1. بسم الله الرحمن الرحیم
با سلام

2. Tuberculous Pleural Effusion
BY ASADOLLAH ASADIAN MD

6. Epidemiology
Pleural TB is second most common extrapulmonary TB site behind lymph node involvement

7. Pathogenesis
TB Pleural effusion can be seen in either primary disease or reactivation disease
Effusion a result of the rupture of a subpleural foci of TB into the pleural space that leads to a delayed hypersensitivity reaction to the TB antigens
Tuberculous empyema – same mechanism as above with spillage of large amount of mycobacterium into pleural space  purulent effusion that requires surgical intervention and can result in pleural fibrosis and restrictive lung disease

10. Clinical Presentation
usually presents as an acute illness (1 wk – 1 mo symptoms)
presenting symptoms: pleuritic chest pain and nonproductive cough
common to have other symptoms of TB – night sweats, weight loss, dyspnea
physical exam consistent with pleural effusion – decreased breath sounds, dullness to percussion at site of disease

11. paraclinical Presentation
CXR – small to moderate sized unilateral pleural effusion
Pleural Fluid
-Straw colored appearance
-exudative
-pH 7.3 – 7.4
-glucose usually > 60
-Cell count usually 1000 – 6000 with lymphocytic predominance

12. paraclinical Presentation
CXR – small to moderate sized unilateral pleural effusion
Pleural Fluid
-Straw colored appearance
-exudative
-pH 7.3 – 7.4
-glucose usually > 60
-Cell count usually 1000 – 6000 with lymphocytic predominance

17. CT scan showing a parenchymal focus of tuberculosis close to the pleura and an ipsilateral pleural effusion. Courtesy of Paul Stark, MD.
2008

18. Figure 1a. Patient 6.
Figure 1a. Patient 6. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 23-year-old man. (a) Transverse contrast-enhanced chest CT scan (10-mm collimation) obtained through the right lower lobe a month after initial detection of pleural effusion shows loculated pleural fluid and well-enhancing parietal pleura (arrowheads) in the right side. Also note peripheral homogeneously enhancing consolidations (arrows), which appear to be passive atelectasis due to pleural effusion. (b) Magnified frontal chest radiograph showing the right lower lung, obtained 20 days after a, demonstrates a pleural abnormality obliterating the right costophrenic angle. Note an area of focal consolidation (arrow) abutting the pleural abnormality; the consolidation may represent atelectasis or an incipient lesion of a subsequent lung nodule (arrow in c). (c) Magnified frontal chest radiograph showing the right lower lung, obtained 2 months after b, demonstrates a peripheral pulmonary nodule (arrow) in the same area in which focal consolidation was noted before (arrow in b). However, this lesion is far larger than the one in b. Note an acute angle between the lesion and the pleura, suggesting its peripheral pulmonary origin. (d) Transverse contrast-enhanced chest CT scan (1.5-mm collimation) obtained at the same level as a, 10 days after c, shows that a well-enhancing peripheral lung nodule (arrow) with central low attenuation is responsible for the nodule in c. It abuts the thickened pleura, which also enhances. The nodule disappeared 14 months later with use of the same medication (image not shown).
Choi Y W et al. Radiology 2002;224:
©2002 by Radiological Society of North America

19. Figure 1a. Patient 6.
Figure 1a. Patient 6. Paradoxical response to antituberculous medication for tuberculous pleural effusion in a 23-year-old man. (a) Transverse contrast-enhanced chest CT scan (10-mm collimation) obtained through the right lower lobe a month after initial detection of pleural effusion shows loculated pleural fluid and well-enhancing parietal pleura (arrowheads) in the right side. Also note peripheral homogeneously enhancing consolidations (arrows), which appear to be passive atelectasis due to pleural effusion. (b) Magnified frontal chest radiograph showing the right lower lung, obtained 20 days after a, demonstrates a pleural abnormality obliterating the right costophrenic angle. Note an area of focal consolidation (arrow) abutting the pleural abnormality; the consolidation may represent atelectasis or an incipient lesion of a subsequent lung nodule (arrow in c). (c) Magnified frontal chest radiograph showing the right lower lung, obtained 2 months after b, demonstrates a peripheral pulmonary nodule (arrow) in the same area in which focal consolidation was noted before (arrow in b). However, this lesion is far larger than the one in b. Note an acute angle between the lesion and the pleura, suggesting its peripheral pulmonary origin. (d) Transverse contrast-enhanced chest CT scan (1.5-mm collimation) obtained at the same level as a, 10 days after c, shows that a well-enhancing peripheral lung nodule (arrow) with central low attenuation is responsible for the nodule in c. It abuts the thickened pleura, which also enhances. The nodule disappeared 14 months later with use of the same medication (image not shown).
Choi Y W et al. Radiology 2002;224:
©2002 by Radiological Society of North America

