Tuberculous
Pleural Effusion
Epidemiology
• Pleural TB is second most common
extrapulmonary TB site behind lymph node
involvement
Pathogenesis
• TB Pleural effusion can be seen in either primary disease
or reactivation disease
• Effusion a result of the rupture of a subpleural foci of TB
into the pleural space that leads to a delayed
hypersensitivity reaction to the TB antigens
• Tuberculous empyema – same mechanism as above with
spillage of large amount of mycobacterium into pleural
space purulent effusion that requires surgical
intervention and can result in pleural fibrosis and
restrictive lung disease
Clinical Presentation
• usually presents as an acute illness (1 wk – 1
mo symptoms)
• presenting symptoms: pleuritic chest pain and
nonproductive cough
• common to have other symptoms of TB –
night sweats, weight loss, dyspnea
• physical exam consistent with pleural effusion
– decreased breath sounds, dullness to
percussion at site of disease
Clinical Presentation
• CXR – small to moderate sized unilateral
pleural effusion
• Pleural Fluid
-Straw colored appearance
-exudative
-pH 7.3 – 7.4
-glucose usually <60
-Cell count usually 1000 – 6000 with lymphocytic
predominance(>85%)
Differential Diagnosis
• Lymphocytic Effusion
– TB
– Malignancy
– Lymphoma
– Collagen vascular disease
– Post coronary artery bypass grafting
Diagnosis
• TB skin test
-helpful if +, especially in areas of low prevalence of disease
-oftentimes negative but if repeated 6-8 weeks later usually +
• Radiology
-CXR with small – moderate sized unilateral effusion and
associated parenchymal lung lesions in 20-50%
-CT scan better at documenting parenchymal lung disease (80% of
cases). Also better at delineating TB pleural effusion
complications such as pleural thickening, calcification, loculated
effusions, empyema, empyema necessitatis, and bronchopleural
fistula
Diagnosis
• Sputum
-can have + M Tuberculosis cultures 20-50% time
-increased yield on sputum cultures with
parenchymal lung lesions on radiographs
-should still be pursued in areas where other means
of diagnosis not available
Diagnosis – Pleural Fluid
• Microbiology
for + smear, need 10,000 tubercle/ml, so AFB detects <10%
for + M Tuberculosis culture, need 10-100 viable bacilli, so has a
higher yield, but still usually <30%
• Adenosine Deaminase (ADA)
enzyme in purine salvage pathway that is important in
differentiation of lymphoid cells and has increased activity with
increased lymphocyte activity
high sensitivity (90-100%)
cutoff is 60: >60 supportive of TB, <40 virtually excludes TB
• Interferon gamma
produced by t-lymphocytes to activate macrophages
increased in TB pleural effusion due to increased numbers of T-
lymphocytes present
more sensitive and specific vs. ADA, but more expensive and less
available so not used as much
Diagnosis
• Pleural Biopsy
– most sensitive test
– tissue via closed needle biopsy or thoracoscopy
– Histology: caseating granulomas (50-97%)
– Culture for M Tuberculosis + in 40-80%
– Combo of above two leads to diagnosis in 60 –
95% cases
Treatment
• If left untreated, effusions usually resolve in 4-16
weeks and are followed by development of active
pulmonary TB or extrapulmonary TB in 43-65% cases
• Antimicrobial therapy is the same as for pulmonary
TB
– 4 drug therapy for 2 months with isoniazid, rifampin,
pyrazinamide, and ethambutol followed by 4 mo of
isoniazid and rifampin
• Steroids have been studied in TB pleural effusion
with no definite benefit.
– Studies did note earlier resolution of symptoms (fever,
chest pain, dyspnea) in patients treated with steroids, but
no difference in the development of pleural thickening,
adhesions, or residual lung function.
