An undiagnosed pleural effusion with surprising consequences

Casalini, Angelo Gianni; Cusmano, F; Sverzellati, Nicola; Mori, Pier Anselmo; Majori, Maria

doi:10.1016/j.rmcr.2017.05.007

Cited by 8 publications

(5 citation statements)

References 27 publications

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“…The main message of this study is that if thoracoscopy had not been performed, a diagnosis of pleural TB would have been achieved in 15 out of 52 patients (28.8%) and in four of them only with the culture after 30–40 days ( table 3 ). Spontaneous resolution of pleural TB is a well-known phenomenon [ 32 ], but 65% of patients may progress to pulmonary or extrapulmonary TB within 5 years [ 33 , 34 ]. The usefulness of medical thoracoscopy for the diagnosis and treatment of pleural TB has been previously reported [ 35 ].…”

Section: Discussionmentioning

confidence: 99%

Pleural tuberculosis: medical thoracoscopy greatly increases the diagnostic accuracy

et al. 2018

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Our objective was to evaluate the efficacy of a standardised work-up in the diagnosis of pleural tuberculosis (TB) that included fibreoptic bronchoscopy and medical thoracoscopy.A consecutive series of 52 pleural TB patients observed during the period 2001–2015 was evaluated retrospectively. 20 females, mean (range) age 39.7 (18–74) years, and 32 males, mean (range) age 45.75 (21–83) years, were included (28 non-EU citizens (53.8%)). The diagnosis of TB infections was established by identification (using stains, culture or molecular tests) of Mycobacterium tuberculosis in the pleura, sputum and/or bronchial specimens, or by evidence of caseous granulomas on pleural biopsies. Patients with and without lung lesions were considered separately.The diagnostic yield of the microbiological tests on pleural fluid was 17.3% (nine out of 52 patients). Among the 18 patients with lung lesions, bronchial samples (washing, lavage or biopsy) were positive in 50% of cases (nine patients). Cultures of pleural biopsies were positive in 63% of cases (29 out of 46 patients); pleural histology was relevant in all patients. Without pleural biopsy, a diagnosis would have been reached in 15 out of 52 patients (28.6%) and in four of them only following culture at 30–40 days.An integrated diagnostic work-up that includes all the diagnostic methods of interventional pulmonology is required for a diagnosis of pleural TB. In the majority of patients, a diagnosis can be reached only with pleural biopsy.

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Section: Discussionmentioning

confidence: 99%

Pleural tuberculosis: medical thoracoscopy greatly increases the diagnostic accuracy

et al. 2018

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“…The natural history of TB pleural effusion in HIVnegative individuals is a slow resolution without treatment, although, up to 65% will progress to active TB within 5 years [7,8]. However, with HIV-coinfection, progression to active disease is more frequent and occurs faster.…”

Section: Introductionmentioning

confidence: 99%

Mycobacterial antigens in pleural fluid mononuclear cells to diagnose pleural tuberculosis in HIV co-infected patients

