Is there gender inequality in the epidemiological profile of tuberculosis?

BACKGROUND: Worldwide, many more males than females were diagnosed with tuberculosis (TB) and died from it globally. In light of this, examining the gender differences among patients with TB is crucial to institute effective prevention, coverage and treatment. AIM: To analyze gender differences in the epidemiological, clinical and evolutionary specificities of TB in Southern Tunisia. METHODS: We conducted a retrospective study including all new cases of TB of any age, diagnosed between January 1995 and December 2016. Data were collected from the regional register of TB at the Center of Tuberculosis Control of Sfax, Southern Tunisia. RESULTS: We recorded 2771 new cases of TB. The sex ratio was 1.2. We noted 1160 new cases with pulmonary TB (PTB) (41.9%). Males were more likely to have PTB than females (Odds Ratio (OR)=2.5;p<0.001), while extra-pulmonary TB (EPTB) was more common in females (OR=0.4;p<0.001). Lymph node (OR=2.6;p<0.001), cutaneous (OR=2.3;p<0.001) and abdominal TB (OR=2;p<0.001) were significantly more frequent in females. Pleural TB was significantly more common in males (OR=1.2; p<0.001). Case fatality rate was significantly higher in males (OR=1.7;p=0.02). Females experienced recovery more frequently (OR=1.3;p=0.04). Treatment duration was significantly higher in females (8.88±3.6months vs.8.41±3.2months; p<0.001). Between 1995 and 2016, the age standardized notification rate (ASNR) of TB (Rho=0.68; p<0.001) and EPTB (Rho=0.59 p=0.003) had significantly increased in females, while it had not significantly changed in males. CONCLUSION: Our study highlighted higher burden and morbidity in males in TB cases in Southern Tunisia. National TB programs should actively focus on these facts with more routine diagnostic and screening targeting males.

Immune reconstitution inflammatory syndrome in tuberculous pleurisy and ulcerative colitis: a case report.

We present the case of a 46-year-old Caucasian male, affected by ulcerative colitis, who developed tuberculous pleurisy during immunosuppressive therapy; despite proper therapy, worsening of the radiological findings was observed. The case was discussed among an online group of Italian physicians and diagnosis of immune reconstitution inflammatory syndrome (IRIS) tuberculosis was established. Therapy was continued and full recovery was obtained. IRIS is a syndrome initially described during opportunistic infections in HIV infected after being placed in anti-retroviral therapy. It reveals itself through a wide variety of manifestations, including fever, lymphadenopathies, worsening of lung infiltrates, pleural or pericardial effusion, central nervous system involvement. Few data are available regarding the best therapeutic options. IRIS is an insidious and potentially serious complication of opportunistic infections in immunocompromised patients. The always wider diffusion of immunosuppressive therapies increases the number of patients at risk, therefore physicians need to be aware of the issue.

Comparison of pleural effusion features and biomarkers between talaromycosis and tuberculosis in non-human immunodeficiency virus-infected patients.

BACKGROUND: Due to the similar clinical, lung imaging, and pathological characteristics, talaromycosis is most commonly misdiagnosed as tuberculosis. This study aimed to identify the characteristics of talaromycosis pleural effusion (TMPE) and to distinguish TMPE from tuberculosis pleural effusion (TPE). METHODS: We enrolled 19 cases each of TMPE and TPE from Guangxi, China. Patients' clinical records, pleural effusion tests, biomarker test results, and receiver operating characteristic curves were analyzed. RESULTS: In total, 39.8% (65/163) of patients exhibited serous effusion, of whom 61 were non-human immunodeficiency virus (HIV)-infected patients; 68.85% of the non-HIV-infected patients (42/61) had TMPE. Thoracentesis was performed only in 19 patients, all of whom were misdiagnosed with tuberculosis and received long-term anti-tuberculosis treatment. In four of these patients, interleukin (IL)-23, IL-27, and interferon-gamma (IFN-γ) measurements were not performed since pleural effusion samples could not be collected because the effusion had been drained prior to the study. In the remaining 15 patients, pleural effusion samples were collected. Talaromyces marneffei was isolated from the pleural effusion and pleural nodules. Most TMPEs were characterized by yellowish fluid, with marked elevation of protein content and nucleated cell counts. However, neutrophils were predominantly found in TMPEs, and lymphocytes were predominantly found in TPEs (both p < 0.05). Adenosine deaminase (ADA) and IFN-γ levels in TMPEs were significantly lower than those in TPEs (all p < 0.05) and provided similar accuracies for distinguishing TMPEs from TPEs. IL-23 concentration in TMPEs was significantly higher than that in TPEs (p < 0.05), and it provided similar accuracy for diagnosing TMPEs. IL-27 concentrations in TMPEs were significantly lower than those in TPEs (all p < 0.05) but was not useful for distinguishing TMPE from TPE. CONCLUSIONS: Talaromycosis can infringe on the pleural cavity via the translocation of T. marneffei into the pleural space. Nonetheless, this phenomenon is still commonly neglected by clinicians. TMPE is a yellowish fluid with exudative PEs and predominant neutrophils. Higher neutrophil counts and IL-23 may suggest talaromycosis. Higher lymphocyte counts, ADA activity, and IFN-γ concentration may suggest tuberculosis.

