Thoracic ultrasound-guided real-time pleural biopsy in the diagnosis of pleural diseases: a systematic review and meta-analysis.

BACKGROUND: Real-time thoracic ultrasound-guided pleural biopsy (TUSPB) is an important diagnostic method for pleural diseases. Traditional two-dimensional thoracic ultrasound, as well as newly developed contrast-enhanced ultrasound (CEUS) and ultrasound elastography (UE), are all used as guidance tools for pleural biopsies. Herein, we aimed to determine the diagnostic yield of real-time TUSPB for pleural diseases to better inform the decision-making process. METHODS: A literature search of the MEDLINE/PubMed, Embase, and Cochrane Library databases was performed up to June 2023. A binary random-effects model was applied to determine the pooled diagnostic yield. RESULTS: Fifteen studies comprising 1553 patients with pleural diseases were included and analyzed. The overall diagnostic yield of TUSPB for pleural diseases was 85.58% (95% confidence interval [CI]: 81.57-89.58%). The sensitivity was 77.56% for pleural malignancy and 80.13% for tuberculous pleurisy. The sub-analysis result revealed that CEUS-guided pleural biopsy provided a pooled diagnostic yield of 98.24%, which was higher than that of conventional TUSPB (78.97%; p < 0.01). The overall proportion of adverse events for TUSPB was 6.68% (95% CI: 5.31-8.04%). CONCLUSION: Conventional TUSPB has good pooled diagnostic yields and high safety. CEUS and UE are promising guidance tools for pleural biopsy with the potential to increase diagnostic yield.

Different characteristics of pleural abnormalities on computed tomography between tuberculous and malignant pleural effusions.

BACKGROUND: Computed tomography (CT) is the mainstay imaging modality for suspected pleural malignancy. Tuberculous pleural effusion (TPE) can present with various pleural abnormalities. However, few studies have evaluated the different characteristics of pleural abnormalities on chest CT between TPE and malignant pleural effusion (MPE). METHODS: Pleural abnormalities on contrast-enhanced CT in 277 and 289 patients with confirmed TPE and MPE diagnoses, respectively, were retrospectively assessed and compared between the two groups. Discriminating factors and diagnostic performance for MPE were evaluated using multivariate analysis and receiver operating characteristic curves. RESULTS: Focal pleural thickening was present in 44 (16%) cases of TPEs and 202 (70%) of MPEs. Further characterization of focal pleural thickening showed that MPEs had a significantly greater number, larger maximal thickness, and more nodular contour form, compared to TPEs. On the other hand, diffuse and circumferential pleural thickening were significantly more common in TPEs. In multivariate analysis, independent predictors for MPE included focally thickened pleurae ≥7, maximum thickness ≥6 mm, nodular contour pattern, and the absence of diffuse pleural thickening. Out of all the individual or combined predictors for MPE, the presence of any one of the three sub-parameters of focal pleural thickening provided the best diagnostic yield with 66% sensitivity and 92% specificity. CONCLUSION: Although focal pleural thickening in TPE mimics that in MPE, the features of MPE are significantly different from those of TPE in terms of size, number, and contour. These different characteristics may help differentiate MPE from TPE in patients with suspected MPE.

The Value of 18F-FDG PET/CT in the Diagnosis of Tuberculous Pleurisy and in the Differential Diagnosis between Tuberculous Pleurisy and Pleural Metastasis from Lung Adenocarcinoma.

