1. Pleural Fluid Cholesterol in Exudative Pleural Effusions
Thidar Oo, Ne Myo Aung, Mar Mar Kyi, Yadanar Kyaw
and Myo Lwin Nyein

2. Granted from Department of Medical Research
Funding
Granted from Department of Medical Research

3. Background Pleural effusion is common in clinical practice
As a generalization, transudative pleural effusions are manifestation of systemic disorders, whereas exudative effusions are an indication of pathologic process within the respiratory system
Porcel, J. and Light, R.(2006), American academy of family Physician

4. Seibert, A.,Haynes, J., Middleton, R andBass,J.(1991), Chest
Pleural effusion is one of the common complications of primary tuberculosis or in conjunction with pulmonary infiltrate, typical of post-primary tuberculosis(TB)
The clinical presentation of TB can mimic several diseases and can be a diagnostic problem even in endemic areas
Virulence and load of the infecting mycobacterium, the immune status of the host, the organ system involved, all influences the clinical manifestations of tuberculosis
Seibert, A.,Haynes, J., Middleton, R andBass,J.(1991), Chest

5. Pleural fluid cholesterol has been used to classify exudates and transudates as it misclassifies fewer cases than any other Light’s parameters.
To evaluate the utility of cholesterol in lymphocytic exudates in diagnosing TB pleural effusion in a region of high prevalence of TB
Goyal, V., Agrawal, Y., Singh, S.B. and Singh, A. (2017),
Scholars Journal of Applied Medical Sciences

6. Method
Aim - to study the pleural fluid cholesterol in exudative pleural effusions
Study Area – General medical wards and Chest medical wards of North Okkalapa General and Teaching Hospital and Thingangyun General Hospital, and Medical ward of Insein General Hospital

7. Inclusion criteria
patients with pleural effusion admitted to studying hospitals
patients above the age of 18 years
Exclusion criteria
Pleural effusions associated with
acute pulmonary oedema,
cirrhosis of liver
renal failure and
rheumatoid arthritis

8. Case collection was done to patients with pleural effusion admitted to studied hospitals. Pleural effusion was confirmed by CXR (PA)
History taking and physical examination were done by researcher to detect transudative or exudative causes
Detailed information was given to the patients with likely exudative pleural effusion and informed consent was requested

9. Aspiration of pleural fluid and biopsy of pleural tissue were performed according to standard procedures
20 cc of pleural fluid was sent to the lab for protein, LDH, cell counts, cholesterol, cytology and biopsy for histology
Case selection was done after pleural fluid protein and/or LDH result according to inclusion criteria
The results of pleural fluid analysis and histology were recorded

10. Pleural effusion diagnosed by clinically and radiologically
Pleural protein >2.9 g/dl or pleural fluid LDH >2/3rd of normal serum LDH
Sputum for AFB, sputum for Gene Xpert and pleural biopsy, pleural fluid cytology

11. Measurement of pleural fluid cholesterol
TB effusion
Non- TB effusion
Measurement of pleural fluid cholesterol
Compare the levels of pleural fluid cholesterol in TB and non-TB pleural effusions

12. Results
Total 70 patients of exudative pleural effusions were recruited
35 cases were tuberculous pleural effusion and another 35 cases were non-tuberculous in origin such as malignant and parapneumonic effusions

13. Parameters in exudate
Mean±SD
Cholesterol(mg/dl)
89.3 ± 34.5
Protein (g/dl)
4.9 ± 0.9
LDH(IU/L)
624.7 ± 706.1
Lymphocytes
73.0 ± 25.9

14. Parameters
TB effusion
(N=35)
Non-TB effusion
P value
Protein (g/dl)
5.1±0.8
4.8±1.1
0.281
LDH(IU/L)
Mean rank=34.36
Sum rank=1202.5
Mean rank=36.64
Sum rank=1282.5
0.638
Lymphocyte(%)
Mean rank=43.06
Sum rank=1507
Mean rank=27.94
Sum rank=978
0.001

15. Non-TB pleural effusion Pleural fluid cholesterol
p value
Pleural fluid cholesterol
(mg/dl)
98.2±26.5
80.3 ±39.2
0.029

16. The optimum cut-off level from ROC curve analysis for pleural fluid cholesterol concentration was 70 mg/dl for tuberculous pleural effusion (sensitivity = 88.6%, specificity = 42.9%).

17. Discussion
cholesterol is synthesized by pleural cells themselves for their own needs
Concentration of cholesterol in pleural cavity is increased by the degeneration of leukocytes and macrophages
Mycobacterium tuberculosis resides predominantly in a cholesterol-rich region of the macrophage
Goyal, V., Agrawal, Y., Singh, S.B. and Singh, A. (2017),
Scholars Journal of Applied Medical Sciences

18. Around 250 genes potentially involved in lipid metabolism have been discovered in M. tuberculosis
These observations indicate utilization of cholesterol by M. tuberculosis and hence higher level in TB pleural effusion
Goyal, V., Agrawal, Y., Singh, S.B. and Singh, A. (2017),
Scholars Journal of Applied Medical Sciences

19. In a study in India, 80 patients of pleural effusion were studied
49 cases were found to be tuberculous pleural effusion
Pleural fluid cholesterol in TB pleural effusion was 81.5±31.3 mg/dL and in non-TB pleural effusion was 28.8±8.8 mg/dL (pvalue-<0.05)
The best cutoff value of pleural fluid cholesterol for TB pleural effusion was 50 mg/dl

20. In this study, 70 patients of pleural effusion were studied
35 cases were found to be tuberculous pleural effusion
Pleural fluid cholesterol in TB pleural effusion was 98.2±26.5 mg/dl while that in non-TB pleural effusion was 80.3±39.2 mg/dl (p value-0.029)
The best cutoff value of pleural fluid cholesterol was 70 mg/dl

21. According to this study, some parameters in pleural fluid analysis, such as, pleural fluid protein and LDH were not specific for diagnosing TB pleural effusion
But, pleural fluid lymphocyte percentage was significantly increased in TB pleural effusion

22. So, pleural fluid cholesterol could be done to support the diagnosis of TB in lymphocyte dominant exudative pleural effusion, in area of high TB prevalance with poor resources

23. In high TB prevalence area with poor resources, histological diagnosis of TB pleural effusion might not be routinely performed
But, pleural fluid aspiration and analysis would be performed not only for diagnosis but also for therapeutic purpose

24. Conclusion
Pleural fluid cholesterol was significantly higher in TB pleural effusion than non-TB pleural effusion
So, measurement of pleural fluid cholesterol was an easy and inexpensive test supporting to differentiate TB from non-TB in lymphocyte dominant exudative pleural effusions

25. Recommendation
Measurement of pleural fluid cholesterol should be done in establishing the etiology of exudative pleural effusions
If pleural fluid cholesterol is > 70 mg/dl, tuberculous pleural effusion should be considered

26. Acknowledgement Special thanks to
Department of Medical Research Myanmar

27. References
Goyal, V., Agrawal, Y., Singh, S.B. and Singh, A. (2017). Efficacy of Estimating Pleural Fluid Cholesterol in Diagnosing Tubercular Pleural Effusion. Scholars Journal of Applied Medical Sciences. 5(10D), p
Porcel, J. and Light, R.(2006). A diagnostic approach to pleural effusion in adult.American academy of family Physician. 73, p
Seibert, A.,Haynes, J., Middleton, R andBass,J.(1991). Tuberculous Pleural Effusion. Chest, 99(4), p

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