Pleural TB

Case 233y Male Smoker (10 pack) Aboriginal1 Month Cough, SOBE ,FeverCough non productiveNo orthopnea , PND , LL swellingFever intermittent ,night sweatingWt loss 12 lbs , decrease appetite

HistoryLives in reserve No Contact with TBNo travel ,petsPMH vePSH : MVA Rt arm atrophy 1991 Blood Tx after MVANo IV drugs

ExaminationTemp 39.8 BP 120/65 HR 80RR 16 Sat 93% RANo enlarged LNChest : decreased BS Lt lower 2/3 Post Dull percussion noteCNS : Rt Arm weakness 3/5 distal > proximalAbd & LL Unremarkable

InvestigationCBC N

Creat , BUN , Lytes N

LFT & Liver enzymes N

CXR

InvestigationSputum GS & C/S -veSputum AFB ve 3 times PPD +ve 18 mmVATS Pleura Thickened with adhesions 1500 Pleural fluid drained Pleural lysis Pleural Bx Granuloma with +ve DNA For Mycobacterium

Management4 Anti TB Rx + Pyridoxine

Improved afebrile ,no SOB

Chest tube was removed

Discharged Home

TB Pleural Effusion5% of all diseases attributed to TBResults from delayed hypersensitivity reaction to TB antigenDifferent from tuberculous empyema which is purulent fluid abundant in TB organism with thickened calcified pleuraDifferent presentation in Non HIV Vs HIV

Presentation60 Pt study*In Non HIV

Non productive Cough ,Pleuritic CP , SOBFever ,Night sweating & Wt Loss

* In HIV Younger Patient , more Wt Loss & extrapulmonary involvement

Frye et al Chest Aug 1997

Imaging*In Non HIV70 Pleural TB/1700 Dx TB patientUnilateral effusion Associated Lung infiltrates 50% Upper Lobes 75% Reactivation Lower lobes 25% Primary Disease Seibert et al Chest April 1991

ImagingIn HIV963 HIV Vs 1000 Non HIVUnilateral effusion Lung infiltrate Lower LobesAdenopathy 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

MicrobiologySputum 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

ADA216 Patients 100 TB , 86 Malignancy 19 empyema , 6 transudate 15 miscellaneous , 8 unknownHigh ADA in TB 110 & in Empyema 191 No difference Between HIV +ve & -ve TB PtCut off 60 u/l PPV & NPV 95% Riantawan P et al Chest 1999 Jul

ADA106 lymphocytic effusion {Non TB}ADA measured once in all & second time 6weeks later in 26 cases 45 Post CABG , 27 Malignant 10 Miscellaneous , 24 TransudativeWith cut off 40 u/l only 3 patients +ve 2 Lymphoma & 1 complicated parapneumonicHigh NPV & reproducible Gary Lee et al Chest Aug 2001

ADA ,PCR & Interferon Gamma140 Patient had ADA , PCR & INF pleural fluid levels42 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

TreatmentSimilar to Pulmonary TBSteroid ? 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