[A case of tuberculous meningitis with pleural effusion as a manifestation of a paradoxical reaction during anti-tuberculosis therapy].

We present a case of tuberculous meningitis (TBM), wherein pleural effusion developed as a manifestation of paradoxical reaction during anti-tuberculosis therapy. An 87-year-old diabetic man was referred to our clinic for fever and impaired consciousness. He did not obey vocal commands. No ocular motor deficit, facial palsy, or limb weakness was observed. He had hyponatremia due to inappropriate antidiuresis. Examination of the cerebrospinal fluid revealed lymphocytosis and high adenosine deaminase (ADA) activity, suggestive of TBM. He was treated with isoniazid, rifampicin, and pyrazinamide, after which his symptoms quickly resolved. Lymphocyte count, ADA activity, and protein concentration in the cerebrospinal fluid decreased. However, approximately 30 days after the initiation of therapy, he developed mild hypoxemia. A chest CT scan revealed pleural effusion. The pleural fluid was exudate with elevated ADA activity, which was consistent with tuberculous pleural effusion. Shortly after the use of a herbal medicine, Goreisan extract, hyponatremia and hypoproteinemia improved, and the pleural effusion was reduced. Approximately one-third of patients with TBM are reported to develop a paradoxical reaction, such as tuberculoma, hydrocephalus, and optochiasmatic and spinal arachnoiditis. The present case suggests that extra-central nervous system manifestations, including pleural effusion, should be considered when treating TBM.

Tubercular liver abscess rupturing into the pleural cavity: a rare complication.

Liver abscesses, either pyogenic or amoebic, with or without the involvement of the pleura, are not infrequently encountered in children. Isolated tubercular liver abscess without active pulmonary, gastrointestinal or other clinical evidence of tuberculosis is, however, rare and more so its rupture into the pleura. We report a case of a 14-year-old girl who presented with a liver abscess rupturing into the pleura causing an empyema. Successful management was achieved by intercostal tube drainage and antitubercular treatment.

Tuberculous pleural effusion: diagnosis & management.

Background: Tuberculosis (TB) is the world's leading cause of death from infectious disease. The World Health Organization (WHO) recognized 6.3 million new TB cases in 2017, 16% corresponding to extrapulmonary forms; pleural tuberculosis (PT) is the most common extrapulmonary form in adults. PT diagnosis is often challenging because the scarcity of bacilli in pleural fluid (PF), sometimes requiring invasive procedures to obtain pleural tissue for histological, microbiological or molecular examination. In regions of medium and high disease prevalence, adenosine deaminase (ADA), interferon gamma (IFN-γ) and interleukin 27 (IL-27) dosages are useful to establish presumptive diagnosis in patients with compatible clinical/radiological picture who present with lymphocytic pleural effusion. PT treatment is similar to the pulmonary TB treatment regimen recommended by WHO. Area covered: In this update, we present a PT review, including epidemiology, pathogenesis, clinical features, diagnosis, and therapy. Expert opinion: There is no PF test alone accurate for PT diagnosis, despite the evolution in clinical laboratory. ADA, IFN-γ and IL-27 are valuable laboratory biomarkers; however, IFN-γ and IL-27 are quite expensive. Molecular tests present low sensitivity in PF, being useful for diagnostic confirmation. Multidrug therapy remains the PT treatment choice. Advancing research in immunotherapy may bring benefits to PT patients.