et al. 2020

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Background: Extra pulmonary manifestation of tuberculosis (TB) accounts for approximately one-half of TB cases in HIVinfected individuals with pleural TB as the second most common location. Even though mycobacteria are cleared, mycobacterial antigens may persist in infected tissues, causing sustained inflammation and chronicity of the disease. The aim of this study was to explore various mycobacterial antigens in pleural effusions, the impact of HIV infection and CD4+ T-cell depletion on the presence of antigens, and the diagnostic potential of antigens for improved and rapid diagnosis of pleural TB. Methods: Pleural fluid specimens were collected from patients presenting with clinically suspected pleural TB, and processed routinely for culture, cytology, and adenosine deaminase activity analysis. HIV status and CD4+ T-cell counts were recorded. Pleural fluid mononuclear cells (PFMC) were isolated, and cell smears were stained with acid-fast staining and immunocytochemistry for various mycobacterial antigens. Real-time and nested-PCR were performed. Patients were categorized as pleural TB or non-TB cases using a composite reference standard. Performance of the mycobacterial antigens as diagnostic test was assessed. Results: A total of 41 patients were enrolled, of which 32 were classified as pleural TB and 9 as non-TB. Thirteen patients had culture confirmed pleural TB, 26 (81%) were HIV-TB co-infected, and 64% had < 100 CD4+ T-cells/microL. Both secreted and cell-wall mycobacterial antigens were detected in PFMC. Lipoarabinomannan (LAM) was the most frequently detected antigen. There was no direct correlation between positive culture and antigens. Cases with low CD4+ T-cell counts had higher bacterial and antigen burden. By combining detection of secreted antigen or LAM, the sensitivity and specificity to diagnose pleural TB was 56 and 78%, respectively, as compared to 41 and 100% for culture, 53 and 89% for nested PCR, and 6 and 100% for realtime PCR. Conclusion: Mycobacterial antigens were detectable in PFMC from tuberculous pleural effusions, even in cases where viable mycobacteria or bacterial DNA were not always detected. Thus, a combination of secreted antigen and LAM detection by immunocytochemistry may be a complement to acid-fast staining and contribute to rapid and accurate diagnosis of pleural TB.

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“…Inappropriate treatment in tuberculous pleural effusion will produce partial healing or development of pulmonary/extra-pulmonary TB within a few years 15 . Casalini et al reported a patient with tuberculous pleural effusion who did not receive ATD and later developed wrist tenosynovitis and pulmonary tuberculosis within the next three months 16 . Loh et al reported 20 tuberculous pleural effusion cases with moderatelarge pleural effusion who received two months of daily isoniazid, rifampicin, pyrazinamide with or without ethambutol or streptomycin followed by four months of a daily or three times a week of isoniazid and rifampicin.…”

Section: Discussionmentioning

confidence: 99%

Tuberculous Pyopneumothorax as A Complication of Inadequate Treatment in Active Pulmonary Tuberculosis: A Case Report

Maranatha¹,

Bahri²

2020

J Pure Appl Microbiol

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Various factors in tuberculosis (tB) management can cause inadequate treatment or failures in therapy. Drug-induced hepatotoxicity is one of the adverse effects of anti-tuberculosis drugs (ATD), which can reduce the effectiveness of treatment. Pneumothorax, empyema, and pyopneumothorax are complications of pulmonary tuberculosis, whilst infrequent but leading to significant morbidity and mortality. A 24-year-old woman came with the main complaint of shortness of breath. she was referred with pulmonary TB, right-side pneumothorax, and drug-induced liver injury (DILI) related to ATD. After DILI resolved, standard 6-month treatment (2HRZE/4HR) was continued, but the patient experienced nausea, vomiting, icteric sclera, and an elevation of transaminases. The combination of ATD was discontinued, just ethambutol and streptomycin were given until the transaminases improved. Afterward, the patient was given isoniazid (H), rifampicin (R), and ethambutol (E). The following week an elevation of transaminases was seen, all ATD was discontinued and the patient was given hepatoprotective therapy. After DILI resolved, a regimen of isoniazid (H), pyrazinamide (Z), ethambutol (E) were given. Later in the follow-up chest X-ray, there was worsening homogeneous opacity in the right hemithorax. Pus was observed on thoracentesis and chest tube was inserted for drainage. We presented a case of a pulmonary TB patient with hydropneumothorax having episodes of drug-induced liver injury. The hepatotoxicity related to ATD leads to repetitive discontinuation and change of regiment, resulting in inadequate therapy in the intensive phase of tuberculosis therapy which resulted in pyopneumothorax.

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An undiagnosed pleural effusion with surprising consequences

Cited by 8 publications

References 27 publications

Pleural tuberculosis: medical thoracoscopy greatly increases the diagnostic accuracy

Pleural tuberculosis: medical thoracoscopy greatly increases the diagnostic accuracy

Mycobacterial antigens in pleural fluid mononuclear cells to diagnose pleural tuberculosis in HIV co-infected patients

Tuberculous Pyopneumothorax as A Complication of Inadequate Treatment in Active Pulmonary Tuberculosis: A Case Report

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