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Brief Communication

Tuberculous pleural effusion: clinico-radiological and biochemical features observed in an Indian region

Anand Patel, Sushmita Choudhury

Department of Pulmonary Medicine, Smt. B. K. Shah Medical Institute & Research Centre, Sumandeep Vidhyapeeth, Piparia, Vadodara, Gujarat, India.

Corresponding Author: Dr. Anand K. Patel,

A/15, Krishnadeep Society, B/h Saurabh Park, Near Samta, Subhanpura, Vadodara 390021,Gujarat, India. Email:dranandkpatel@gmail.com

Abstract

Pleural effusion is one of the common manifestations of pulmonary tuberculosis. Knowledge of clinical, radiological and pleural fluid analysis pattern of tuberculous pleural effusion may be specifically useful for the Indian populace. This study was carried out to see the clinical, radiological and biochemical pattern of tuberculous pleural effusion. A total of 53 patients of tuberculous pleural effusion were studied. Majority of the patients were in the age group of 21-40 years. Commonest symptom was cough and onset was sub-acute. Tuberculous pleural effusion was found to occur at a young age with no preference for either right or left side; commonly affected less than two thirds of the hemithorax and was unaccompanied by pulmonary infiltrates in three-fifths. Pleural fluid was generally lymphocyte-rich, exudative and high ADA levels were noticed.

Introduction

Tuberculosis is a common cause of pleural effusion, especially in countries like India. Moreover incidence of tuberculosis is increasing worldwide. Tuberculous pleural effusion is thought to result from a delayed hypersensitivity reaction which occurs in response to the presence of mycobacterial antigens in the pleural space. These mycobacterial antigens may gain access to the pleural space from the rupture of a small, subpleural caseous focus. Tuberculous pleural effusion has been described as an acute granulomatous pleuritis occurring as a sequel to recent tuberculous infection in young adults and children who usually do not have roentgenographically apparent parenchymal tuberculosis. However, it is now known that tuberculous pleural effusion may occur in older adults and in patients with classic reactivation tuberculosis. With advent of HIV infection, the epidemiology of tuberculous pleural effusion may be changing. Diagnosis of pulmonary tuberculosis is confirmed mainly by sputum examination of acid fast bascilli (AFB), while the diagnosis of tuberculous pleural effusion requires investigation of pleural fluid biochemistry, cytology and pleural biopsy. Positivity for AFB in pleural fluid and histopathological (HP) study of pleura is very low and culture is very time consuming. ELISA, polymerase chain reaction (PCR) & Quantiferon are expensive tests and not widely

available. Definitive diagnosis of tuberculous pleural effusion is often difficult as in more than 50% of patients, pleura is the only site of infection. Tuberculin test is nonspecific and can be negative. Because bacterial load is less so pleural fluid culture for Mycobacterium tuberculosis is also low (<20%). The present study aimed to determine the clinico-radiological and biochemical profile of tuberculous pleural effusions.

Methods

This prospective observational study was carried out in the Department of Tuberculosis & Respiratory Diseases, Shree M. P. Shah Medical College, Guru Gobindsing Hospital, Jamnagar, Gujarat from January 2003 to December 2004. Adult patients of either sex with pleural effusion underwent detailed history and thorough clinical examination. They were then subjected to detailed investigations which included routine haemogram, urine examination, skiagram chest PA view, sputum smear examination for AFB. Pleural fluid analysis was done for protein, sugar, total cell count and differential count in all patients. Pleural fluid cholesterol; LDH; ADA and pleural fluid to serum ratio of protein; LDH; cholesterol; bilirubin were done in selected patients. Additional films, fluoroscopy, ultrasonography, bronchoscopy, echocardiography and other tests were performed, wherever indicated. Pleural biopsy was done in selected patients only in whom diagnosis was not derived in spite of above means. Diagnosis was made on basis of clinical examination, analysis of laboratory data and response to anti-tubercular treatment (ATT) according to Revised National Tuberculosis Control Programme (RNTCP) guidelines. Pleural effusions were classified as small (when fluid occupied < 1/3 of the hemithorax), moderate (when fluid occupied >1/3 to < 2/3 of hemithorax) and large (when fluid occupied > 2/3 of hemithorax). All patients diagnosed as tuberculous pleural effusion responded to ATT which were evaluated during hospital stay and during follow up. A total of 53 patients were diagnosed as tuberculous pleural effusion during the study period and were included in the study.