Potential biomarkers for antidiastole of tuberculous and malignant pleural effusion by proteome analysis.

AIM: To investigate novel potential biomarkers for antidiastole of tuberculous pleural effusion (TPE) from malignant pleural effusion (MPE). MATERIALS & METHODS: iTRAQTM-coupled LC-MS/MS were applied to analyze the proteome of TPE and MPE samples. The candidate proteins were verified by enzyme-linked immunosorbent assay. RESULTS: A total of 432 differential proteins were identified. Enzyme-linked immunosorbent assay revealed significantly higher levels of fibronectin (FN) and cathepsin G (CTSG) in MPE than in TPE, but lower levels of leukotriene-A4 hydrolase (LTA4H). The receiver operator characteristic values were 0.285 for FN, 0.64 for LTA4H, 0.337 for CTSG and 0.793 for a combination of these candidate markers. CONCLUSION: FN, LTA4H and CTSG were identified as potential biomarkers to differentiate TPE from MPE and their combination exhibited higher diagnostic capacity.

Pleurisy Caused by Mycobacterium abscessus in a Young Patient with Dermatomyositis: A Case Report and Brief Review of the Literature.

M. abscessus is a rapidly growing mycobacteria (RGM) and is the most common cause of pulmonary RGM infection. M. abscessus pleurisy is extremely rare. We herein report the case of a young patient with M. abscessus pleurisy without any lung lesions. A laboratory analysis of the pleural effusion revealed lymphocyte predominance and increased adenosine deaminase, similar to the findings observed in tuberculous pleurisy. The patient was initially treated for tuberculous pleurisy, which resulted in the partial improvement of the patient's symptoms and pleural effusion. M. abscessus pleurisy should be considered, especially in immunocompromised individuals, even in the absence of pulmonary involvement.

The Role of Video-Assisted Thoracoscopic Therapeutic Resection for Medically Failed Pulmonary Tuberculosis.

There are few reports regarding video-assisted thoracoscopic therapeutic resection for medically failed pulmonary tuberculosis (TB). We reviewed our surgical results of video-assisted thoracoscopic surgery (VATS) therapeutic resection for pulmonary TB with medical failure, and its correlation with image characteristics on chest computed tomography (CT) scan.Between January 2007 and December 2012, among the 203 patients who had surgery for TB, the medical records of 89 patients undergoing therapeutic resection for medically failed pulmonary TB were reviewed. Clinical information and the image characteristics of CT scan were investigated and analyzed.Forty-six of the 89 patients undergoing successful VATS therapeutic resection had significantly lower grading in pleural thickening (P < 0.001), peribronchial lymph node calcification (P < 0.001), tuberculoma (P = 0.015), cavity (P = 0.006), and aspergilloma (P = 0.038); they had less operative blood loss (171.0 ±â€Š218.7 vs 542.8 ±â€Š622.8 mL; P < 0.001) and shorter hospital stay (5.2 ±â€Š2.2 vs 15.6 ±â€Š15.6 days; P < 0.001). They also had a lower percentage of anatomic resection (73.9% vs 93.0%; P = 0.016), a higher percentage of sublobar resection (56.5% vs 32.6%; P = 0.023), and a lower disease relapse rate (4.3% vs 23.3%; P = 0.009). Eighteen of the 38 patients with multi-drug resistant pulmonary tuberculosis (MDRTB) who successfully underwent VATS had significantly lower grading in pleural thickening (P = 0.001), peribronchial lymph node calcification (P = 0.019), and cavity (P = 0.017). They were preoperatively medicated for a shorter period of time (221.6 ±â€Š90.8 vs 596.1 ±â€Š432.5 days; P = 0.001), and had more sublobar resection (44.4% vs 10%), less blood loss (165.3 ±â€Š148.3 vs 468.0 ±â€Š439.9 mL; P = 0.009), and shorter hospital stay (5.4 ±â€Š2.6 vs 11.8 ±â€Š6.9 days; P = 0.001).Without multiple cavities, peribronchial lymph node calcification, and extensive pleural thickening, VATS therapeutic resection could be safely performed in selected patients with medically failed pulmonary TB as an effective adjunct with satisfactory results.

