Update on tuberculous pleural effusion

The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of γ‐interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.     

Tuberculous pleural effusions

While a number of recent reports have documented the changing clinical and radiographic spectrum of parenchymal tuberculosis, relatively little attention has been paid to changes in the patterns of pleural tuberculosis. We therefore reviewed the clinical, laboratory, and radiographic characteristics of 26 adult patients with tuberculous pleural effusions. We found that pleural tuberculosis has become a disease of older adults (median age, 56 years) and that 19 percent (5/26) of the cases were due to postprimary (reactivation) disease. This shift in age led to problems in diagnosis, since many of these older patients had underlying or coexisting disease that could have caused a pleural effusion. Both specimens of pleural fluid and pleural biopsy were useful in establishing the diagnosis. Examination of sputum was less helpful. All patients who were not anergic had positive cutaneous reactions to first-strength purified protein derivative of tuberculin. Lymphocytosis of the pleural fluid was not a uniform finding; only 62 percent of our patients had greater than 50 percent lymphocytes on their initial examinations of pleural fluid, and four patients had greater than 90 percent polymorphonuclear cells. All of the effusions were exudates, and four had glucose levels in the pleural fluid that were less than 30 mg/dl. Pleural tuberculosis is an important diagnostic consideration in adult or elderly patients with exudative pleural effusions.     

Pleuritis as a manifestation of reactivation tuberculosis

PURPOSE: The purpose of this study was to determine the frequency with which tuberculous pleuritis is a manifestation of reactivation tuberculosis and to compare the clinical manifestations of reactivation tuberculous pleuritis with "classic" tuberculous pleuritis, in which chest roentgenograms reveal no parenchymal infiltrates. PATIENTS AND METHODS: We evaluated the medical records of 59 patients in whom tuberculous pleuritis was confirmed by histologic findings or mycobacterial culture. Twenty-seven patients (46%) had typical chest roentgenographic findings of reactivation tuberculosis, whereas 32 (54%) had classic tuberculous pleuritis. The clinical and laboratory features of these two groups were compared. RESULTS: Symptoms were more prolonged and pleural fluid glucose and lactate dehydrogenase concentrations were more markedly abnormal in patients with reactivation pleuritis than in those with classic pleuritis, suggesting a more chronic inflammatory process in the former group. Compared with patients with classic tuberculous pleuritis, those with reactivation pleuritis had a lower frequency of reactive tuberculin skin tests (61% versus 88%) and granulomatous pleural inflammation (25% versus 72%), but a higher bacillary burden, manifest by a higher frequency of positive sputum smears for acid-fast bacilli (50% versus 0%) and positive mycobacterial cultures from sputum (60% versus 23%) and pleural fluid (91% versus 66%). CONCLUSIONS: In contrast to previous reports, tuberculous pleuritis was a manifestation of reactivation tuberculosis in 46% (27 of 59) of patients. Tuberculous pleuritis is a more chronic process in patients with reactivation disease than in those with classic pleuritis. The lower frequency of reactive tuberculin skin tests and granuloma formation, combined with the higher bacillary burden in patients with reactivation pleuritis, suggest that these patients mount a less effective immune response to Mycobacterium tuberculosis infection than do patients with the classic form of tuberculous pleuritis.     

胸膜活检对原因不明的渗出性胸腔积液的诊断价值

目的观察胸膜活检术在渗出性胸腔积液诊断中的价值。方法对146例渗出性胸腔积液患者行胸膜活检，同时取胸水及痰送检抗酸杆菌及癌细胞。结果146例胸膜活检第一次活检成功率71．9％，特异性病理诊断92例，病理诊断阳性率63％。恶性胸腔积液胸膜活检阳性率58％，胸水细胞学检查阳性率22％，痰找癌细胞阳性率16％。结核性胸腔积液胸膜活检阳性率66．6％，痰找抗酸杆菌阳性率5．2％。结论胸膜活检是一项安全、简单、有效的胸膜疾病的重要的内科确诊手段。     

