Predictive model for the diagnosis of tuberculous pleural effusion

Abstract

This study developed a predictive model to identify pleural tuberculosis. A consecutive cases study of patients investigating the cause of pleural effusion, in an area of high prevalence of tuberculosis (Rio de Janeiro, Brazil). Clinical and laboratory variables were compared among patients with tuberculosis (TB) and without tuberculosis (NTB), individually and using logistic regression. The performance was described as diagnostic accuracy, compared to a gold standard in a masked way. We have studied 104 TB patients, 41 with malignant, 29 transudates, 28 parapneumonic, 13 with miscellaneous diseases. After identification of individual discrimination power aided by clinical, radiological and laboratory variables, the following ones were included in a multivariate analysis: ADA, total leukocytes, percentile of lymphocytes, protein, lactate dehydrogenase, duration of disease, age and gender. A logistic regression model to predict pleural tuberculosis including the five first variables showed the best performance. A receiver operating characteristic curve identified the best cutoff at 0.7, resulting in a sensitivity and specificity of more then 95%. The predictive model improved the specificity of ADA alone, keeping its sensitivity. This model seems helpful when a microbiological or histological diagnosis of pleural tuberculosis could not be established. External validation of these results is necessary before recommendation for routine application.

Aspectos epidemiológicos da tuberculose pleural no estado de São Paulo (1998-2005)

“…These data are significant because they emphasize that the diagnosis of pleural effusion secondary to TB should be considered regardless of the age of the patient. (22,23) This fact was also reported in the United States (1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003), there being a higher percentage of cases of pleural TB in patients older than 65 years (probable reactivation of a previous infection). (18) Regarding the diagnostic criteria for pleural TB in the state of São Paulo, the limitation of this study refers to the analysis of cases reported with unspecified criteria (55.6%), which allows the assumption that diagnoses were based only on clinical-epidemiological or radiological criteria, biochemical criteria and cytological criteria.…”

“…(21) However, a study of pleural TB conducted in Brazil revealed that age presents low sensitivity (73%) and low specificity (46%). (22) In the present investigation, the highest incidence was found to occur between 30 and 59 years of age, there being a TB, histology and bacteriology were not the most commonly reported methods, which suggests that these methods are being underutilized. Finally, we reiterate that TB should be considered in all cases of pleural effusion, regardless of gender or age.…”

“…In countries with a high incidence of TB, the association of epidemiological history, biochemical analysis (an increase in proteins), cytology (lymphocytes/neutrophils > 0.75) and especially the determination of adenosine deaminase levels in the pleural fluid (> 40 U/L) has high sensitivity and specificity for the diagnosis of the disease. (21)(22)(23) The analysis of the cases in which the criterion considered the gold standard for the diagnosis (bacteriology and histology of the pleura) was used (44.4% of all reported cases) revealed that, in approximately 14.2%, the diagnosis was confirmed through bacteriology-sputum testing positive for AFB (in 5.6%), pleural fluid or tissue testing positive for AFB (in 3.0%) and a positive culture for M. tuberculosis (in 5.6%)-and the diagnosis was confirmed through histology in only 30.2%.…”

Study of Diagnostic Importance of Adenosine Deaminase (ADA) Level in Pleural Effusions

“…In one recent series from Qatar, Ibrahim WH et al 9 reported the mean age of 100 patients with tuberculous pleuritis was 31.5 years. Denise Duprat Neves et al 10 , the mean age in patients with TB (mean = 33.76; SD = 13.96 years old) was significant lower (p < 0.0001) than in NTB group (mean = 49.29; SD = 18.01 years old).…”

Optimising the utility of pleural fluid adenosine deaminase for the diagnosis of adult tuberculous pleural effusion in Hong Kong

“…Another study that developed a predictive model for TBPE also failed to show any significant association between TBPE and either age or sex. 33 Among patients with pfADA level of ≤100 U/L, when pfADA level is ≥26.5 U/L with early negative findings in PF for malignancy and non-tuberculous infection, it is probably appropriate to manage the patient as a case of TBPE, without additionally performing pleural biopsy (also a surrogate marker for TBPE). Nonetheless, it is important to remain vigilant due to a 20.8% (1 minus PPV) chance of mistaking non-tuberculous diseases for TBPE and prescribing unnecessary TB treatment.…”