Objectives: This study aims to investigate the diagnostic value of 18F-FDG PET/CT in tuberculous pleurisy (TBP) and the differential diagnostic value of 18F-FDG PET/CT between TBP and pleural metastasis from lung adenocarcinoma (PMLAC). Materials and Methods: The features of pleura on PET and hybrid CT were retrospectively studied in 20 patients with TBP and 32 patients with PMLAC. The ROC curve was used to evaluate the diagnostic effectiveness of these indices for TBP and PMLAC, and binary logistic regression analysis was conducted to identify independent predictors of TBP and PMLAC. Results: There were significant differences in pleural 18F-FDG uptake pattern on PET (P=0.001), pleural morphology pattern on CT (P=0.002), the maximum diameter of the pleural nodule (P=0.001), and interlobular fissure nodule (P=0.001) between TBP and PMLAC groups. The diffused pleural FDG uptake type on PET (odds ratio (OR) = 6.0, 95% CI 2.216-16.248, P=0.001) and the lamellar pleural thickening type on CT (OR = 4.4, 95% CI 2.536-7.635, P=0.001) were independent predictors of TBP, with 60% and 55% sensitivity, 96.6% and 90.6% specificity, and 82.7% and 77.0% accuracy. The combined diagnostic sensitivity, specificity, and accuracy for TBP were 70%, 87.5%, and 80.8%. The mixed pleural FDG uptake type on PET (OR = 5.106, 95% CI 2.024-12.879, P=0.001), the mixed pleural thickening type on CT (OR = 2.289, 95% CI 1.442-3.634, P=0.001), and the maximum diameter of the pleural nodule (OR = 1.027, 95% CI 1.012-1.042, P=0.001) were independent predictors of PMLAC, with 78.1%, 71.9%, and 87.5% sensitivity, 85%, 80%, and 85% specificity, and 80.8%, 75%, and 86.5% accuracy. The combined diagnostic sensitivity, specificity, and accuracy for PMLAC were 96.9%, 85%, and 90.4%. Conclusions: 18F-FDG PET/CT is of great clinical value in the diagnosis of TBP and in the differential diagnosis between TBP and PMLAC.

Evaluation of radiological sequelae after treatment completion in new cases of pulmonary and pleural tuberculosis.

Background: The objective of this study was to evaluate the residual parenchymal and pleural lesions on chest X-ray posttherapy in new tuberculosis (TB) cases. Methods: This prospective study was done from January 2018 to December 2020, which involved the evaluation of medical records of 60 pulmonary or pleural TB patients who underwent successful treatment. Chest X-rays of the patients at the start and end of treatment were studied as per the guidelines by Revised National Tuberculosis Control Program. The primary outcome measures were residual chest X-ray lesions after the complete treatment of new cases of TB. Secondary outcomes measures were significant factors affecting the chest X-ray clearance. Results: Chest X-ray showed clearing in 48.33% of cases. Residual chest X-ray findings were present in 31 cases which mainly included fibrosis in 23.33% and pleural thickening in 20%. None of the clinical and demographic characters and biochemical parameters showed significant association with chest X-ray clearance (P > 0.05). Sputum microscopy was done in 45 cases of which 25 (41.66%) were positive for acid-fast bacilli. Sputum positivity showed no significant correlation with chest X-ray clearance (odds ratio [OR]: 0.734, confidence interval [CI]: 0.224-2.411, P = 0.592). Compared to nonstandardized regimen, standardized regimen showed no significant correlation with chest X-ray clearance (OR: 0.664; CI: 0.233-1.892, P = 0.426). Conclusion: Residual radiological sequelae were seen in more than half of the study subjects who were successfully treated for TB (51.67%). Demographic, clinical characteristics, sputum positivity, and treatment regimen showed no significant association with chest X-ray clearance.

Post tuberculosis radiological sequelae in patients treated for pulmonary and pleural tuberculosis at a tertiary center in Pakistan.

Treating tuberculosis (TB) is not the end of the disease because of the wide spectrum of post TB sequelae associated with the disease. There is insufficient data on post TB radiological sequelae. The aim of this study is to evaluate the post TB radiological sequelae on chest x-rays in patients who had completed the treatment for pulmonary and pleural TB at a tertiary care hospital of a high TB burden country. This is a retrospective cross-sectional study conducted on patients treated for pulmonary and pleural TB. Adult patients (18 years or above) with a clinical or microbiological diagnosis of pulmonary or pleural TB were included. Patients were classified on the basis of site of TB into pulmonary and pleural TB. Post-treatment radiological sequelae on chest x-ray were evaluated and divided into three main types i.e. fibrosis, bronchiectasis and pleural thickening. During the study period a total of 321 patients were included with a mean age of 44(SD±19) years. Only 17.13% (n=55) patients had normal chest x-rays at the end of treatment and 82.87% (n=266) patients had post-TB radiological sequelae with fibrosis being the most common followed by pleural thickening. The post TB radiological sequelae were high in patients who had diabetes mellitus (78.94%), AFB smear-positive (90.19%), AFB culture-positive (89.84%), Xpert MTB/Rif positive (88.40%) and with drug-resistant TB (100%). As a clinician, one should be aware of all the post TB sequelae so that early diagnosis and management can be facilitated.