结核性与恶性胸腔积液内科胸腔镜下特征比较及诊断相关因素分析

目的对比结核性与恶性胸腔积液内科胸腔镜下的特征及常见危险因素、临床表现的差异,为不明原因胸腔积液鉴别诊断提供依据。方法收集山西医科大学第一医院呼吸科2016年1月至2018年1月“胸腔积液待查”的90例患者临床资料,均因病因不明行内科胸腔镜下胸膜活检,按病理结果分为结核组与恶性组,对比分析2组镜下特征和常见危险因素、临床表现等指标。结果90例患者经胸腔镜和病理检查明确诊断85例,确诊率为944%,其中结核性胸腔积液40例,恶性胸腔积液36例。结核组镜下表现以胸膜充血水肿、广泛粘连、胸膜均匀一致小结节为主(χ^2值分别为23.175、7.361、6.064,P值均<005);恶性组镜下表现以胸膜增生增厚、大小不等结节、白斑样改变、肿块为主(χ^2值分别为23.095、8.717、11.577、5.127,P值均<005)。单因素回归分析:发热、体质量减轻对结核性胸腔积液诊断有意义;年龄>40岁、气促、病程>1个月、吸烟指数>400年支及血性胸腔积液对恶性胸腔积液的诊断有提示意义。多因素回归分析:发热和体质量减轻是结核性胸腔积液的特征性表现;年龄>40岁、病程>1个月、吸烟指数>400年支和血性胸腔积液对恶性胸腔积液诊断有较大价值。结论内科胸腔镜是确诊不明原因胸腔积液的有效检查方法,恶性胸腔积液和结核性胸腔积液是最常见的病因。危险因素、临床表现等指标及内镜下特征性表现对结核性与恶性胸腔积液鉴别有较大提示意义。     

Yield of sputum induction in the diagnosis of pleural tuberculosis

We prospectively evaluated the diagnostic yield of acid-fast bacilli smear and culture for Mycobacterium tuberculosis using sputum induction (SI) in the workup of patients with suspected pleural tuberculosis (TB) who were unable to produce sputum spontaneously. Of the 113 patients studied, a final diagnosis of pleural TB was made in 84 patients (71 HIV seronegative) and a final diagnosis of another disease in 29 patients. Histopathologic examination of the pleural biopsy tissue had the highest diagnostic yield (78%; 66/84). The bacteriologic yield was 62% (52/84) for the pleural tissue, 12% (10/84) for pleural fluid, and 52% (44/84) for sputum cultures obtained by SI. The yield of SI culture for M. tuberculosis was 55% (35/64) in patients with a normal radiograph (except for the pleural effusion) and 45% (9/20) in those with evidence of parenchymal disease suggestive of pulmonary TB (p = 0.6). The yield of sputum cultures obtained by SI is high in patients suspected of having pleural TB even in those cases with no pulmonary parenchymal abnormalities on the chest radiograph.     

A clinical study of tuberculous pleurisy]

Forty-eight cases of tuberculous pleurisy were examined and the following results were obtained. (1) Most of the patients were male, and there was no significant age and underlying diseases. (2) Fever and chest pain were observed mainly in younger patients, and sputum and dyspnea in older patients. (3) All of the cases examined had exudative pleural effusion, and increased ADA activity was frequently observed. (4) Mycobacterium tuberculosis was detected in the sputum of 65%, and also in the pleural effusion of 28% of the patients. The pathological diagnosis of tuberculosis was made by pleural biopsy in 83% of the patients, suggesting that pleural biopsy is very useful in the diagnosis of tuberculosis pleurisy. (5) The prognosis of the patients with tuberculosis pleurisy was good. Steroid therapy was generally ineffective.     

