Tuberculous Pleural Effusion: New Pulmonary Lesions during Treatment

Choi, Yo Won; Jeon, Seok Chol; Seo, Hye‐Sook; Park, Choong Ki; Park, Sung Soo; Hahm, Chang Kok; Joo, Kyung Bin

doi:10.1148/radiol.2242011280

Cited by 38 publications

(29 citation statements)

References 25 publications

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“…This study suggests that this may be due to immune rebound, by which the improved cell-mediated immunity after treatment coincided with excessive antigen load resulting from rapid bacterial lysis [79]. Some patients with TB pleuritis can develop a peripheral nodule during treatment [80]. These nodules usually represent pulmonary TB and disappear as the anti-TB therapy is continued [80].…”

Section: Treatment Chemotherapymentioning

confidence: 99%

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Tuberculous Pleural Effusion

Cohen

Light

2015

Tur Toraks Der

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When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult. KEY WORDS:Tuberculosis, pleural effusions, adenosine deaminase, gamma interferon, pleural biopsy, empyema INTRODUCTION Tuberculosis (TB) remains a major public health problem in developing countries. Most patients with TB have pulmonary TB; however, 25% of adults can present with extrapulmonary TB, which mainly involves the lymph nodes and pleura but can affect any organ system, including the central nervous system (CNS), cardiovascular system, and gastrointestinal (GI) tract [1]. The most common form of extrapulmonary TB is infection of the pleura. In a patient who presents with undiagnosed pleural effusion, the diagnosis of TB pleuritis should be considered. Pleural effusion, as an isolated manifestation of TB, may be selflimited and of little immediate concern, but untreated, it can lead to serious disease many years later. Pathogenesis and Pathologic FeaturesTuberculous pleural effusion may occur in the absence of radiologically apparent TB [2]. The effusion may result as a sequela to a primary infection from 6-12 weeks earlier, or it may represent the reactivation of TB [2]. In developed countries, TB pleural effusions present more often in older patients. The median age in one North American study was 56, suggesting reactivation of the disease [3]. However, a study from 2004 in San Francisco showed that pleural TB cases were 2 times more likely to be clustered (when assessed by genotyping of the mycobacterial organisms) than pulmonary TB and 3 times more likely to be clustered than nonrespiratory TB cases [4]. The observations made in the San Francisco study suggest that the majority of patients has a postprimary infection [4]. This was not confirmed in studies performed in both Houston [5] and Baltimore [6] or in a study in sub-Saharan Africa, in which the prevalence of pleural TB was 63.2% in patients with a primary TB infection [7].The pathogenesis of TB pleural effusion is thought to be related to the rupture of a subpleural caseous focus in the lung into the pleural space [8]. The basis for this was the observation that a caseous TB focus could be demonstrated in the lung, contiguous with the diseased pleural, in 12 to 15 patients with TB pleuritis [9]. The 3 other patients in this study had parenchymal disease but did not have caseous foci adjacent...

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Section: Treatment Chemotherapymentioning

confidence: 99%

“…Some patients with TB pleuritis can develop a peripheral nodule during treatment [80]. These nodules usually represent pulmonary TB and disappear as the anti-TB therapy is continued [80].…”

Section: Treatment Chemotherapymentioning

confidence: 99%

Tuberculous Pleural Effusion

Cohen

Light

2015

Tur Toraks Der

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“…Clinically, PR may be confused with treatment failure, drug resistant TB, or other infection, especially in extra-pulmonary cases that have a low positive rate of pathogen culture (Baumann et al 2007). However, only limited information is available on the clinical characteristics and risk factors for PR of pleural TB in HIV-negative patients (Al-Majed 1996;Kumar and Vasu 2001;Choi et al 2002).…”

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confidence: 99%

Risk Factors for Development of Paradoxical Response during Anti-Tuberculosis Treatment in HIV-Negative Patients with Pleural Tuberculosis

Jung

Shin

Kim

et al. 2011

Tohoku J. Exp. Med.

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Paradoxical response (PR) is the unusual expansion or new formation of a tuberculous lesion during anti-tuberculosis (TB) treatment. Pleural TB is the second most common form of extrapulmonary TB and has clinical importance because it occurs in a restricted space. Limited information is available for PR in HIV-negative patients with pleural TB. The aim of this study was to evaluate the clinical characteristics and risk factors of PR in HIV-negative patients with pleural TB. Patients diagnosed with pleural TB between 2003 and 2008 at Chung-Ang University Hospital and Yong-San Hospital, Seoul, South Korea were included. We evaluated the incidence and treatment outcome of PR in pleural TB, and compared baseline clinical characteristics and laboratory findings between TB patients with PR and those without PR. PR was present in 32 (23%) of 139 patients after mean 51.1 days following initiation of treatment. Out of 32 patients, 18 patients needed additional treatment for symptom control. PR patients had a high incidence of adverse drug reaction such as drug skin reaction or liver function abnormality (P < 0.05). The risk factors for PR are younger age, high serum albumin level, low proportion of lymphocyte, and high proportion of PMN in pleural fluid (P < 0.05). PR is not an uncommon problem in HIV-negative pleural TB and half of these patients need additional treatment. Therefore, physicians must pay more attention for PR during the management of pleural TB in the expected patients to develop PR.