22. Diagnosis TB skin test Radiology
-helpful if +, especially in areas of low prevalence of disease
-oftentimes negative but if repeated 6-8 weeks later usually +
Radiology
-CXR with small – moderate sized unilateral effusion and associated parenchymal lung lesions in 20-50%
-CT scan better at documenting parenchymal lung disease (80% of cases). Also better at delineating TB pleural effusion complications such as pleural thickening, calcification, loculated effusions, empyema, empyema necessitatis, and bronchopleural fistula
Negative test from: (anergy, T-lympho’s sequestered in pleural space, recent infection, suppression of T-lympho’s in blood)

29. Differential Diagnosis
Lymphocytic Effusion TB
Malignancy
Lymphoma
Collagen vascular disease
Post coronary artery bypass grafting

39. Diagnosis TB skin test Radiology
-helpful if +, especially in areas of low prevalence of disease
-oftentimes negative but if repeated 6-8 weeks later usually +
Radiology
-CXR with small – moderate sized unilateral effusion and associated parenchymal lung lesions in 20-50%
-CT scan better at documenting parenchymal lung disease (80% of cases). Also better at delineating TB pleural effusion complications such as pleural thickening, calcification, loculated effusions, empyema, empyema necessitatis, and bronchopleural fistula
Negative test from: (anergy, T-lympho’s sequestered in pleural space, recent infection, suppression of T-lympho’s in blood)

40. Diagnosis Sputum -can have + M Tuberculosis cultures 20-50% time
-increased yield on sputum cultures with parenchymal lung lesions on radiographs
-should still be pursued in areas where other means of diagnosis not available
-from , 1.7% cases had + AFB sputum smear, 3.5% cases had + sputum M Tuberculosis culture

41. Diagnosis – Pleural Fluid
Microbiology
Adenosine Deaminase (ADA)
enzyme in purine salvage pathway that is important in differentiation of lymphoid cells and has increased activity with increased lymphocyte activity
high sensitivity (90-100%)
cutoff is 40: >40 supportive of TB, <40 virtually excludes TB
Interferon gamma
produced by t-lymphocytes to activate macrophages
increased in TB pleural effusion due to increased numbers of T-lymphocytes present
more sensitive and specific vs. ADA, but more expensive and less available so not used as much

42. Diagnosis Pleural Biopsy most sensitive test
tissue via closed needle biopsy or thoracoscopy
Histology: caseating granulomas (50-97%)
Culture for M Tuberculosis + in 40-80%
Combo of above two leads to diagnosis in 60 – 95% cases

43. Goal of treament
(I ) e thsubseqto prevent uent development of active TB
(2 ) to relieve the symptoms of the patient,
(3) to prevent the development of a fibrothorax.

44. Treatment
If left untreated, effusions usually resolve in 4-16 weeks and are followed by development of active pulmonary TB or extrapulmonary TB in 43-65% cases
Antimicrobial therapy is the same as for pulmonary TB
4 drug therapy for 2 months with isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4 mo of isoniazid and rifampin
Steroids have been studied in TB pleural effusion with no definite benefit.
Studies did note earlier resolution of symptoms (fever, chest pain, dyspnea) in patients treated with steroids, but no difference in the development of pleural thickening, adhesions, or residual lung function.

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