水通道蛋白-1在结核性胸腔积液大鼠胸膜上的表达

目的探讨胸膜上水通道蛋白-1(AQP-1)的表达与结核性胸腔积液大鼠胸液形成之间的关系。方法 48只健康Wistar大鼠随机分为结核性胸腔积液1d组,3d组,5d组和生理盐水对照组(每组各12只),实验组胸膜腔内注射标准人型结核分枝杆菌。应用免疫组织化学检测AQP-1在大鼠胸膜上的分布及蛋白质的表达。实时荧光定量RT-PCR及westernblot方法检测各组大鼠AQP-1在结核性胸腔积液形成前后胸膜上mRNA及蛋白表达的变化。结果大鼠胸腔内注射结核杆菌5d内均有双侧胸腔积液,胸腔积液量于第3d最多(4.4±1.2ml),结核性胸腔积液1d组,3d组和5d组脏壁层胸膜AQP-1mRNA和蛋白表达均高于生理盐水对照组,P均0.05。结论结核性胸腔积液大鼠胸膜的AQP-1表达增多,AQP-1的增多可能与结核性胸腔积液的形成有关。     

T lymphocyte activation in patients with active tuberculosis

Soluble interleukin-2 receptor (sIL-2R) is a marker of T lymphocyte activation. We measured the amount of serum sIL-2R in 35 patients with active tuberculosis before the initiation of antituberculous treatment. Twenty had pulmonary parenchymal lesion, 8 had tuberculous pleural effusion, and 7 had tuberculous lymphadenitis. The serum sIL-2R values were markedly elevated in patients with pulmonary tuberculosis (parenchymal lesion and pleural effusion) compared with patients with tuberculous lymphadenitis (2,612 +/- 536 versus 538 +/- 121 U/ml, p = 0.023), old, inactive tuberculosis (335 +/- 23 U/ml, p = 0.001), and normal control subjects (376 +/- 38 U/ml, p = 0.001). No significant difference was found between patients with parenchymal lesion and those with tuberculous pleural effusion. There was a positive correlation between serum sIL-2R values and the extent of disease on chest radiograph (r = 0.58, p less than 0.001). We conclude that the amount of sIL-2R may be a useful marker of disease activity and extent of involvement in patients with active tuberculous lesions.     

水通道蛋白1在结核性胸腔积液大鼠胸膜上的表达

目的 探讨胸膜上水通道蛋白-1（AQP-1）的表达与结核性胸腔积液大鼠胸液形成之间的关系。 方法 48只健康Wistar大鼠随机分为结核性胸腔积液1-d组,3-d组,5-d组和生理盐水对照组（每组各12只）,实验组胸膜腔内注射标准人型结核分枝杆菌。应用免疫组织化学检测AQP-1在大鼠胸膜上的分布及蛋白质的表达。实时荧光定量RT-PCR及western blot方法 检测各组大鼠AQP-1在结核性胸腔积液形成前后胸膜上mRNA及蛋白表达的变化。 结果大鼠胸腔内注射结核杆菌5-d内均有双侧胸腔积液,胸腔积液量于第3-d最多（4.4±1.2-ml）,结核性胸腔积液1-d组,3-d组和5-d组脏壁层胸膜AQP-1mRNA和蛋白表达均高于生理盐水对照组, P均＜0.05。 结论 结核性胸腔积液大鼠胸膜的AQP-1表达增多,AQP-1的增多可能与结核性胸腔积液的形成有关。     

超声引导下改良胸膜活检术对诊断原因不明胸腔积液的临床观察(附49例临床分析)

目的 观察超声引导下改良胸膜活检术对原因不明胸腔积液诊断中的价值.方法 使用改良胸膜活检术对49例不明原因胸腔积液患者进行胸膜活检术.结果 所有患者胸膜活检均成功,其中间皮瘤3例,低分化癌6例,腺癌7例,未分型4例,结核18例,慢性炎症11例(经治疗最终证实为结核),病理确诊率77.6％,仅2例出现胸膜反应,未出现局部出血及气胸.结论 超声引导下改良胸膜活检术安全、方便,对胸腔积液确诊率高、并发症少.     

