Successful Nonsurgical Treatment of Tuberculous Empyema in an Irreducible Pleural Space

Neihart, Robert E.; Hof, D. G.

doi:10.1378/chest.88.5.792

Cited by 14 publications

(9 citation statements)

References 4 publications

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“…All of these procedures have substantial morbidity and some mortality, usually because of the compromised respiratory status of the patient. The initial approach involves intensive chemotherapy with serial thoracentesis, as this can be curative at times [88]. It is important to use a multiple (three or more)-drug regimen and to employ agents at their maximal tolerated dosages, because these patients have a strong tendency to develop resistant organisms.…”

Section: Tuberculous Empyemamentioning

confidence: 99%

Tuberculous Pleural Effusion

Cohen

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2015

Tur Toraks Der

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When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult. KEY WORDS:Tuberculosis, pleural effusions, adenosine deaminase, gamma interferon, pleural biopsy, empyema INTRODUCTION Tuberculosis (TB) remains a major public health problem in developing countries. Most patients with TB have pulmonary TB; however, 25% of adults can present with extrapulmonary TB, which mainly involves the lymph nodes and pleura but can affect any organ system, including the central nervous system (CNS), cardiovascular system, and gastrointestinal (GI) tract [1]. The most common form of extrapulmonary TB is infection of the pleura. In a patient who presents with undiagnosed pleural effusion, the diagnosis of TB pleuritis should be considered. Pleural effusion, as an isolated manifestation of TB, may be selflimited and of little immediate concern, but untreated, it can lead to serious disease many years later. Pathogenesis and Pathologic FeaturesTuberculous pleural effusion may occur in the absence of radiologically apparent TB [2]. The effusion may result as a sequela to a primary infection from 6-12 weeks earlier, or it may represent the reactivation of TB [2]. In developed countries, TB pleural effusions present more often in older patients. The median age in one North American study was 56, suggesting reactivation of the disease [3]. However, a study from 2004 in San Francisco showed that pleural TB cases were 2 times more likely to be clustered (when assessed by genotyping of the mycobacterial organisms) than pulmonary TB and 3 times more likely to be clustered than nonrespiratory TB cases [4]. The observations made in the San Francisco study suggest that the majority of patients has a postprimary infection [4]. This was not confirmed in studies performed in both Houston [5] and Baltimore [6] or in a study in sub-Saharan Africa, in which the prevalence of pleural TB was 63.2% in patients with a primary TB infection [7].The pathogenesis of TB pleural effusion is thought to be related to the rupture of a subpleural caseous focus in the lung into the pleural space [8]. The basis for this was the observation that a caseous TB focus could be demonstrated in the lung, contiguous with the diseased pleural, in 12 to 15 patients with TB pleuritis [9]. The 3 other patients in this study had parenchymal disease but did not have caseous foci adjacent...

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Section: Tuberculous Empyemamentioning

confidence: 99%

Tuberculous Pleural Effusion

Cohen

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2015

Tur Toraks Der

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“…However, tuberculous empyema has not been reported as a cause of SVC syndrome [17,18]. Since this patient had neither lymphadenopathy nor mediastinal fibrosis, tuberculous empyema may have resulted in the clinical picture.…”

