Pleural Tuberculosis.

Pleural tuberculosis (TB) is common and often follows a benign course but may result in serious long-term morbidity. Diagnosis is challenging because of the paucibacillary nature of the condition. Advances in Mycobacterium culture media and PCR-based techniques have increased the yield from mycobacteriologic tests. Surrogate biomarkers perform well in diagnostic accuracy studies but must be interpreted in the context of the pretest probability in the individual patient. Confirming the diagnosis often requires biopsy, which may be acquired through thoracoscopy or image-guided closed pleural biopsy. Treatment is standard anti-TB therapy, with optional drainage and intrapleural fibrinolytics or surgery in complicated cases.

Tuberculous pleural effusion.

Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti-tuberculous therapy or a guideline-based individualized regimen in the case of drug resistance. There is low-quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short- and long-term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.

[Contribution of the Xpert MTB/RIF to the etiological diagnosis of tuberculous pleurisy]. / Apport de l'Xpert MTB/RIF dans le diagnostic étiologique des pleurésies tuberculeuses.

INTRODUCTION: Performance of the Xpert MTB/RIF for the detection of Mycobacterium tuberculosis in pleural liquid is poorly described. The aim of this study was to determine its usefulness for the etiological diagnosis of a tuberculous pleurisy. PATIENTS AND METHOD: We performed a descriptive cross-sectional study, with analytical design, including all the patients having a unilateral serofibrinous pleurisy, exudative, lymphocytic, and sterile. The diagnosis of pleural tuberculosis was considered based on epidemiological, clinical, paraclinical and therapeutic arguments. The Xpert MTB/RIF of the pleural fluid was carried out among all patients. RESULTS: Pleural tuberculosis was confirmed in 301 patients. The median age was 32years. Our study has included 217 men (72.1%) with a final sex ratio of 2.6. The cost of the pleural biopsy coupled with histology made it practicable in only 90 patients (29.9%) with a yield of 80%. The Xpert MTB/RIF of the pleural liquid was positive in only 10 patients (3.3% of the cases). CONCLUSION: Gene amplification by Xpert MTB/RIF of the pleural liquid is much less effective in establishing the diagnosis of tuberculous pleurisy than pleural biopsy, which remains the gold standard.

Treatment of free-flowing tuberculous pleurisy with intrapleural urokinase.

BACKGROUND AND OBJECTIVE: Patients with loculated tuberculous pleurisy (TBP) treated with urokinase suffer less from residual pleural thickening (RPT) than those treated with simple drainage. However, the role of intrapleural urokinase in free-flowing TBP patients remains unclear. METHODS: A total of 318 patients with presumed TBP were screened. The final 171 patients who participated in the study were randomly allocated to the urokinase group (n = 86) and the control group (n = 85). Personalised doses of urokinase were infused via a catheter. This procedure was repeated every 24 h until the volume of pleural fluid obtained was less than 50 ml after three injections. Changes in lung function and pleural thickening were recorded and compared between both groups periodically for 24 weeks. RESULTS: Seven patients (9.1%) had restrictive functional sequelae in the control group, while no patient in the urokinase group suffered from sequelae (P < 0.05). The incidence of RPT (⩾10 mm) was 0 for the urokinase group and 9.1% for the control group (P < 0.05). A lower percentage of patients treated with intrapleural urokinase had blunted costophrenic angle than controls (5.1% vs.19.5%, P < 0.05). CONCLUSIONS: Patients with free-flowing TBP treated with urokinase suffered less from RPT than those treated with drainage.

Normativa sobre el diagnóstico y tratamiento del derrame pleural. Actualización / Recommendations of Diagnosis and Treatment of Pleural Effusion. Update

