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%
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 gamma
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
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