Section: Discussionmentioning

confidence: 74%

Superior vena cava syndrome caused by encapsulated pleural effusion

Lai

Tsai

et al. 1997

Eur Respir J

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Pleural effusion is often a manifestation of the superior vena cava (SVC) syndrome. However, pleural effusion has never been reported to be a cause of the SVC syndrome.We report the case of a 68 yr old male patient who presented with SVC syndrome and respiratory failure, both attributable to an encapsulated pleural effusion over the right upper mediastinum. Simple drainage was performed as a diagnostic and therapeutic procedure.The pleural effusion was confirmed to be a tuberculous empyema. Chest computed tomography (CT) scan is the most appropriate initial diagnostic procedure for superior vena cava syndrome. Eur Respir J 1997; 10: 1675-1677 Nonmalignant aetiologies account for approximately 12% of all cases of superior vena cava (SVC) syndrome, and have been comprehensively reviewed [1][2][3][4][5][6]. However, SVC syndrome resulting from an encapsulated pleural effusion has never been reported. We report a case of SVC syndrome due to an encapsulated pleural effusion over the right upper mediastinum. Case reportA 68 yr old man was admitted to our hospital because of progressive orthopnoea. He had been well until a week prior to admission, when he experienced rightsided upper back pain. Shortly afterwards, he experienced exertional dyspnoea, which progressed to intolerable orthopnoea within a week, prompting an emergency admission.Physical examination in the emergency room showed that the patient was in respiratory distress. He was afebrile. His face was puffy and flushed, and the neck and upper trunk were swollen, but displayed no visible signs of a collateral circulation. There was no palpable cervical lymphoadenopathy. No lower leg oedema were present. Chest radiography showed cardiomegaly, rightsided pleural effusion, widening of the upper mediastinum, and left-sided displacement of the trachea ( fig. 1). Chest computed tomography (CT) scan disclosed a right-sided encapsulated pleural effusion, compressing the superior vena cava (SVC), lower trachea, and main bronchi ( fig. 2). There was no evidence of pericardial effusion, mediastinal or hilar lymphadenopathy, or dissecting aneurysm.Diagnostic and therapeutic drainage of the effusion was performed and 1.5 L of bloody effusion was removed.Cell counts showed 60×10 9 red blood cells·L -1 , and 2.8×10 9 white blood cells·L -1 , with a neutrophil lymphocyte ratio of 78/22. The patient was hospitalized. On the day after admission, he developed respiratory distress necessitating mechanical ventilation. A pigtail catheter was inserted to drain the pleural effusion. Electro-cardiographic changes were noted 24 h after resuscitation, and subsequent elevation of cardiac enzyme confirmed the occurrence of an acute myocardial infarction. The patient recovered uneventfully from the cardiac event after resuscitation, and was successfully weaned from the ventilator. Symptoms of the SVC syndrome resolved completely after most of the effusion had been drained. Follow-up chest CT scan showed a minimal residual encapsulated pleural effusion, good patency of the SVC ...

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“…120,121 Pleural fluid obtained at thoracocentesis is purulent, with low pH and glucose, elevated lactate dehydrogenase, more than 100,000 cells per microliter, and mostly polymorphonuclear leukocytes. 122 The diagnosis of tuberculous empyema is established if Mycobacterium tuberculosis is cultured from the pleural fluid. This occurs in the majority of cases, although 35% of patients with empyema after pulmonary tuberculosis in whom antituberculous chemotherapy had been instituted have negative cultures.…”

Section: Tuberculous Empyemamentioning

confidence: 99%

“…However, the lung is often trapped by extensive visceral pleural fibrosis. Although successful conservative treatment with serial thoracocentesis has been reported, 122 complete pleural space drainage is preferred if possible. Therefore, an intercostal tube should be inserted in most cases.…”

Section: Tuberculous Empyemamentioning

confidence: 99%

Tuberculous Pleural Effusion and Tuberculous Empyema

Ferrer

2001

Seminars in Respiratory and Critical Care Medicine

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Tuberculous pleuritis has increased worldwide, especially in developing countries, as a consequence of human immunodeficiency virus co-infection. Tuberculous pleuritis is a delayed hypersensitivity reaction against mycobacterial antigens in the pleural space. Mycobacteria are detected in less than 50% of pleural samples, but the characteristic pleural involvement, granulomas with or without caseous necrosis, is evident in 56 to 80% of cases from samples obtained by percutaneous pleural biopsy. Of several pleural fluid parameters studied, adenosine deaminase and interferon gamma (IFN-gamma) have the best diagnostic yield, while polymerase chain reaction remains a promising test. Treatment of patients with tuberculous pleuritis is discussed. Tuberculous empyema is a rare form of tuberculous pleuritis. It consists of a purulent infection of the pleural cavity with detectable bacilli in pleural fluid. Diagnosis is easily established clinically and bacteriologically. Treatment is to adequately drain the pleural space and achieve lung reexpansion, in conjunction with antituberculous chemotherapy. The efficacy of different surgical techniques is discussed.

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Successful Nonsurgical Treatment of Tuberculous Empyema in an Irreducible Pleural Space

Cited by 14 publications

References 4 publications

Tuberculous Pleural Effusion

Tuberculous Pleural Effusion

Superior vena cava syndrome caused by encapsulated pleural effusion

Tuberculous Pleural Effusion and Tuberculous Empyema

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