Role of thoracentesis in the management of tuberculous pleural effusion

Abstract

Background: Tuberculous pleural effusion (TPE) is the second most common form of extrapulmonary tuberculosis (EPTB). Up to 50% after treatment complicated with pleural thickening. Pleural biopsy has been considered the gold standard in diagnosis of TPE but it is invasive, so that pleural fluid markers of TPE have been extensively evaluated as an alternative to pleural biopsy. Thoracentesis for measuring these fluid markers is important.Aim: Assessing the value of diagnostic thoracentesis (by measuring pleural adenosine deaminase levels) and role of therapeutic thoracentesis in preventing pleural thickening.Subjects and methods: 10 cases with transudative pleural effusion and 45 cases with already diagnosed exudative effusion (30 cases of TPE, and 15 cases of Malignant PE) were included. 50 ml pleural fluid samples were aspirated and sent for measuring ADA levels. The 30 cases of TPE were classified into 2 equal groups the 1st group started 6 months anti tuberculous therapy plus repeated thoracentesis while the 2nd started anti tuberculous therapy only. Chest CT scan was done after 2 and 6 months for assessment of pleural effusion and pleural thickening.Results: Patients with tuberculous pleural effusion had higher pleural effusion ADA levels (mean ± SD 68.51 ± 24.06) than those with malignant pleural effusion (mean ± SD 25.47 ± 12.09) or transudative pleural effusion (mean ± SD 16.58 ± 2.93) and these levels had highly a significant difference (P-value <0.001). Also, there was a significant difference (P-value <0.05) between levels of ADA in malignant and transudative pleural effusion. Using a cut-off point of the pleural fluid ADA (30.49 IU/L) with AUC of 96.7 (sensitivity 96.7%, specificity 84%, NPV 88%, PPV 95% and accuracy 91%) discrimination between tuberculous and other causes of pleural effusion occurred. Regarding the pleural thickening, after 2 months of ttt, in group I, 3 cases developed pleural thickening, while in group II, 9 cases developed thickening. After 6 months, there was one case of pleural thickening in group I, while in group II, 5 cases developed pleural thickening. And there was a significant difference (P value <0.05) between both groups, after 2 and 6 months of treatment.

Novel biomarkers for Diagnosis of Pulmonary Tuberculosis and Tuberculous Pleural Effusion

“…[12] Patients with TB-PLE tend to be younger than patients with P-TB. In one recent series from Qatar and Agha et al 2015, the mean age of 100 patients with TBP-E was 31.5 year, [13] thus, the age of patients in present study matched the age reported to be susceptible to tubercular pleurisy in previous series. [11] Significantly increased ADA activity in the serum of pulmonary TB and tubercular pleural effusion patients compared to healthy controls and non-TB pleural effusion is due to activation of cell mediated immunity (delayed hypersensitivity) to Mycobacterium tuberculosis antigen.…”

Indwelling pleural catheter for outpatient management of tuberculous empyema

“…Severe inflammatory reaction secondary to TB results in residual pleural thickening. Previous several studies have demonstrated use of combined antituberculous treatment with pleural drainage in early stages to relieve dyspnoea and reduce residual pleural thickening 4–7. One other study reported use of intercostal pleural drainage as an inpatient for median 57 days to successfully treat tuberculous empyema 8…”

Tuberculous Pleural Effusion- Residual Pleural Thickening

“…6 Another study showed thoracocentesis prevented the occurrence of pleural thickening, apart from being diagnostic and therapeutic. 7 Thus management of pleural TB involves four-drug regimen along with therapeutic thoracocentesis and the radiological resolution takes longer exists even after the required duration of treatment is completed.…”