Results

Out of 53 patients, 43 were males and 10 were females. Mean age was 37.21 ± 15.64 years. Majority of the patients (56.6%) were in the age group of 21- 40 years. Five patients (9%) had past history of pulmonary tuberculosis. Four (7.55%) patients were having diabetes mellitus. Most common symptom was cough (94.3%) followed by chest pain (71.7%) while fever, anorexia, breathlessness and weight loss were present in 64.15%, 64.15%, 58.5% and 49.1% of patients, respectively. Out of 31 patients (58.5%) without parenchymal lesion, 30 had history of cough; of which 19 (63.3%) had expectoration while out of 22 patients with parenchymal lesion, 20 patients had cough; of which 19 (95%) had expectoration. Majority of the patients had a subacute (67.9%) or chronic (22.6%) duration of symptoms while only 9.4% had acute onset. Right sided pleural effusion was present in 52.8%; leftsided was in 41.5% while only 5.66% had bilateral pleural effusion. Mediastinal shift to opposite side was present in 30.2%. Majority of the patients (67.9%) had moderate pleural effusion while small and large effusion was present in 20.8% and 11.3%, respectively. Forty three (81.1%) patients had free fluid while 10 (18.9%) had encysted pleuraleffusion. Twenty two (41.5%) patients had associated parenchymal lesion. Ten (18.87%) patients had associated ipsilateral pneumothorax (hydropenumothorax). Out of 22 patients with parenchymal lesion sputum for AFB was positive in 15 (68.18%) patients while out of 31 patients without any parenchymal lesion it was positive in only two (6.45%). Forty two (79.25%) patients had straw coloured fluid while haemorrhagic and purulent (empyema) was found in 9.44% and 11.31% respectively. Turbidity (hazy fluid) was present in 48 (90.57%) of the patients. Cobweb and clot formation was present in 18.87% and 15.09% respectively. Pleural fluid protein was > 3gm/dL in 94.34%; sugar was < 60mg/dL in 83.02%; cholesterol was > 60 mg/dL in 97.44%; LDH was > 200 IU/L in 97.44% and ADA was > 40 IU/L in 96.67% of the patients. Predominant lymphocyte count was found in 73.59% of the patients. Pleural fluid total cell counts were in the range of 0-250; 251-1000; 1001-5000 and >5000 in 13.21%; 50.94%; 30.19% and 5.66% of the patients respectively. Pleural fluid to serum ratio of protein >0.5; bilirubin >0.6; cholesterol >0.3 and LDH >0.6 was

found in 100%; 76.67%; 100% and 86.67% of the patients respectively.

Discussion

Tuberculous pleurisy was once considered generally to be a primary form of tuberculosis because it usually occurred in children and young adults in whom tuberculin skin test results had only recently been positive rather than negative. In recent years, it has been reported that mean patient age has gradually risen [1] and that tuberculous pleurisy is becoming a predominantly reactivated form of tuberculosis.

Average occurrence of tuberculous pleural effusion in the present study is similar to that in previous studies [2,3] and considerably less than that reported by some other authors [1]. Patient’s age is of great diagnostic importance because in young patients the presence of pleural exudates with a high ADA concentration and a majority of lymphocytes among its leucocytes is highly suggestive of tuberculosis to the extent that pleural biopsy may be superfluous [1]. The diagnosis of tuberculous pleurisy in older patients is more problematic because of the higher incidence of clinically similar disorders, neoplastic effusions in particular.

Furthermore, as noted above, in our region, the presence of a pleural exudate with a high ADA concentration and majority of lymphocytes among its leucocytes makes pleural biopsy unnecessary if the patient is young (< 35 years). This is partly because of the high prevalence of tuberculous pleuritis in this region, which increases the positive predictive value and efficiency of ADA concentration as a diagnostic marker [4]. In other regions, the efficiency of this marker will not necessarily be as high, and clinicians are accordingly advised to determine this variable for their own region

In this study 41.51% of patients had tuberculous pleural effusion accompanied by parenchymal infiltrates. If the effusion was accompanied by parenchymal infiltrates, sputum was the specimen most likely to be positive for AFB smear. The sputum was positive in 6.45% percent of cases without infiltrates. In previously reported cases, largely those of patients without infiltrates, there was sputum positivity in only 11.11% of patients [2]. Although the yield of sputum AFB smear is low when there are no parenchymal infiltrates, sputum for AFB smear is simple to perform, without risk, and should always be performed when tuberculous disease is a diagnostic possibility.

The results of our pleural fluid analyses are also consistent with those in previous reports. All 53 patients with pleural fluid analysis had exudative effusions, 73.59% had predominant lymphocytic effusion and 96.67% had pleural fluid ADA > 40 IU/L.

We conclude that in our region, the mean age of patients with tuberculous pleural effusion is still low with no tendency to occur preferentially on either the right or the left side, and bilateral effusions are uncommon. Moderated effusion is seen most commonly while massive effusion is rare.The effusions have the biochemical characteristics of exudates with lymphocytic predominance and high ADA is a characteristic marker.

Key Points

Tuberculous pleural effusions are common in younger age group and commonly present with mild to moderate effusion.and high ADA is a characteristic marker. Key Points Pleural fluid is characteristically exudative, lymphocytic

Pleural fluid is characteristically exudative, lymphocytic predominant, with ADA levels > 40 IU/L.pleural effusions are common in younger age group and commonly present with mild to moderate effusion.

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