Pleural TB

Case 2  33y Male Smoker (10 pack) Aboriginal  1 Month Cough, SOBE,Fever  Cough non productive  No orthopnea, PND, LL swelling  Fever intermittent,night sweating  Wt loss 12 lbs, decrease appetite

History  Lives in reserve  No Contact with TB  No travel,pets  PMH –ve  PSH : MVA  Rt arm atrophy 1991  Blood Tx after MVA  No IV drugs

Examination  Temp 39.8 BP 120/65 HR 80  RR 16 Sat 93% RA  No enlarged LN  Chest : decreased BS Lt lower 2/3 Post Dull percussion note Dull percussion note  CNS : Rt Arm weakness 3/5 distal > proximal  Abd & LL Unremarkable

Investigation  CBC N  Creat, BUN, Lytes N  LFT & Liver enzymes N  CXR

Investigation  Sputum GS & C/S -ve  Sputum AFB –ve 3 times  PPD +ve 18 mm  VATS  Pleura Thickened with adhesions 1500 Pleural fluid drained 1500 Pleural fluid drained Pleural lysis Pleural lysis Pleural Bx  Granuloma Pleural Bx  Granuloma with +ve DNA For Mycobacterium with +ve DNA For Mycobacterium

Management  4 Anti TB Rx + Pyridoxine  Improved afebrile,no SOB  Chest tube was removed  Discharged Home

TB Pleural Effusion  5% of all diseases attributed to TB  Results from delayed hypersensitivity reaction to TB antigen  Different from tuberculous empyema which is purulent fluid abundant in TB organism with thickened calcified pleura  Different presentation in Non HIV Vs HIV

Presentation 60 Pt study *In Non HIV  Non productive Cough,Pleuritic CP, SOB  Fever,Night sweating & Wt Loss * In HIV  Younger Patient, more Wt Loss &  Younger Patient, more Wt Loss & extrapulmonary involvement extrapulmonary involvement Frye et al Frye et al Chest Aug 1997 Chest Aug 1997

Imaging * In Non HIV 70 Pleural TB/1700 Dx TB patient  Unilateral effusion  Associated Lung infiltrates 50% Upper Lobes 75%  Reactivation Upper Lobes 75%  Reactivation Lower lobes 25%  Primary Disease Lower lobes 25%  Primary Disease Seibert et al Seibert et al Chest April 1991 Chest April 1991

Imaging In HIV 963 HIV Vs 1000 Non HIV  Unilateral effusion  Lung infiltrate  Lower Lobes  Adenopathy 5-18%  Miliary Pattern 7-10%  Less cavitations 33% Tshibwabwa-Tumba et al Tshibwabwa-Tumba et al Clin Radiol 1997 Nov Clin Radiol 1997 Nov

PPD Skin Test  70 Patients 43 HIV & 27 Non HIV  HIV mainly IVDU  Non HIV 73% +ve Vs 41% HIV  Age Non HIV 52 Vs 37 HIV Relkin et al Relkin et al Chest may 1994 Chest may 1994

Microbiology  Sputum culture +ve 20-50%  involvement of lung parenchyma  involvement of lung parenchyma  Pleural Fluid culture +ve %  Pleural Bx culture +ve %  Higher yield in HIV patients in all specimens

ADA  216 Patients 100 TB, 86 Malignancy 19 empyema, 6 transudate 19 empyema, 6 transudate 15 miscellaneous, 8 unknown 15 miscellaneous, 8 unknown  High ADA in TB 110 & in Empyema 191 No difference Between HIV +ve & -ve TB Pt No difference Between HIV +ve & -ve TB Pt  Cut off 60 u/l  PPV & NPV 95% Riantawan P et al Riantawan P et al Chest 1999 Jul Chest 1999 Jul

ADA  106 lymphocytic effusion {Non TB}  ADA measured once in all & second time 6weeks later in 26 cases & second time 6weeks later in 26 cases  45 Post CABG, 27 Malignant 10 Miscellaneous, 24 Transudative 10 Miscellaneous, 24 Transudative  With cut off 40 u/l only 3 patients +ve 2 Lymphoma & 1 complicated parapneumonic 2 Lymphoma & 1 complicated parapneumonic  High NPV & reproducible Gary Lee et al Gary Lee et al Chest Aug 2001 Chest Aug 2001

ADA,PCR & Interferon Gamma  140 Patient  had ADA, PCR & INF pleural fluid levels  had ADA, PCR & INF pleural fluid levels  42 Confirmed TB (+ve fluid smear or culture or +ve histology) (+ve fluid smear or culture or +ve histology)  19 Probable TB Symptoms or signs, Bx chronic inflammation Symptoms or signs, Bx chronic inflammation +ve sputum or Response to Anti TB +ve sputum or Response to Anti TB  70 Non TB etiology, 9 Unknown Villegas Chest, Nov 2000 Villegas Chest, Nov 2000

Treatment  Similar to Pulmonary TB  Steroid ? Effect small study 40 pt faster resolution of Fever & SOB & effusion faster resolution of Fever & SOB & effusion But no effect on pleural thickening But no effect on pleural thickening  Drainage Small study 60 pt Initial improvement in SOB in first week Initial improvement in SOB in first week No effect later on symptoms No effect later on symptoms or pleural thickening or pleural thickening