Estabilidad de la adenosina deaminasa en diferentes medios de transporte del líquido pleural / Adenosine deaminase stability in pleural effusions defferent means of transport

La determinación de los niveles de la adenosina deaminasa en el líquido pleural es sensible y específica para la tuberculosis pleural. La adenosina deaminasa en el líquido pleural disminuye con el tiempo a temperatura ambiente. El objetivo de este estudio es demostrar si existe diferencia en los valores de la adenosina deaminasa en líquidos pleurales en cuatro medios diferentes de transporte (hielo, citrato de sodio, heparina y ninguna sustancia, química añadida). Se determinaron los niveles de la enzima en ochenta y ocho (88) muestras de líquido pleural procedentes de 22 pacientes con derrames pleurales no diagnosticados. Se demostró la concordancia diagnóstica entre los diferentes medios de transporte. No se demostró diferencia significativa entre los niveles de la adenosina deaminasa en cada una de los diferentes medios de transporte hasta dos (2) horas posterior a su recolección. Se recomienda enviar las muestras de líquido pleural con el conservativo adecuado o con ácido etilen diamino tetracético de rutina en nuestro país

The determination of the levels of adenosine deaminase in pleural fluid is sensitive and specific for pleural tuberculosis. Adenosine deaminase in pleural fluid decreases over time at room temperature. The objective of this study is to demostrate if there is difference on the average values of adenosine deaminasa in pleural fluids in four different means of transport (ice, sodium citrate, heparin and no added chemical substance). The levels of the enzyme in eighty-eight (88) pleural fluid samples from 22 patients with diagnosed pleural effusions were determined. We demonstrated diagnostic concodance between the differents modes of transport. No significant difference is between the levels of adenosine deaminase in each of the different means of transport up to two (2) hours after collection. It is recommended to send by routine in our country samples of pleural fluid with the right conservative or Acid etilen diamino tetracetic

Pleural tuberculosis following lung cancer chemotherapy: a report of two cases proven pathologically by pleural biopsy.

Malignancy per se and cytotoxic chemotherapy given for its treatment both are recognised risk factors for the development of tuberculosis (TB). However, individual case descriptions of pleural tuberculosis (TB-PE) following chemotherapy for lung cancer (LC) have not been published previously. We herein report the first two cases of histopathologically proven TB-PE following LC chemotherapy. The first patient was a 38-year-old man with stage IV non-small cell LC (adenocarcinoma) who developed TB-PE following four cycles of chemotherapy (pemetrexed-cisplatin). The second patient was a 49-year-old man with extensive disease small cell LC who developed TB-PE after six cycles of chemotherapy (irinotecan-cisplatin). In both patients, diagnosis of TB-PE was established by demonstration of granulomatous inflammation, caseous necrosis and positive stain for acid-fast bacilli in pleural biopsy specimens. Both cases responded to standard four-drug antitubercular therapy. These cases highlight the importance of carrying out an extensive evaluation for exudative pleural effusions in LC patients receiving chemotherapy, especially in countries with high TB prevalence. Attributing such pleural effusions to disease progression, without histopathological confirmation, may be associated with disastrous consequences.

[Non-tuberculous pleural infections versus tuberculous pleural infections]. / Atteintes pleurales non tuberculeuses versus atteintes pleurales tuberculeuses.