Asbestos exposure and tuberculous pleurisy as developmental causes of progressive unilateral upper-lung field pulmonary fibrosis radiologically consistent with pleuroparenchymal fibroelastosis.

BACKGROUND: Unilateral upper-lung field pulmonary fibrosis (upper-PF), which is radiologically consistent with pleuroparenchymal fibroelastosis, develops after thoracic surgery. In most patients with unilateral upper-PF, aberrant intra-/extra thoracic air commonly emerges and an autopsy shows chronic pleuritis, which indicates that pleural involvement is associated with upper-PF development. If so, there may be patients with unilateral upper-PF who have a history of pleural involvement, including tuberculous pleurisy (TP) or asbestos exposure (AE). This study aimed to examine this supposition. METHODS: We examined the radiological reports of all consecutive patients from 2012 to 2018 to investigate whether there were patients having unilateral upper-PF and a history of TP or AE. RESULTS: Eight patients were included in the study. Five patients had a history of TP, and the remaining three had that of AE. All patients were men and had respiratory symptoms, and seven patients presented with restrictive ventilatory impairment. The interval between TP or last AE and upper-PF development was long, with a median of over 20 years. The upper-PF lesion was commonly located in the right lung, and aberrant intrathoracic air was observed in five patients during their clinical course. Additionally, the upper-PF lesion transformed into a cystic lesion in six patients, which resulted in Aspergillus infection in two patients. The prognosis was poor, with a median overall survival of 38 months. CONCLUSIONS: Unilateral upper-PF developed even in patients with a history of pleural involvement. Our results indicate that pleural involvement plays an important role in the development of unilateral upper-PF.

Aspectos clínico-imagenológicos de pacientes diagnosticados con tuberculosis extrapulmonar, La Habana 2016-2019 / Clinical and imaging aspects of the patients diagnosed with extrapulmonary tuberculosis, Havana 2016-2019

RESUMEN Introducción: La tuberculosis extrapulmonar muestra una complejidad diagnóstica que influye sobre la morbilidad y mortalidad. Objetivo: Caracterizar desde una perspectiva clínico-imagenológica a los pacientes diagnosticados con tuberculosis extrapulmonar, en el Hospital Neumológico Benéfico Jurídico de La Habana, en el período 2016-2019. Método: Se realizó un estudio descriptivo, retrospectivo y transversal en 34 pacientes con diagnóstico de tuberculosis extrapulmonar. Las variables medidas fueron: edad, sexo, factores de riesgo para padecer la enfermedad, síntomas y signos clínicos, hallazgos radiológicos, métodos diagnósticos utilizados y su localización. Resultados: Predominaron pacientes del sexo masculino con edad entre 26 a 35 años (29,4 %). El 73,5 % de los pacientes presentó factores de riesgos para esta enfermedad, los más frecuentes fueron: ser contactos de pacientes con tuberculosis (29,4 %), los exreclusos (17,6 %) y los alcohólicos (14,7 %). El 58,8 % presentó fiebre y síntomas o signos generales como anorexia (44,1 %), pérdida de peso (41,2 %) y astenia (38,2 %). El hallazgo radiológico más común fue el derrame pleural (47 %) y la forma extrapulmonar más frecuente dada por 15 casos (44,1 %) fue la pleuritis tuberculosa. El método clínico-radiológico posibilitó el diagnóstico en el 50 % de los pacientes. Conclusiones: Las manifestaciones clínicas más evidentes fueron la fiebre, la pérdida de peso y la astenia. El método diagnóstico clínico-radiológico es el más utilizado y el hallazgo radiológico más reportado es el derrame pleural. La localización pleural es la forma extrapulmonar más frecuente.