A pesar de los múltiples avances diagnósticos o terapéuticos de la medicina de los últimos años, el derrame pleural (DP) continúa siendo una de las enfermedades que con frecuencia tiene que abordar el especialista de aparato respiratorio o el cirujano torácico. El presente texto no tiene como objetivo realizar una revisión exhaustiva sobre las enfermedades que pueden producir DP, su diagnóstico o su tratamiento, sino constituir una actualización de los conocimientos publicados en los últimos años. Teniendo en cuenta la vocación eminentemente práctica de esta normativa, se ha concedido más extensión a las enfermedades que presentan una mayor incidencia o prevalencia, aunque no hemos renunciado a un ligero recordatorio de otras menos frecuentes. Entre los mayores avances destacan los conocimientos sobre la utilidad de la ecografía torácica, los fibrinolíticos y los agentes pleurodésicos, o la utilización de nuevas técnicas de drenaje pleural, como los tubos torácicos finos o los catéteres tunelizados. La actualización periódica de las normativas favorece la potencial incorporación de nuevas técnicas en el estudio de la enfermedad pleural

Although during the last few years there have been several important changes in the diagnostic or therapeutic methods, pleural effusion is still one of the diseases that the respiratory specialist have to evaluate frequently. The aim of this paper is to update the knowledge about pleural effusions, rather than to review the causes of pleural diseases exhaustively. These recommendations have a longer extension for the subjects with a direct clinical usefulness, but a slight update of other pleural diseases has been also included. Among the main scientific advantages are included the thoracic ultrasonography, the intrapleural fibrinolytics, the pleurodesis agents, or the new pleural drainages techniques

[Application of continuous thoracic close drainage using central venous catheter in the treatment of tuberculous pleurisy in children].

OBJECTIVE: To study the clinical effect of continuous thoracic close drainage using central venous catheter instead of repeated thoracocentesis in the treatment of tuberculous pleurisy in children. METHODS: Thirty-nine children with tuberculous pleurisy, who received continuous thoracic close drainage using central venous catheter in addition to conventional antituberculous chemotherapy, were used as the observation group and 42 children with tuberculous pleurisy who underwent repeated thoracocentesis in addition to conventional antituberculous chemotherapy served as the control group. The two groups were compared in terms of time to pleural effusion absorption, improvement in pleural thickening, length of hospital stay, and puncture-related expenses. RESULTS: Compared with the control group, the observation group had significantly faster pleural effusion absorption (8 ± 4 d vs 12 ± 6 d; P < 0.01), significantly more improvement in pleural thickening (1.50 ± 0.25 mm vs 3.10 ± 0.30 mm; P < 0.05), a significantly shorter length of hospital stay (11 ± 3 d vs 18 ± 6 d; P < 0.01), and significantly lower puncture-related expenses (269 ± 24 yuan vs 475 ± 50 yuan; P < 0.05), as well as alleviated pain. CONCLUSIONS: Continuous thoracic close drainage using central venous catheter is superior to repeated thoracocentesis in the treatment of tuberculous pleurisy in children, and it holds promise for clinical application in pediatric patients.

Pleuresía tuberculosa como manifestación de reconstitución inmune en un paciente con sida: Descripción de un caso y revisión de la literatura / Tuberculous pleurisy as the manifestation of immune reconstitution in an AIDS patient: Description of a case and a review of the literature

El síndrome inflamatorio de reconstitución inmune es una complicación importante y precoz en respuesta a la implementación de la terapia antirretroviral de gran actividad, especialmente en pacientes con tuberculosis. Se describe el caso de un paciente de 35 años, con serología reactiva para HIV desde mayo 2011, y bajo terapia antirretroviral de gran actividad desde julio del mismo año. Se presentó a la consulta con síntomas de derrame pleural, y se le diagnosticó pleuresía tuberculosa. El paciente presentó una mejora en los síntomas generales y respiratorios a partir del quinto día de tratamiento.

Pleuresía tuberculosa como manifestación de reconstitución inmune en un paciente con sida: Descripción de un caso y revisión de la literatura / Tuberculous pleurisy as the manifestation of immune reconstitution in an AIDS patient: Description of a case and a review of the literature

El síndrome inflamatorio de reconstitución inmune es una complicación importante y precoz en respuesta a la implementación de la terapia antirretroviral de gran actividad, especialmente en pacientes con tuberculosis. Se describe el caso de un paciente de 35 años, con serología reactiva para HIV desde mayo 2011, y bajo terapia antirretroviral de gran actividad desde julio del mismo año. Se presentó a la consulta con síntomas de derrame pleural, y se le diagnosticó pleuresía tuberculosa. El paciente presentó una mejora en los síntomas generales y respiratorios a partir del quinto día de tratamiento.(AU)