INTRODUCTION: In countries where tuberculosis is endemic, the main differential diagnosis for pleural infection by common bacteria is pleural tuberculosis. OBJECTIVE: The purpose of our study was to determine the differences between pleural infection by common bacteria and that caused by pleural tuberculosis. METHODOLOGY: Our study was a retrospective analysis and compared the characteristics of confirmed pleural infection by common bacteria (PIB) and that due to pleural tuberculosis (PT). RESULTS: For the PIB, the signs evolved for 2.4 ± 1.4 weeks versus 5.6 ± 2.2 weeks for the PT (P=0.01). In multivariate analysis, for PIB the onset of symptoms was more abrupt (OR=3.8 [1.5; 9.9]; P=0.01), asthenia was less frequent (OR=0.3 [0.1; 0.9]; P=0.03), pleural liquid was more purulent (OR=40.0 [15.0; 106.7]; P<0.01). The blood neutrophil count was more frequently raised in cases of PIB (OR=2.5 [1.2; 5.4]; P=0.02). Pneumothorax/hydropneumothorax was less frequent in PIB (OR=0.3 [0.1; 1.0]; P=0.04). CONCLUSION: Clinical differences exist between pleural effusions caused by tuberculosis (TB) and those due to other bacterial infections. However, they are not sufficiently sensitive and therefore the search for the tuberculous bacillus must be systematic while waiting for implementation of new diagnostic tests for the organism.

[A case of Mycobacterium avium pleuritis and pneumothorax in a rheumatoid arthritis patient treated with a TNF-alpha antagonist].

A 70-year-old woman with rheumatoid arthritis received treatment with corticosteroids and methotrexate for 4 years, followed by an additional TNF-alpha antagonist (infliximab) for about 3 years. She presented with a several-week history of persistent cough, and CT images of the lung showed a thin-walled cavitary lesion abutting the pleural surface of the left upper lobe. While we investigated the cause of this lesion, we admitted her because of acute chest pain. Chest radiography demonstrated moderate left-sided pneumothorax with pleural effusion. After further investigation, we suspected that her pneumothorax and pleuritis had been caused by a ruptured cavitary lesion arising from a Mycobacterium avium infection. Despite multi-drug therapy, chest tube drainage and surgical pulmorrhaphy her pleural complications were intractable. This is a rare case of pneumothorax and pleuritis caused by Mycobacterium avium infection induced by a TNF-alpha antagonist. Physicians should be aware of nontuberculous mycobacterial infections in patients treated with TNF-alpha antagonists.

Tuberculosis pleural: Utilidad de la reacción en cadena de la polimerasa en muestras de tejido / Pleural tuberculosis: use of the polymerase chain reaction in tissue samples

El diagnóstico etiológico del derrame pleural tuberculoso, es difícil. La clínica y los ensayos paraclínicos suelen ser inespecíficos. El objetivo de este trabajo fue evaluar la sensibilidad y especificidad de la reacción en cadena de la polimerasa en tejido pleural para el diagnóstico de tuberculosis en comparación con el cultivo e histopatología, en pacientes con derrame pleural que ingresaron al servicio de Medicina Interna del Hospital “Dr. Domingo Luciani”, Caracas, Venezuela, entre abril de 2005 y agosto de 2006. Se estudiaron 52 pacientes, M/F (30 (57,7 por ciento)/22 (42,3 por ciento), con una edad promedio de 39 años. El valor de sospecha clínica fue del 69,2 por ciento. El cultivo resultó positivo en 6 casos (11,5 por ciento) y se identificaron lesiones granulomatosas tuberculoides en 40,4 por ciento. La reacción en cadena de la polimerasa mostró una sensibilidad del 50 por ciento y especificidad del 61 por ciento. Se concluyó que es una prueba eficaz para el diagnóstico de tuberculosis pleural

The diagnosis of tuberculous pleural effusion is difficult. The clinical trials and paraclinical essays are often nonspecific. The aim of this study was to evaluate the sensitivity and specificity of the polymerase chain reaction in pleural tissue for the diagnosis of tuberculosis in comparison with the culture and histopathological studies in patients with pleural effusion admited to the service of Internal Medicine Hospital Dr. Domingo Luciani, Caracas, Venezuela, between April 2005 and August 2006. We studied 52 patients, M/F (30 (57.7 percent)/22 (42.3 percent), with an average age of 39 years. The value of clinical suspicion was 69.2 percent. The culture was positive in 6 cases (11.5 percent) and tuberculoides granulomatous lesions were identified in 40.4 percent. Polymerase chain reaction showed a sensitivity of 50 percent and specificity of 61 percent. It was concluded that it is an effective test for the diagnosis of pleural tuberculosis

Renal allograft tuberculosis: report of three cases and review of literature.

