Diagnostic tools in tuberculous pleurisy: a direct comparative study

Abstract

Thoracoscopy is the most accurate yet most expensive tool for establishing the diagnosis of tuberculous (TB) pleurisy. However, most high TBincidence regions have limited financial resources, lack the infrastructure needed for routine thoracoscopy and require an alternative, cost-effective diagnostic approach for pleural effusions.Altogether, 51 patients with undiagnosed exudative pleural effusions were recruited for a prospective, direct comparison between bronchial wash, pleural fluid microbiology and biochemistry (adenosine deaminase (ADA) and cell count), closed needle biopsy, and medical thoracoscopy.The final diagnosis was TB in 42 patients (82%), malignancy in five (10%) and idiopathic in four patients (8%). Sensitivity of histology, culture and combined histology/culture was 66, 48 and 79%, respectively for closed needle biopsy and 100, 76 and 100%, respectively for thoracoscopy. Both were 100% specific. Pleural fluid ADA of o50 U?L -1 was 95% sensitive and 89% specific. Combined ADA, lymphocyte/ neutrophil ratio o0.75 plus closed needle biopsy reached 93% sensitivity and 100% specificity.A combination of pleural fluid adenosine deaminase, differential cell count and closed needle biopsy has a high diagnostic accuracy in undiagnosed exudative pleural effusions in areas with high incidences of tuberculosis and might substitute medical thoracoscopy at considerably lower expense in resource-poor countries. Eur Respir J 2003; 22: 589-591. Tuberculous (TB) pleurisy remains a diagnostic challenge. A high regional incidence for TB often correlates with poor financial resources necessitating a cost-effective diagnostic strategy. Pleural fluid staining for acid fast bacilli (AFB) and culture of M. tuberculosis has a poor yield and sputum or bronchial sampling via bronchoscopy can diagnose only a minority of cases with additional open lung tuberculosis. Closed needle pleural biopsy has a yield of 60-80% for TB pleurisy and 50% for malignancy [1,2]. Its role is controversial, as pleural fluid cytology has a high yield in malignancy and medical thoracoscopy is diagnostic in w90% of TB and malignant pleural effusions [3]. Adenosine deaminase (ADA) is raised in TB pleural effusions and has gained popularity in high-incidence areas for TB. High diagnostic accuracy has been reported and the test is cheap and readily available [4]. The drawbacks of relying on ADA alone are the low number of TB cultures yielded on pleural fluid and the possibility of false positives. Specificity can be improved by including the lymphocyte/neutrophil-ratio (L:N) into the test [5].Although the different diagnostic options have been studied alone, this study is the first prospective head-to-head comparison of bronchial wash, pleural fluid microbiology, pleural fluid biochemistry and closed needle biopsy versus thoracoscopic biopsy in a series of patients with undiagnosed exudative pleural effusions. The study was conducted at Tygerberg Hospital, Cape Town, South Africa, situated in a region with a very high incidence of TB (588 cas...

Medical Thoracoscopy vs Closed Pleural Biopsy in Pleural Effusions: A Randomized Controlled Study

“…This may be due to complexity of cases which were referred to a teritiary care teaching institute. The yield of closed pleural biopsy was comparable to that seen in a study done by Diacon et al, [8] and it was better than that seen in study done by Loddenkemper et al, [10]. The complication rates of both procedures were lower than those seen in the study done by Metintas et al, [11].…”

Clinical and Laboratory Parameters in the Differential Diagnosis of Pleural Effusion Secondary to Tuberculosis or Cancer

“…[19][20][21][22][23][24][25] Despite the high diagnostic sensitivity of ADA, its specificity is influenced by other clinical conditions and by the regional prevalence of tuberculosis. 26,27 In the present study, 13 (9%) patients with cancer presented an ADA activity higher than 40 U/L. Five of these patients had lymphomas (diagnosed by immunophenotypying) and eight had solid tumors.…”

Thoracic Ultrasound-Assisted Selection for Pleural Biopsy With Abrams Needle

“…4,5 For the diagnosis of pleural effusion with apparent diffuse pleura, such as that observed in tuberculous pleural effusion, CPB is the technique of choice. 19 Ultrasound-guided pleural biopsy with an Abrams needle is more likely to contain pleural samples and has a significantly higher diagnostic sensitivity for pleural tuberculosis. 12 But for patients with partially affected pleura or pleural thickening, such as in malignant pleural effusion, other techniques should be used.…”