was 29% of the extrapulmonary cases From 1993 -2003, of patients with Pleural TB 36% black, 25% white, 20% hispanic and 36% were foreign born

Pathogenesis

TB Pleural effusion can be seen in either primary disease or reactivation disease Effusion a result of the rupture of a subpleural foci of TB into the pleural space that leads to a delayed hypersensitivity reaction to the TB antigens Tuberculous empyema same mechanism as above with spillage of large amount of mycobacterium into pleural space purulent effusion that requires surgical intervention and can result in pleural fibrosis and restrictive lung disease

CT scan showing a parenchymal focus of tuberculosis close to the pleura and an ipsilateral pleural effusion. Courtesy of Paul Stark, MD www.uptodate.com 2008

Clinical Presentation

usually presents as an acute illness (1 wk 1 mo symptoms) presenting symptoms: pleuritic chest pain and nonproductive cough common to have other symptoms of TB night sweats, weight loss, dyspnea physical exam consistent with pleural effusion decreased breath sounds, dullness to percussion at site of disease

Clinical Presentation

CXR small to moderate sized unilateral pleural effusion Pleural Fluid

-Straw colored appearance -exudative -pH 7.3 7.4 -glucose usually > 60 -Cell count usually 1000 6000 with lymphocytic predominance

Differential Diagnosis

Lymphocytic Effusion

TB Malignancy Lymphoma Collagen vascular disease Post coronary artery bypass grafting

Diagnosis

TB skin test
-helpful if +, especially in areas of low prevalence of disease -oftentimes negative but if repeated 6-8 weeks later usually +

Radiology
-CXR with small moderate sized unilateral effusion and associated parenchymal lung lesions in 20-50% -CT scan better at documenting parenchymal lung disease (80% of cases). Also better at delineating TB pleural effusion complications such as pleural thickening, calcification, loculated effusions, empyema, empyema necessitatis, and bronchopleural fistula

Diagnosis

Sputum
-can have + M Tuberculosis cultures 20-50% time -increased yield on sputum cultures with parenchymal lung lesions on radiographs -should still be pursued in areas where other means of diagnosis not available

Diagnosis Pleural Fluid

Microbiology

for + smear, need 10,000 tubercle/ml, so AFB detects <10% for + M Tuberculosis culture, need 10-100 viable bacilli, so has a higher yield, but still usually <30% enzyme in purine salvage pathway that is important in differentiation of lymphoid cells and has increased activity with increased lymphocyte activity high sensitivity (90-100%) cutoff is 40: >40 supportive of TB, <40 virtually excludes TB produced by t-lymphocytes to activate macrophages increased in TB pleural effusion due to increased numbers of T-lymphocytes present more sensitive and specific vs. ADA, but more expensive and less available so not used as much

Adenosine Deaminase (ADA)

Interferon gamma

Diagnosis

Pleural Biopsy

most sensitive test tissue via closed needle biopsy or thoracoscopy Histology: caseating granulomas (50-97%) Culture for M Tuberculosis + in 40-80% Combo of above two leads to diagnosis in 60 95% cases

Treatment

If left untreated, effusions usually resolve in 4-16 weeks and are followed by development of active pulmonary TB or extrapulmonary TB in 43-65% cases Antimicrobial therapy is the same as for pulmonary TB

4 drug therapy for 2 months with isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4 mo of isoniazid and rifampin

Steroids have been studied in TB pleural effusion with no definite benefit.

Studies did note earlier resolution of symptoms (fever, chest pain, dyspnea) in patients treated with steroids, but no difference in the development of pleural thickening, adhesions, or residual lung function.

References

Gopi et al. Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006. Chest. 2007, 131: 880. Baumann et al. Pleural Tuberculosis in the United States Incidence and Drug Resistance. Chest 2007, 131: 1125. Frye, M. and Sahn, S. Tuberculous pleural effusions in non-HIV infected patients. www.uptodate.com 2008 Lee et al. Adenosine Deaminase Levels in Nontuberculous Lymphocytic Pleural Effusions. Chest 2001, 120:356