The tuberculous pleural effusion

Abstract

Pleural tuberculosis (TB) is a common entity with similar epidemiological characteristics to pulmonary TB. It represents a spectrum of disease that can variably self-resolve or progress to TB empyema with severe sequelae such as chronic fibrothorax or empyema necessitans. Coexistence of and progression to pulmonary TB is high. Diagnosis is challenging, as pleural TB is paucibacillary in most cases, but every effort should be made to obtain microbiological diagnosis, especially where drug resistance is suspected. Much attention has been focussed on adjunctive investigations to support diagnosis, but clinicians must be aware that apparent diagnostic accuracy is affected both by the underlying TB prevalence in the population, and by the diagnostic standard against which the specified investigation is being evaluated. Pharmacological treatment of pleural TB is similar to that of pulmonary TB, but penetration of the pleural space may be suboptimal in complicated effusions. Evidence for routine drainage is limited, but evacuation of the pleural space is indicated in complicated disease.Educational aimsTo demonstrate that pleural TB incorporates a wide spectrum of disease, ranging from self-resolving lymphocytic effusions to severe TB empyema with serious sequelae.To emphasise the high coexistence of pulmonary TB with pleural TB, and the importance of obtaining sputum for culture (induced if necessary) in all cases.To explore the significant diagnostic challenges posed by pleural TB, and consequently the frequent lack of information about drug sensitivity prior to initiating treatment.To highlight the influence of underlying TB prevalence in the population on the diagnostic accuracy of adjunctive investigations for the diagnosis of pleural TB.To discuss concerns around penetration of anti-TB medications into the pleural space and how this can influence decisions around treatment duration in practice.

Infective Pleural Effusions—A Comprehensive Narrative Review Article

“…Pleural effusions and empyema secondary to tuberculosis represent unique and challenging diseases. Their occurrence is rare in developed countries [ 7 , 8 ]. Findings suggestive of such diseases include a pleural fluid lymphocyte/neutrophil ratio of >0.75 in combination with elevated adenosine deaminase [ 7 ].…”

“…Their occurrence is rare in developed countries [ 7 , 8 ]. Findings suggestive of such diseases include a pleural fluid lymphocyte/neutrophil ratio of >0.75 in combination with elevated adenosine deaminase [ 7 ]. Regardless, their presence requires a longer duration of treatment [ 7 ].…”

“…Findings suggestive of such diseases include a pleural fluid lymphocyte/neutrophil ratio of >0.75 in combination with elevated adenosine deaminase [ 7 ]. Regardless, their presence requires a longer duration of treatment [ 7 ]. Details regarding the specific diagnosis and management of such conditions will not be discussed in this text as they are infrequently encountered and often require multi-disciplinary and specialized care.…”

Diagnosing and managing pleural disease

“…Dealing with pleural disease is made substantially more straightforward by easy access to tools like thoracic ultrasound, but much of the Breathe readership will be all too aware that a huge proportion of the global burden of pleural disease has to be dealt with in resource-limited environments. S haw et al [ 3 ] outline practical approaches to the diagnosis and management of malignant pleural effusions in resource-constrained settings, while M c N ally et al [ 4 ] examine the unique clinical challenges posed by pleural tuberculosis.…”