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Tuberculous Pleural Effusion  AM Report 8/11/08 Maggie Davis Hovda, MD

8.11.08 Davis-Hovda. TB pleurisy.ppt

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TuberculousPleural Effusion

 AM Report

8/11/08

Maggie Davis Hovda, MD

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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 TB36% black, 25% white, 20% hispanic and

36% were foreign born

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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 delayedhypersensitivity reaction to the TB antigens

Tuberculous empyema  – same mechanism as

above with spillage of large amount of 

mycobacterium into pleural space purulenteffusion that requires surgical intervention and can

result in pleural fibrosis and restrictive lung disease

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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 

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Clinical Presentation

usually presents as an acute illness (1 wk  – 1mo 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 topercussion at site of disease

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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

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Differential Diagnosis

Lymphocytic Effusion

TB

Malignancy

Lymphoma

Collagen vascular disease

Post coronary artery bypass grafting

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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 pleuraleffusion complications such as pleural thickening,

calcification, loculated effusions, empyema, empyema

necessitatis, and bronchopleural fistula

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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

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Diagnosis  – Pleural Fluid

Microbiologyfor + 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%

 Adenosine Deaminase (ADA)

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

Interferon gammaproduced by t-lymphocytes to activate macrophages

increased in TB pleural effusion due to increased numbers of T-lymphocytespresent

more sensitive and specific vs. ADA, but more expensive and less available sonot used as much

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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

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Treatment

If left untreated, effusions usually resolve in 4-16 weeks and arefollowed 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 definitebenefit.

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 lungfunction.

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References

Gopi et al. Diagnosis and Treatment of TuberculousPleural 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 effusionsin non-HIV infected patients. www.uptodate.com 2008

Lee et al. Adenosine Deaminase Levels inNontuberculous Lymphocytic Pleural Effusions.Chest 2001, 120:356