Thoracoscopic Decortication of Stage III Tuberculous Empyema Is Effective and Safe in Selected Cases

Kumar, Arvind; Asaf, Belal Bin; Lingaraju, Vijay Cholenahalli; Yendamuri, Sai; Pulle, Mohan Venkatesh; Sood, Jayashree

doi:10.1016/j.athoracsur.2017.06.038

Cited by 36 publications

(51 citation statements)

References 11 publications

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“…TB empyema is thought to arise through various mechanisms including progression of TB pleural effusion, direct spread of infection from a ruptured thoracic lymph node or a subdiaphragmatic focus, haematogenous spread from a distant focus, post‐pneumonectomy and, in the historical context, following therapeutic pneumothorax, Lucite ball plombage or oleothorax . Where the empyema arises from a pleural effusion, three stages of evolution have been described: the exudative phase (clear, viscous and often sterile effusion), the fibrinopurulent phase (thick, infected, purulent fluid) and the organizing phase (granulation tissue formation with lung encasement) …”

Section: Clinical Featuresmentioning

confidence: 99%

“…Instillation of intrapleural fibrinolytics has a role to play in the treatment of TB empyema; however, surgical intervention is often required to control infection and prevent progression to fibrothorax. Traditionally, open thoracotomy with decortication (removal of thickened visceral and parietal pleural peel) has been the intervention of choice for patients in whom pleural peel has been present for months and who have symptoms related to restriction or trapped viable lung; however, recent data have demonstrated good outcomes with video‐assisted thoracic surgery (VATS) decortication . Kumar et al .…”

Section: Managementmentioning

confidence: 99%

“…There were no perioperative deaths amongst the cohort, and the morbidity rate of 33% was composed mainly of persistent air leak. At 6‐month follow‐up, 89 patients had expanded lungs on imaging . All the above‐mentioned interventions have yet to be conclusively correlated with meaningful long‐term benefits for patients.…”

Section: Managementmentioning

confidence: 99%

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Tuberculous pleural effusion

2019

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Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti‐tuberculous therapy or a guideline‐based individualized regimen in the case of drug resistance. There is low‐quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short‐ and long‐term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.

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Section: Clinical Featuresmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

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Tuberculous pleural effusion

2019

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“…This may develop through various mechanisms: progression of primary TB pleuritis as suggested above, direct spread of infection into the pleural space from ruptured thoracic lymph nodes or a subdiaphragmatic focus, haematogenous spread, post pneumonectomy, or historically following therapeutic pneumothorax that lead to lung entrapment . The empyema evolves through 3 stages: Stage I—the pre‐empyema exudative phase characterised by a clear, viscous, sterile pleural effusion; Stage II—the fibrinopurulent phase, in which the fluid becomes thick, infected and purulent; Stage III—the organising or consolidation phase, involving the formation of granulation tissue and lung encasement . The majority of TB empyemas will leave a thickened scarred calcified pleura …”

Section: Tb Empyemamentioning

confidence: 99%

“…Empyema necessitans (necessitatis) occurs when there is extension of purulent fluid through the parietal pleura into the chest wall . A TB pleural effusion with severe concomitant parenchymal involvement can cause an alveolar‐pleural or broncho‐pleural fistula, with subsequent secondary spontaneous pneumothorax and empyema . The development of a persistent air leak in this situation is not unusual, especially in the presence of significant pleural adhesions .…”

Section: Complicationsmentioning

confidence: 99%

Pleural tuberculosis: A concise clinical review

Shaw

Irusen

Diacon

et al. 2018

Clinical Respiratory J

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Tuberculosis (TB) is the leading infectious cause of death worldwide, and the commonest cause of death in people living with HIV. Globally, pleural TB remains one of the most frequent causes of pleural exudates, particularly in TB-endemic areas and in the HIV positive population. Most TB pleural effusions are exudates with high adenosine deaminase (ADA), lymphocyte-rich, straw-coloured and free flowing, with a low yield on mycobacterial culture. TB pleurisy can also present as loculated neutrophil-predominant effusions which mimic parapneumonic effusions. Rarely, they can present as frank TB empyema, containing an abundance of mycobacteria. Up to 80% of patients have parenchymal involvement on chest imaging. The diagnosis is simple if M. tuberculosis is detected in sputum, pleural fluid or biopsy specimens, and the recent advent of liquid medium culture techniques has increased the microbiological yield dramatically. Where the prevalence of TB is high the presence of a lymphocyte-predominant exudate with a high ADA has a positive predictive value of 98%. In low prevalence areas, the absence of an elevated ADA and lymphocyte predominance makes TB very unlikely, and pleural biopsy should be performed to confirm the diagnosis. Pleural biopsy for liquid culture and susceptibility testing must also be considered where the prevalence of drug resistant TB is high. Treatment regimens are identical to those administered for pulmonary TB. Initial pleural drainage may have a role in symptom relief and in hastening the resolution of the effusion. Surgical intervention may be required in loculated effusions and empyemas.

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