Utilidad de la adenosina deaminasa (ADA): interferón gamma y biopsia pleural para el diagnóstico de tuberculosis pleural / Efficacy of the adenosine deaminase: interferon gamma and pleural biopsy for the diagnosis of pleural tuberculosis

El diagnóstico de la tuberculosis pleural es difícil usando solo los métodos convencionales. El objetivo de este trabajo es demostrar la eficacia de la adenosina deaminasa, interferón gamma y biopsia pleural para el diagnóstico de tuberculosis pleural y si estos biomarcadores podrían obviar la práctica de la biopsia. Se realizó el estudio prospectivo de 52 muestras de líquido pleural y 54 biopsias pleurales de 52 pacientes (M/F: 30/22). La edad promedio fue 38,8 ± 20,6 años. Los derrames fueron: tuberculosis pleural, 33 (63,46%), asociados a infección respiratoria baja. 10 (19,23%) y 9 neoplásicos (17,30%). La sensibilidad de interferon gamma, adenosina deaminasa y biopsia fue de: 88,0%, 76,0% y 65,0%, respectivamente y especificidad de: 78,0%, 63,0% y 100,0% respectivamente. Conclusiones: la adenosina deaminasa no es util aislada como método diagnóstico para la tuberculosis pleural. Se recomienda no obviar el cultivo ni la biopsia plaural y siendo Venezuela un país de alta prevalencia de tuberculosis, hacer de rutina, la medición de interferón gamma y la toracoscopia.

The diagnosis of pleural tuberculous is difficult using only conventional methods. The aim of this paper is to demostrate the efficacy of the adenosine deaminase Interferon gamma and pleural biopsy for the diagnosis of pleural tuberculosis and if these biomarkers could ignore the practice of the biopsy. The prospective study of 52 samples of pleural fluid and 54 pleural biopsies of 52 patients was conducted. The median age was 38.8 (20.6 years.). Tuberculosis etiology spills were 33 (63.46%): associated with low respiratory infection 10 (19.23%) and 9 neoplastic (17,30%). The sensitivity of Interferon gamma, adenosine deaminase and biopsy was 88.0%, 76.0% to 65.0% respectively and the specificity was 78.0% and 63.0% 100.0% respectively. Conclusions: the adenosine deaminase is not useful only as a diagnostic method for the pleural tuberculosis. It is recommended to not override the cultivation or do the pleural biopsy and being Venezuela as a country of high prevalence of tuberculosis. make routine, the measurement of gamma interferon and the thoracoscopy it is recommended.

[Extrapulmonary tuberculosis]. / La tuberculose extrapulmonaire.

Extrapulmonary tuberculosis represents an increasing proportion of all cases of tuberculosis reaching 20 to 40% according to published reports. Extrapulmonary TB is found in a higher proportion of women, black people and immunosuppressed individuals. A significant proportion of cases have a normal chest X-Ray at the time of diagnosis. The most frequent clinical presentations are lymphadenitis, pleuritis and osteoarticular TB. Peritoneal, urogenital or meningeal tuberculosis are less frequent, and their diagnosis is often difficult due to the often wide differential diagnosis and the low sensitivity of diagnostic tests including cultures and genetic amplification tests. The key clinical elements are reported and for each form the diagnostic yield of available tests. International therapeutic recommendations and practical issues are reviewed according to clinical presentation.

[Boerhaave's syndrome and pleural tuberculosis]. / Syndrome de Boerhaave et tuberculose pleurale.

INTRODUCTION: Boerhaave's syndrome is a rare condition involving spontaneous rupture of the oesophagus. The diagnosis is difficult and the prognosis depends on early diagnosis and treatment. CASE REPORT: We report a case of spontaneous rupture of the oesophagus in a 70-year-old woman where the diagnosis was delayed. Initial treatment comprised dual antibiotic therapy and feeding via a jejunostomy. Three months later, direct suture of the oesophagus was performed successfully. A routine pleural biopsy performed during the surgery revealed pleural tuberculosis. Antituberculous treatment was given for 6 months with good progress after 16 months follow up. CONCLUSION: Boerhaave's syndrome is a rare condition, the diagnosis of which remains difficult. The prognosis is related essentially to the speed of diagnosis. The treatment is always surgical within the framework of appropriate medical management (intensive care, antibiotic therapy). There should be a systematic search for associated pathology.