ABSTRACT Introduction: Extrapulmonary tuberculosis shows a complexity that can influence in its morbidity and mortality rates. Objective: To characterize the patients with extrapulmonary tuberculosis from a clinical-imaging perspective in the Hospital Neumológico Benéfico Jurídico in Havana in the period 2016-2019. Method: A descriptive, retrospective and cross-sectional study was carried out in 34 patients with the diagnosis of extrapulmonary tuberculosis. The variables taken into account were: age, gender, risk factors for the disease, symptoms and clinical signs, radiological findings, diagnosis methods used, and location. Results: Male patients with ages ranging between 26 to 35 years predominated in the study (29.4%). 73.5% of the patients presented risk factors of the disease, being most common: contact of previous tuberculosis patients (29.4%), ex-inmates (17.6%) and alcoholics (14.7%). 58.8% of the patients presented fever and general symptoms like anorexia (44.1%), weight loss (41.2%) and asthenia (38.2%). The most common radiological finding was pleural effusion (47%), and the most frequent extrapulomary form of the disease was tuberculous pleurisy (15 cases representing a 44.1%). The clinical-radiological method made diagnose possible in 50% of the patients. Conclusions: The most common clinical manifestations were fever, weight loss and asthenia. The clinical-radiological method is the most frequently used, and the most frequent radiological finding was the pleural effusion. Pleural location was the most common extrapulmonary form of tuberculosis.

Nódulo pleural único: una forma de reacción paradójica tardía al tratamiento antituberculoso / Solitary pleural nodule: a late paradoxical reaction to antituberculosis treatment

Se presenta el caso de una mujer joven con antecedente de tuberculosis pleural y pulmonar previamente tratada, que acudió a nuestro hospital por dolor torácico y nódulo pleural único visualizado en radiografía simple y TC torácicas. Se realizó punción con aguja fina guiada por ecografía torácica de la lesión pleural con la que se obtuvo material de tipo inflamatorio para estudio con cultivo positivo para Mycobacterium tuberculosis complex. El diagnóstico fue de reacción paradójica al tratamiento antituberculoso y fue tratada durante 6 meses más con resolución de la lesión pleural y el dolor torácico

We present the case of a young woman with a history of previously treated pleural and pulmonary tuberculosis referred to our hospital for chest pain and a single pleural nodule seen on plain chest films and chest CT. Cultures of inflammatory-type material obtained by US-guided fine-needle biopsy of the pleural lesion were positive for Mycobacterium tuberculosis complex. The diagnosis was a paradoxical reaction to antituberculosis treatment; after 6 more months of treatment, the pleural lesion and chest pain disappeared

Solitary pleural nodule: a late paradoxical reaction to antituberculosis treatment. / Nódulo pleural único: una forma de reacción paradójica tardía al tratamiento antituberculoso.

We present the case of a young woman with a history of previously treated pleural and pulmonary tuberculosis referred to our hospital for chest pain and a single pleural nodule seen on plain chest films and chest CT. Cultures of inflammatory-type material obtained by US-guided fine-needle biopsy of the pleural lesion were positive for Mycobacterium tuberculosis complex. The diagnosis was a paradoxical reaction to antituberculosis treatment; after 6 more months of treatment, the pleural lesion and chest pain disappeared.

[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.

Internal Mammary Lymph Node Visualization as a Sentinel Sonographic Sign of Tuberculous Pleurisy.

BACKGROUND: Tuberculous pleurisy is one of the primary sites of extrapulmonary tuberculosis, but clinicians currently lack the diagnostic tools necessary for early recognition in the absence of typical signs and symptoms. With this study, we aimed to test the association between internal mammary adenopathies and tuberculous pleurisy (TP). METHODS: 60 patients with a post-thoracoscopic histological diagnosis of granulomatosis or acute infective pleurisy were retrospectively enrolled. All of them had chest sonography and/or CT scan data available. At least two expert chest sonography physicians re-analyzed the sonography images to look for any internal mammary adenopathy. Such findings were compared to the CT data. RESULTS: Chest sonography showed internal mammary adenopathy ipsilateral to the pleural effusion in 97 % of 29 patients who had a diagnosis of TP, and in 13 % of those with an acute infective pleurisy (p < 0.001). Receiver operator characteristic analysis revealed 97 % sensitivity and 87 % specificity for this technique in predicting TP (area under curve 0.92 ± 0.04, p < 0.001). CT detection power and node measures were significantly similar (p < 0.001). CONCLUSION: Sonographic internal mammary node visualization ipsilateral to the pleural effusion may become a sentinel sign for TP, contributing to early diagnosis or orienting the diagnostic management towards invasive procedures in uncertain cases.

Prospective Study of the Utility of Computed Tomography Triage of Pleural Biopsy Strategies in Patients With Pleural Diseases.