结核性胸膜炎发病早期的CT征象及其动态变化特点的分析

目的 分析结核性胸膜炎发病早期的CT征象及其动态演变的特点,提高诊断准确率。方法 收集首都医科大学附属北京胸科医院于2015年3月至2017年2月确诊为结核性胸膜炎的38例患者的影像资料。研究对象中包括男16例,女22例;年龄21~61岁,平均年龄为(35.74±11.92)岁;所有患者均在初次发病7~10d内就诊。分析研究对象发病早期的CT检查资料,提取CT表现特点及征象。结果 38例研究对象中,发生于单侧胸膜病变者34例。其中,病变位于左侧胸膜者18例,位于右侧胸膜者16例,双侧同时出现病变者4例;累及纵隔胸膜者14例(累及左侧纵隔胸膜者6例,累及右侧纵隔胸膜者8例),累及叶间裂胸膜者34例;出现包裹性胸腔积液者38例,出现胸膜下小叶间隔增厚者24例,出现胸膜下条索状影者24例。CT动态随访过程中,37例患者胸膜增厚程度减轻;1例患者在开始治疗6个月复查时增厚程度加重,最厚约1.1cm,12个月再次复查增厚的胸膜较前吸收减轻。随访过程中所有患者胸腔积液均表现吸收减少,胸膜下小叶间隔增厚表现为吸收减少,胸膜下条索状影亦逐渐减少、减薄。另有22例患者在随访中出现胸膜结核瘤。结论 结核性胸膜炎发病早期行CT检查可发现单侧胸膜增厚且不光滑、叶间裂受累伴多发粟粒状改变及微结节,以及包裹性胸腔积液、胸膜下小叶间隔增厚及条索状影等征象,可作为其诊断依据。     

胸水中LPS、IL-35、RORα在结核性胸腔积液中的表达变化及临床意义

目的:探讨胸水中脂多糖(LPS)、白细胞介素35(IL-35)、维甲酸相关孤儿受体α(RORα)在结核性胸腔积液中的表达变化及临床意义。方法:采用回顾性研究方法,选择2017年1月至2020年1月襄阳市中心医院收治的79例结核性胸膜炎患者为结核组,66例恶性胸膜炎患者为恶性组。比较2组胸水LPS、IL-35、RORα水平,采用spearman相关分析胸水LPS、IL-35、RORα水平与结核性胸膜炎的相关性,采用多因素logistic回归分析结核性胸膜炎的影响因素,采用受试者工作特征曲线分析胸水LPS、IL-35、RORα对结核性胸膜炎与恶性胸膜炎的鉴别诊断价值。结果:结核组胸水LPS、IL-35、RORα水平显著高于恶性组( t值分别为2.691、2.908、6.017, P值均<0.05);胸水LPS、IL-35、RORα水平与结核性胸膜炎均呈正相关( r值分别0.375、0.583、0.604, P值均<0.05);胸水LPS、IL-35、RORα水平升高是结核性胸膜炎的危险因素( P值均<0.05);胸水LPS对结核性胸膜炎与恶性胸膜炎的准确性明显高于胸水RORα( P<0.05);胸水IL-35对结核性胸膜炎与恶性胸膜炎的准确性明显高于胸水LPS( P<0.05);胸水LPS、IL-35、RORα联合检测对结核性胸膜炎与恶性胸膜炎的准确性明显高于各项指标单独检测( P<0.05)。 结论:胸水LPS、IL-35、RORα在结核性胸膜炎患者中呈高水平,胸水LPS、IL-35、RORα联合检测在结核性胸膜炎与恶性胸膜炎的鉴别诊断中价值较高,有望在临床推广。     

Tuberculous peritonitis in children：Report of nine patients and review of the literature

