Pleural tuberculosis: medical thoracoscopy greatly increases the diagnostic accuracy

Abstract

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.

Tuberculous pleural effusion

“…The sensitivity of pleural biopsy is 69–97%, and tends to be higher in HIV‐positive individuals . The technique used to acquire pleural tissue is often dictated by the local expertise and resource availability, and while medical thoracoscopy has a sensitivity of up to 100% for tuberculous pleuritis, and is known to improve the yield for both culture and Xpert, it is not always available . In resource‐limited settings, an ultrasound‐guided closed pleural biopsy represents a reasonable alternative with a diagnostic yield of up to 90% .…”

Pleural tuberculosis: A concise clinical review

“…51 Where sputum analysis fails, samples may be acquired through fiberoptic bronchoscopy in patients with parenchymal lesions. 52 The yield of pleural fluid microscopy for Mtb is less than 10%, with the exception of HIV positive patients and those with empyema, where the yield is increased up to 20%. 13 The yield of pleural fluid culture is dependent on the method used.…”

“…The role of sputum nucleic acid amplification tests (NAAT) such as Xpert MTB/RIF (Cepheid) has yet to be elucidated but can be expected to be similar to that of sputum culture . Where sputum analysis fails, samples may be acquired through fiberoptic bronchoscopy in patients with parenchymal lesions . The yield of pleural fluid microscopy for Mtb is less than 10%, with the exception of HIV positive patients and those with empyema, where the yield is increased up to 20% .…”

“…Abrams needle is favoured over Tru‐cut needle for these procedures . Pleural biopsies taken under direct visualisation via thoracoscopy have a sensitivity of up to 100% for TB pleuritis . The addition of closed pleural biopsy to thoracentesis increased the yield for TB pleural disease from 77.8% to 88.9% .…”

“…60 Pleural biopsies taken under direct visualisation via thoracoscopy have a sensitivity of up to 100% for TB pleuritis. 5,52 The addition of closed pleural biopsy to thoracentesis increased the yield for TB pleural disease from 77.8% to 88.9%. 32 In another study, a combined ADA of more than 50 IU/L, lymphocyte/neutrophil ratio more than 0.75 plus closed pleural biopsy reached 93% sensitivity and 100% specificity.…”