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
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
Pleural lysis
Pleural Bx Granuloma
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 &
extrapulmonary involvement
Frye et al
Chest Aug 1997

Imaging
*In Non HIV

70 Pleural TB/1700 Dx TB patient

Unilateral effusion
Associated Lung infiltrates 50%
Upper Lobes 75% Reactivation
Lower lobes 25% Primary Disease
Seibert et al
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
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
Chest may 1994

Microbiology
Sputum culture +ve 20-50%
involvement of lung parenchyma
Pleural Fluid culture +ve 40-50 %
Pleural Bx culture +ve 60-80 %
Higher yield in HIV patients in all specimens

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

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

ADA ,PCR & Interferon Gamma

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

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