AIM：To present our experience with tuberculous peritonitis treated in our hospital from 2002-2007. METHODS： We reviewed the medical records of 9 children with tuberculous peritonitis. RESULTS： Nine patients （5 boys, 4 girls） of mean age 14.2 years were diagnosed with peritoneal tuberculosis. All patients presented with abdominal distention. Abdominal pain was seen in 55.5% and fever in 44.4% of the patients. Four cases had coexisting pleural effusion and two had pulmonary tuberculosis with parenchymal consolidation. Ultrasonography found ascites with septation in 7 patients. Two patients had only ascites without septation. Ascitic fluid analysis of 8 patients yielded serum-ascite albumin gradients of less than 1.1 gr/dL. Laparoscopy and laparotomy showed that whitish tuberculi were the most common appearance. Adhesions were also seen in three cases. The diagnosis of peritoneal tuberculosis was confirmed histo-pathologically in 7 patients and microbiologically in two. Two patients had been diagnosed by ascitic fluid diagnostic features and a positive response to antituberculous treatment. All patients completed the antituberculous therapy without any complications. CONCLUSION： Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. Laparoscopy and peritoneal biopsy are still the most reliable, quick and safe methods for the diagnosis of tuberculous peritonitis.     

An unusual case of a pleural effusion with an abdominal mass

A 38-year-old man presented to us with a left sided pleural effusion. Pleural fluid was aspirated and analysis revealed it to be an exudate with predominant lymphocytes and an elevated ADA level. He was discharged on antituberculous treatment. Patient returned with re-accumulation of pleural fluid. Computed tomography done in our institute picked up not only parenchymal disease in the lung which was not evident on chest radiographs but also picked up an abdominal mass in the left renal fossa. Pathological examination of excised mass revealed its tuberculous nature. The repeated recollection of pleural fluid was attributed to a "paradoxical response"; the patient was reassured and his anti-tuberculous treatment continued. Recognition of the fact that evidence of tuberculosis at distant sites may occasionally be needed to substantiate the diagnosis of tuberculous pleural effusion in a difficult and bacteriologically "negative" case prompted us to report this case.     

Tuberculous effusion: ADA activity correlates with CD4+ cell numbers in the fluid and the pleura

BACKGROUND: Adenosine deaminase (ADA) is a commonly used marker in the diagnosis of tuberculous effusion and there is evidence that its production is linked to T cells and monocytes. Data on the correlation between ADA and T cells or macrophages in tuberculous effusions are conflicting. Furthermore, no studies have examined a possible correlation between pleural tissue infiltration and ADA. OBJECTIVES: We undertook this study to examine cell subsets in the fluid and the pleura in tuberculous effusion and their correlation to ADA. The use of cell subsets as a marker in the differential diagnosis was also examined. METHODS: Pleural fluid from 36 patients with tuberculous and 34 patients with malignant effusion as well as pleural tissue biopsies from 16 patients with tuberculous pleurisy were examined. The APAAP and the avidin-biotin complex immunocytochemical methods were used to examine CD4+ T cells and macrophages (CD68+), while ADA activity was measured by the Giusti colorimetric method. RESULTS: Our results showed that, in pleural fluid, CD4+ cells and ADA were significantly higher in tuberculous compared to malignant effusion (p<0.001 for all measurements). In pleural tissue biopsies, macrophages were the predominant cells but CD4+ T cells were also abundant. A significant correlation was found between ADA and CD4+ numbers in pleural fluid and tissue (r=0.45, p<0.01; r=0.75, p<0.001, respectively). ADA had high sensitivity and specificity for differential diagnosis while cell subsets did not. CONCLUSIONS: These results indicate that ADA activity correlates to CD4+ T cell infiltration in the pleura and the fluid. Moreover, ADA but no cell subsets may be used as markers of tuberculous effusion.     

Pleural effusion in non-Hodgkin's lymphoma.

Intrathoracic non-Hodgkin's lymphoma (NHL) usually presents with roentgenographic evidence of mediastinal lymph node enlargement, pulmonary masses, pleural effusion, and a clinical picture of a systemic disease with lymphadenopathy. The presentation of NHL with pleural effusion as the major roentgenographic abnormality and no clinical peripheral lymphadenopathy or organomegaly is unusual. During a seven-year period, we encountered 19 patients with NHL in whom pleural effusion was the major roentgenographic and clinical finding. Pleural fluid cytologic results were diagnostic in only two patients. Closed pleural biopsy was positive in three. Eight of 11 patients had diagnostic immunophenotypic lymphocyte cell marker studies. Seven of nine patients had diagnostic thoracoscopy and one thoracotomy. The CT scan identified biopsy sites when pleural fluid and tissue studies were nondiagnostic. Lymphomatous tissue was obtained from the pleura in 17 of the 19 patients supporting the contention that pleural effusion in patients with NHL is usually due to pleural lymphoma rather than obstruction to mediastinal lymphatics.     