BACKGROUND: This study aimed to prospectively evaluate the efficacy and reliability of a diagnostic workup, triaging pleural biopsy method according to baseline computerized tomography (CT) findings in the diagnosis of pleural diseases. METHODS: Patients with pleural pathology were divided into 3 arms according to findings on CT scan images. Arm A: patients with pleural thickening/lesion in addition to pleural effusion. These patients underwent CT scan-guided Abrams' needle pleural biopsy. Arm B: patients with pleural effusion alone or suspected benign asbestos pleurisy. This group underwent medical thoracoscopy (MT). Arm C: patients with only pleural thickening. This group underwent ultrasonography-guided cutting needle pleural biopsy. MT was planned in patients who did not have a specific diagnosis in the CT scan-guided Abrams' needle pleural biopsy group. When patients with a histopathologic diagnosis of fibrinous pleuritis after MT were assessed in terms of the risk factors for malignant pleural diseases, we offered a further invasive procedure. RESULTS: A total of 164 patients were enrolled in the study. Diagnostic sensitivity after the initial procedure was 90.2% in Arm A, 93.3% in Arm B, 95.2% in Arm C, and 92.4% in the entire workup. The negative predictive value of the entire workup was 90.4% for malignant pleural mesothelioma, 97.1% for metastatic malignant pleural diseases, and 100% for tuberculous pleurisy. Five cases who had a diagnosis of fibrinous pleuritis after MT were detected to have risk factors, 4 of which (80%) indicated malignant disease. Complication rates were low and acceptable. CONCLUSION: Use of CT scans to triage an appropriate pleural biopsy method is associated with high diagnostic success. We recommend that the proposed diagnostic workup in this study may be used as a diagnostic algorithm for pleural diseases that require a histopathologic analysis. Determination of risk factors predicting malignant disease in patients where fibrinous pleuritis is reported after MT would be useful for clinical practice.

Diagnostic role of medical thoracoscopy in childhood pleural tuberculosis.

Currently, the diagnostic role of medical thoracoscopy in childhood pleural tuberculosis remains uncertain. Therefore, this retrospective study was conducted to evaluate the diagnostic performance of histological examination of tissue samples obtained by medical thoracoscopy in childhood pleural tuberculosis. Hospitalized children who underwent medical thoracoscopy between May 2012 and March 2016 were included in the study. Tissue samples obtained by thoracoscopy were submitted for histological examination (hematoxylin and eosin staining). Descriptive statistical methods were used for data interpretation, and the data were expressed as the mean ± standard deviation. The childhood tuberculosis patients had the following characteristics: 11 had pleural tuberculosis and 9 had pleural tuberculosis + pulmonary tuberculosis, the average age was 13.0 ± 2.2 years old, 60% were male, 26.3% (5/19) of patients tested positive for acid-fast bacilli positive in smears, 21.1% (4/19) of patients were positive for TB-PCR, and 90% (18) of pleural tuberculosis patients were positive in the culture for Mycobacterium tuberculosis. The sensitivity of histological examinations of tissue samples obtained by thoracoscopy in the detection of pleural tuberculosis was 80% (16/20). Complications were reported in 15 cases, and all complications disappeared spontaneously without any specific treatment. Therefore, we concluded that medical thoracoscopy was a sensitive and safe tool for the detection of childhood pleural tuberculosis.

Chest Tuberculosis in Children.

Chest is the commonest site of involvement by tuberculosis (TB) in children; lungs being the most frequently affected region, followed by nodes, pleura and chest wall. It is difficult to diagnose TB in children due to lack of overt symptoms and difficulty in obtaining samples for microbiological confirmation. Hence various imaging modalities play an important role in diagnostic algorithm as well as in follow-up after treatment. Standardization of chest radiograph reporting in context of clinically suspected TB is the need of the hour so as to suggest a proper diagnosis and avoid over-diagnosis. This article aims to discuss the imaging features of chest tuberculosis according to the site of involvement on various imaging modalities in the pediatric population.

Imaging in Pediatric Extra-Pulmonary Tuberculosis.

Extrapulmonary tuberculosis in children tends to be more severe than the adults. It can affect almost any organ system of the body. The clinical manifestations are often non-specific. Imaging findings are also not always very specific. This article describes the imaging spectrum of pediatric extrapulmonary tuberculosis.