Renal transplant recipients are prone to a variety of infections due a persistent immunodepleted state. Incidence of tuberculosis in this population is much higher compared with the general population. While pulmonary tuberculosis still remains the commonest form in this population, renal allograft tuberculosis is very rare. We report two cases of isolated allograft tuberculosis and one case of allograft tuberculosis with coexistent pleuro-pulmonary and bone marrow involvement. All three cases had presented with pyrexia of unknown origin, wherein despite extensive investigations the cause was not found. In two cases the diagnosis was confirmed on histology. Two cases responded to non-rifampicin-based modified antitubercular treatment and one to conventional four-drug Rifampicin-based regimen. Graft function improved in two cases while in one case the graft was lost. Tuberculosis involving the renal allograft is a potential cause for graft dysfunction/loss and requires a high index of suspicion for diagnosis. Timely detection and early institution of therapy can help save the renal allograft.

CD4+CD25+ regulatory T lymphocytes in tuberculous pleural effusion.

BACKGROUND: Active suppression by CD4+CD25+ regulatory T lymphocytes plays an important role in the down-regulation of T cell responses to foreign and self-antigens. This study was conducted to analyze whether the CD4+CD25+ regulatory T cells exist and function normally in tuberculous pleural effusion. METHODS: The percentages of CD4+CD25+ T cells in pleural effusion and peripheral blood from patients with tuberculous pleurisy and peripheral blood from healthy control subjects were determined by flow cytometry. The expression of forkhead transcription factor Foxp3 was also examined. CD4+CD25+ and CD4+CD25(-) T cells from pleural effusion and blood were isolated, and were cultured to observe the effects of CD4+CD25+ T cells on proliferation response of CD4+CD25(-) T cells in vitro. RESULTS: There were increased numbers of CD4+CD25+ T cells in tuberculous pleural effusion compared with peripheral blood from both patients with tuberculous pleurisy and normal subjects, and these cells demonstrated a constitutive high-level expression of Foxp3. Moreover, CD4+CD25+ T cells mediated potent inhibition of proliferation response of CD4+CD25(-) T cells. CONCLUSION: The increased CD4+CD25+ T cells in tuberculous pleural effusion express a high level of Foxp3 transcription factor, while potently suppressing the proliferation of CD4+CD25(-) T cells.

[A study on the model of tuberculous pleurisy and intrapleural inflammatory and immunological responses in rats].

OBJECTIVE: To develop a rat model of tuberculous pleurisy and to explore the mechanism of intrapleural inflammatory and immunological responses. METHODS: Fifty Wistar rats were injected intrapleurally with 0.03 mg of standard human mycobacterium tuberculous bacilli H37Rv each. The rats were killed in group on days 1, 2, 3, 5, 7, 10, 15, 20, 30 and 60 after the day of intrapleural injection. The thorax was opened and the amount of pleural effusion was recorded, and histopathology of pleural tissues and lung tissues were observed. The white blood cell (WBC) count and differentials, levels of total protein (TP), glucose (GLU) and lactic dehydrogenase (LDH) of pleural effusions were determined. Pleural fluid was analyzed for the levels of soluble intercellular adhesion molecule-1 (sICAM-1), transforming growth factor beta1 (TGF-beta1) and interferon gamma (IFN-gamma) by using appropriate bioassays. Ten rats were intrapleurally received 2 ml of normal saline and another 10 rats received 2 ml of undiluted PPD solution each as control. RESULTS: Bilateral pleural effusions appeared within 15 days in all rats intrapleurally received tuberculous bacilli. The peak amount of pleural fluid was on day 5 (6.7 +/- 0.5 ml). The neutrophils were the predominant cells for the first 24 hours, and then were followed by lymphocytes. In the pleural fluid, total protein concentration was between 51-55 g/L. The levels of glucose and LDH were 5.2 mmol/L and 18.1 micromol.s(-1).L(-1) on day 1 and changed to 2.8 mmol/L and 28.9 micromol.s(-1).L(-1) on day 15 respectively. The biochemistry parameters were in accordance with characteristics of tuberculous pleurisy. The sICAM-1 level increased early (21.9 ng/ml on day 1) and peaked on day 3 (38.0 ng/ml), then decreased over time (4.4 ng/ml on day 15). The level of IFN-gamma was 41.2 pg/ml on day 1 and increased and maintained at high levels over time. TGF-beta1 levels increased and peaked on day 7 (47.2 ng/ml), and then on day 15 decreased to a level lower than that of day 1. The ratio of IFN-gamma/TGF-beta1 increased from 1.32 on day 1 to 5.69 on day 15. Correlation analysis showed that sICAM-1 and IFN-gamma were closely related with WBC count and its differentials, as well as with LDH levels. Histopathological study revealed early pleural inflammation and late caseation. CONCLUSIONS: Wistar rats can be used as an experimental model for tuberculous pleurisy. Tuberculous inflammatory and immunological responses in acute tuberculous pleurisy is enhanced rather than suppressed.