结核性与癌性胸腔积液的实验室检测比较研究

目的比较研究实验室检测腺苷脱氨酶(ADA)、乳酸脱氢酶(LDH)、癌胚抗原(CEA)、蛋白(TP)、葡萄糖(GLU)等多项指标对结核性与癌性胸腔积液的鉴别诊断价值。方法对151例明确诊断为结核性或癌性胸腔积液分别测定胸水ADA、LDH、CEA、TP、GLU和血清TP,并进行统计分析。结果结核性胸腔积液中ADA、LDH、TP含量都明显高于癌性胸腔积液,其中胸水ADA以28U/L作为诊断结核性胸水的临界值则其敏感性和特异性均极高,结核性胸水中GLU含量则低于癌性胸水,癌性胸水CEA的阳性率高达76.0%,而结核性胸水CEA均阴性。结论联合检测胸水ADA、LDH、CEA、TP和GLU可以作为结核性与癌性胸腔积液的诊断和鉴别诊断依据,其中ADA28U/L可以考虑作为结核性胸腔积液的单独诊断依据。     

结核性胸膜炎的临床特征(附345例分析)

目的　进一步了解结核性胸膜炎的临床特点及其与肺结核的关系。方法 对345例结核性胸膜炎病人的临床特征进行回顾性分析。结果 ①年龄分布,<35岁占51.6%,≥55岁占23.2%,平均38.1岁。②发热、咳嗽、胸痛的发生率分别为73.6%、57.7%和51.9%。③单侧胸水占93.0%,双侧胸水占7.0%,左、右侧发生率分别为47.8%及45.2%。④中、小量胸水共占94.5%,大量胸水仅占5.5%。⑤胸膜炎同时合并肺结核占47.8%。⑥胸水呈草黄色占89.6%,呈血性占10.4%。⑦胸水结核菌检出率为3.2%。⑧PPD试验阳性反应者占83.3%。⑨红细胞沉降率(ESR)增快者占64.9%,均值为46.9mm/1h。结论 结核性胸膜炎仍是目前的常见疾病之一,多见于青少年,与肺结核关系密切,在诊断时应注意其临床特点。     

TaqMan-PCR技术诊断结核病的临床应用研究

目的　探讨TaqMan-聚合酶链反应 (TaqMan-PCR)技术在结核病快速诊断中的临床价值。方法 对 155例活动性肺结核患者的痰和外周血、130例结核性胸膜炎患者的胸腔积液和外周血以及 61例结核性脑膜炎患者的脑脊液和外周血应用TaqMan -PCR检测结核分支杆菌DNA ,痰、胸腔积液和脑脊液进行抗酸染色涂片检查 ,另外 ,痰标本还进行了BACTEC和改良罗氏培养；同期以52例肺癌患者的痰和外周血、50例恶性胸腔积液患者的胸腔积液以及 33例健康人的外周血作为对照进行TaqMan-PCR检测。 结果 155例活动性肺结核患者的痰和外周血、130例结核性胸膜炎患者的胸腔积液和外周血以及 61例结核性脑膜炎患者的脑脊液和外周血TaqMan-PCR的阳性率分别为 49.0%和 51.6%、45.4%和 38.5%以及 50.8%和 42.6% ,痰、胸腔积液和脑脊液TaqMan-PCR的阳性率显著高于抗酸染色涂片以及BACTEC和罗氏培养 (P＜0.05)。TaqMan-PCR检测痰、胸腔积液和外周血的特异性分别为 96.2%、98%和 96.5%。结论 TaqMan-PCR具有较高的敏感性和特异性 ,对结核病的快速诊断具有一定的价值。