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“…5 La afectación pulmonar en la RP de la edad adulta se sitúa en torno al 10%. 11 Tanto los niños como los adultos presentan empeoramiento moderado del cuadro respiratorio, con aparición de nuevos infiltrados o progresión de los preexistentes, así como derrame pleural en las formas de RP con afectación pulmonar. 7,11 El diagnóstico de la RP es clínico y de exclusión, y, por lo tanto, no existen pruebas específicas.…”

Section: Discussionunclassified

“…11 Tanto los niños como los adultos presentan empeoramiento moderado del cuadro respiratorio, con aparición de nuevos infiltrados o progresión de los preexistentes, así como derrame pleural en las formas de RP con afectación pulmonar. 7,11 El diagnóstico de la RP es clínico y de exclusión, y, por lo tanto, no existen pruebas específicas. Es necesario asegurar el correcto cumplimiento del tratamiento con cuatro fármacos con una dosificación adecuada y descartar la presencia de bacilos resistentes, la existencia de coinfección por el VIH u otras infecciones concomitantes o la presencia de una reacción adversa medicamentosa.…”

Section: Discussionunclassified

Reacción paradójica al tratamiento antituberculosis en una niña inmunocompetente afectada de tuberculosis ganglionar pulmonar

2017

Arch Argent Pediat

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Presentación de casos clínicos RESUMENLa reacción paradójica al tratamiento antituberculoso es una entidad poco frecuente en pediatría. Se presenta el caso de una niña de 9 años con fiebre, tos y expectoración de tres semanas de evolución. La prueba de tuberculina y Quantiferon fueron positivos; la velocidad de sedimentación era de 64 mm/h; el cultivo y la reacción en cadena de la polimerasa para M. tuberculosis fueron negativos. La radiografía de tórax mostró ensanchamiento mediastínico derecho. Ante el diagnóstico de tuberculosis, se inició un tratamiento con rifampicina, isoniacida, pirazinamida y etambutol en dosis estándar. A los 21 días, reapareció la fiebre elevada sin otra sintomatología, empeoramiento radiológico junto con normalidad de serologías, analítica sanguínea y resonancia cerebral. Se diagnosticó una reacción paradójica; se inició 1 mg/kg/día de prednisona oral, y quedó afebril a las 24 horas. Es importante considerar esta entidad cuando otras causas de empeoramiento clínico y/o radiológico se han descartado para evitar pruebas complementarias y modificaciones de tratamiento innecesarias. Palabras clave: tuberculosis, reacción paradójica, inmunocompetencia, linfadenitis, corticosteroides. ABSTRACTParadoxical reaction to antituberculosis treatment is rare in paediatric population. We report a 9-year-old girl with high fever and productive cough for the last three weeks. Tuberculine test and Quantiferon were positive, erythrocyte sedimentation rate was 64 mm/h, culture and polymerase chain reaction for M. tuberculosis negative, and chest X ray showed a widened right mediastinum. Tuberculosis was diagnosed, therefore treatment with standard doses of rifampicin, isoniazid, pyrazinamide and ethambutol was started. Twenty-one days later she presented high fever with no other symptoms, worsening of radiological findings and normal blood tests, serologies and brain magnetic resonance imaging. The patient presented a paradoxical reaction and was Reacción paradójica al tratamiento antituberculosis en una niña inmunocompetente afectada de tuberculosis ganglionar pulmonar Paradoxical reaction to antituberculosis treatment in an immunocompetent girl with pulmonary tuberculosisgiven prednisone 1 mg/kg/day, fever disappeared in 24 hours. It is important to consider a paradoxical reaction when other causes of clinical and/or radiological worsening have been ruled out, to avoid unnecessary tests and treatment modifications.

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Tuberculous Pleural Effusion: New Pulmonary Lesions during Treatment

Abstract: New lung lesions that develop during medication for tuberculous pleural effusion should be considered a transient worsening that ultimately improves with continuation of medication.

Cited by 38 publications

References 25 publications

Tuberculous Pleural Effusion

Tuberculous Pleural Effusion

Risk Factors for Development of Paradoxical Response during Anti-Tuberculosis Treatment in HIV-Negative Patients with Pleural Tuberculosis

Reacción paradójica al tratamiento antituberculosis en una niña inmunocompetente afectada de tuberculosis ganglionar pulmonar

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