Characteristics of patients suffering from tuberculous pleuritis with pleural effusion culture positive and negative for Mycobacterium tuberculosis, and risk factors for fatality.

SETTING: A 2500-bed hospital. OBJECTIVES: To clarify characteristics of tuberculous pleuritis (TP) with pleural effusion culture positive and negative for Mycobacterium tuberculosis (PECP-MT and PECN-MT) and to identify risk factors for fatality. PATIENTS AND METHODS: Retrospective analysis of TP patients with PECP-MT and PECN-MT, and review of medical charts of deceased patients. RESULTS: Of 126 patients enrolled (28 PECP-MT and 98 PECN-MT), those with PECP-MT had a higher prevalence of steroid use (SU) (14.3% vs. 2.0%; P = 0.022) and concurrent tuberculosis involving another site (7.2% vs. 0.0%; P = 0.048), increased neutrophils (36.4% vs. 16.6%; P = 0.020) and decreased glucose levels (mean 88.7 vs. 127.6 g/dl; P = 0.012) in pleural effusion, and a higher fatality rate (28.0% vs. 3.1%; P < 0.001). Deceased patients (n = 10) were older (mean 74.2 vs. 64.4 years; P = 0.047), had a higher incidence of acute renal failure (ARF) (50.0% vs. 11.7%; P = 0.007), and a higher prevalence of malignancy (40.0% vs. 6.3%; P = 0.006), history of stroke (30.0% vs. 7.2%; P = 0.048) and SU (20.0% vs. 1.8%; P = 0.034). CONCLUSION: SU, concurrent tuberculosis involving another site, increased neutrophils and decreased glucose levels in pleural effusion may be predictive factors for PECP-MT. Malignancy, ARF and SU, and perhaps being elderly or history of stroke, are risk factors for fatality in patients with TP.

What is the probability of a patient presenting a pleural effusion due to tuberculosis?

INTRODUCTION: In Rio de Janeiro, in almost half of the cases of pleural tuberculosis (PT) treatment begins without substantiation of diagnosis. We examined variables associated with this disease. METHOD: We studied 215 consecutive patients; 104 had tuberculosis (TB) and 111 did not (NTB): 41 neoplasms, 29 transudates, 28 para-pneumonic and 13 other etiologies. Clinical and laboratory variables were assessed in a combined manner using likelihood ratios (LR) and Bayes' theorem to determine the probability of PT. RESULTS: Among the variables examined, adenosine deaminase (ADA) levels, lymphocyte cell percentage, protein and age were the best indicators for the diagnosis of PT. Association of ADA with any of the other variables led to a LR+ higher than 10 and a LR- lower than 0.1, indicating the presence or absence of PT, with an individual probability of more than 90% or of less than 10% considering that there was a 50% initial probability associated with the presence of PT. CONCLUSIONS: Since ADA is highly sensitive, we can practically exclude TB as the cause of effusion when there are low ADA values. However, to confirm the possibility of TB we recommend that other variables, such as prevalence of lymphocytes (higher than 90%), and high protein levels (more than 4 g/dL); low age (less than 45 years) also should be considered.