Diagnostic role of internal mammary lymph node involvement in tuberculous pleurisy: a multicenter study.

BACKGROUND AND OBJECTIVES: Diagnosis of tuberculous pleurisy (TP) may be challenging and it often requires pleural biopsy. A tool able to increase pre-test probability of TP may be helpful to guide diagnostic work-up and enlargement of internal mammary lymph node (IMLN) has been suggested to play a potential role. The aim of the present investigation was to assess role of IMLN involvement in TP in a multi-centric case-control study, by comparing its prevalence and test performance to those observed in patients with infectious, non-tuberculous pleurisy (NTIP), and in controls free from respiratory diseases (CP). METHODS: A total of 419 patients, from 14 Pulmonology Units across Italy were enrolled (127 patients affected by TP, 163 affected by NTIP and 129 CP). Prevalence, accuracy and predictive values of ipsilateral IMLN involvement between cases and control groups were assessed, as well as concordance between chest computed tomography (CT scan) and thoracic ultrasound (TUS) measurements. RESULTS: The prevalence of ipsilateral IMLN involvement in TP was significantly higher than that observed in NTIP and CP groups (respectively 77.2%, 39.3% and 14.7%). Results on test performance, stratified by age, revealed a high positive predictive value in patients aged ≤50 years, while a high negative predictive value in patients aged >50 years. The comparison between CT scan and ultrasound showed moderate agreement (Kappa=0.502). CONCLUSIONS: Evaluation of IMLN involvement plays a relevant role in assessing the pre-test probability of TP. Considering the increasing global prevalence of mycobacterial infections, a tool able to guide diagnostic work-up of suspected TP is crucial, especially where local sources are limited.

Practical management of pleural empyema.

Empyema is defined as pus in the thoracic cavity due to pleural space infection and has a multifactorial underlying cause, although the majority of cases are post-bacterial pneumonia. Despite treatment with antibiotics, patients with empyema have a considerable morbidity and mortality due at least in part to inappropriate management of the effusion. Timely diagnosis of pleural space infection and rapid initiation of effective pleural drainage represent fundamental principles for managing patients with empyema. Ultrasound is particularly useful to identify early fibrin membranes and septations in the pleural cavity conditioning treatment strategy. Empyema and large or loculated effusion with a pH < 7.20 need to be drained. Thoracoscopy has largely been used in pleural effusion due to lung infection. Whereas the efficacy of video-assisted thoracic surgery (VATS) in empyema management has been evaluated in several retrospective studies showing favourable results, less is known about the role of medical thoracoscopy (MT) in pleural infection. MT, appears to be safe and successful in multiloculated empyema treatment. It is also lower in cost and in frail patients is better tolerated than VATS which requires tracheal intubation.

Thoracoscopy in pleural malignant mesothelioma diagnosis.

On the basis of our personal experience in 70 cases (66 pleural effusions) observed during the period January 1984- January 1996 we are here illustrating and discussing the diagnostic role of thoracoscopy in malignant pleural mesothelioma.A histological diagnosis was achieved in 94.2% of cases. The endoscopic appearance was clearly neoplastic (masses, nodules) in 53 patients (75.7%) and simply inflammatory in 17 pachypleuritis in 13 (18.6%) and of diffuse hyperemia in 3 (5.7%). In all cases fluid cytology (diagnostic yield: 18.5%) and needle biopsy (diagnostic yield 17.1%) were performed.The extension of pleural involvement (endoscopic staging according to Boutin) was also determined. In 16 patients (22.8%) a parietal and diaphragmatic involvement (stage Ia) was found. In 40 patients (57.2%) an associated visceral invasion (stage Ib). In 14 cases (20%) a diffuse parietal, visceral and mediastinal extension (stage II). The exam has always been well tolerated with few immediate complications: subcutaneous emphysema (4 cases) and some negligeable parietal bleeding (2 cases).