Pleural tuberculosis in children.

Pleural tuberculosis effusion (PTE) in children is a diagnosis which must be considered in isolated pleural effusions in non-toxemic children. It is more common in children over 5 years of age. A history of close contact with an adult with pulmonary tuberculosis reinforces the suspicion for its diagnosis. Pleural effusion without any parenchymal lesion is the characteristic finding on the chest x-ray. However, in 20% to 40% of patients, intrathoracic disease may also occur. Adenosine deaminase, interferon-gamma, analysis of pleural fluid and pleural biopsy are the main tools for diagnostic confirmation. Tuberculin skin test may provide supporting evidence of tuberculous infection. PTE has a good prognosis in children and no long term sequelae are expected.

Early effective drainage in the treatment of loculated tuberculous pleurisy.

The role of early effective drainage in loculated tuberculous (TB) pleurisy treatment remains unclear. Consecutive patients with TB pleurisy subjected to anti-TB treatment and pigtail drainage (n = 64) were divided into three groups: 1) patients with free-flowing effusions irrigated with saline (free-flowing group; n = 20); 2) patients with loculated effusions irrigated with streptokinase (streptokinase group; n = 22); and 3) patients with loculated effusions irrigated with saline (saline group; n = 22). Pleural irrigation was performed for 3 days consecutively and the effusion drained as completely as possible. Outcomes were assessed for 12 months by clinical symptoms, effusion removed, radiological scores for effusion amount, lung function and occurrence of residual pleural thickening. The total effusion volumes removed were significantly greater in the free-flowing (2.36+/-1.62 L) and streptokinase groups (2.59+/-1.77 L) than in the saline group (1.28+/-1.21 L). Compared with the saline group, the free-flowing and streptokinase groups showed significant improvement in radiological scores and forced vital capacity at different time-points during follow-up, and a significantly lower occurrence of residual pleural thickening. All outcome variables were comparable between the streptokinase and free-flowing groups. In summary, early effective drainage and complete anti-tuberculosis treatment may hasten clearance of pleural effusion, reduce residual pleural thickening occurrence and accelerate pulmonary function recovery in patients with symptomatic loculated tuberculous pleurisy.

A study of loculated tuberculous pleural effusions treated with intrapleural urokinase.

AIM: To assess the effect of intrapleural urokinase, vis-à-vis simple pleural drainage, on residual pleural thickening in a series of patients suffering from loculated tuberculous pleural effusion. PATIENTS AND METHOD: Twenty-nine patients (21 males and 8 females) with loculated pleural effusion were studied. These patients were randomly allocated to one of two groups: one group received intrapleural urokinase (n=12) and the other was treated by simple drainage with suction (n=17). The urokinase (125,000 UI) was administered into the pleural cavity via an intrathoracic tube. This procedure was repeated every 12h until the quantity of pleural fluid obtained was less than 50 cm3, at which point the intrathoracic tube was removed. RESULTS: In both groups, the biochemical analysis of the pleural fluid was an exudate and the fluid had a serous appearance. Pleural thickening when the drainage tube was removed was 8.09+/-3.36 mm for the group treated with urokinase, and 14.78+/-17.20mm (P>0.05) for the control group. Residual pleural thickening measured upon completion of medical treatment at 6 months was 1.45+/-0.89 mm for the group treated with urokinase and 7.47+/-10.95 mm for the control group (P<0.05). In the control group, only two patients presented over 10mm of residual pleural thickening. The mean quantity of fluid drained in the two groups was 1.487+/-711 ml for the patients with urokinase, and 795+/-519 ml for the control group (P<0.01). CONCLUSION: Our study shows that patients with loculated tuberculous pleural effusion treated with urokinase suffered less from residual pleural thickening, as measured after six months, than those treated by simple drainage. It is therefore suggested that the administration of intrapleural urokinase is a safe and effective treatment for those patients who drain a larger quantity of pleural fluid.