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Title:

Pleural TB

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Pleural TB Case 2 33y Male Smoker (10 pack) Aboriginal 1 Month Cough, SOBE ,Fever Cough non productive No orthopnea , PND , LL swelling Fever intermittent ,night ... – PowerPoint PPT presentation

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Date added: 6 June 2020
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Title: Pleural TB


1
Pleural TB
2
Case 2
  • 33y Male Smoker (10 pack) Aboriginal
  • 1 Month Cough, SOBE ,Fever
  • Cough non productive
  • No orthopnea , PND , LL swelling
  • Fever intermittent ,night sweating
  • Wt loss 12 lbs , decrease appetite

3
History
  • Lives in reserve
  • No Contact with TB
  • No travel ,pets
  • PMH ve
  • PSH MVA? Rt arm atrophy 1991
  • Blood Tx after MVA
  • No IV drugs

4
Examination
  • Temp 39.8 BP 120/65 HR 80
  • RR 16 Sat 93 RA
  • No enlarged LN
  • Chest decreased BS Lt lower 2/3 Post
  • Dull percussion note
  • CNS Rt Arm weakness 3/5 distal gt proximal
  • Abd LL Unremarkable

5
Investigation
  • CBC N
  • Creat , BUN , Lytes N
  • LFT Liver enzymes N
  • CXR

6
Investigation
  • Sputum GS C/S -ve
  • Sputum AFB ve 3 times
  • PPD ve 18 mm
  • VATS ? Pleura Thickened with adhesions
  • 1500 Pleural fluid drained
  • Pleural lysis
  • Pleural Bx ? Granuloma
  • with ve DNA For
    Mycobacterium

7
Management
  • 4 Anti TB Rx Pyridoxine
  • Improved afebrile ,no SOB
  • Chest tube was removed
  • Discharged Home

8
TB Pleural Effusion
  • 5 of all diseases attributed to TB
  • Results from delayed hypersensitivity reaction to
    TB antigen
  • Different from tuberculous empyema which is
    purulent fluid abundant in TB organism with
    thickened calcified pleura
  • Different presentation in Non HIV Vs HIV

9
Presentation
  • 60 Pt study
  • In Non HIV
  • Non productive Cough ,Pleuritic CP , SOB
  • Fever ,Night sweating Wt Loss
  • In HIV
  • ?Younger Patient , more Wt Loss
  • extrapulmonary involvement

  • Frye et al

  • Chest Aug 1997

10
Imaging
  • In Non HIV
  • 70 Pleural TB/1700 Dx TB patient
  • Unilateral effusion
  • Associated Lung infiltrates 50
  • Upper Lobes 75 ? Reactivation
  • Lower lobes 25 ? Primary Disease


  • Seibert et al

  • Chest April 1991

11
Imaging
  • In HIV
  • 963 HIV Vs 1000 Non HIV
  • Unilateral effusion
  • Lung infiltrate ?Lower Lobes
  • Adenopathy 5-18
  • Miliary Pattern 7-10
  • Less cavitations 33

  • Tshibwabwa-Tumba et al

  • Clin Radiol 1997 Nov

12
PPD Skin Test
  • 70 Patients 43 HIV 27 Non HIV
  • HIV mainly IVDU
  • Non HIV 73 ve Vs 41 HIV
  • Age Non HIV 52 Vs 37 HIV


  • Relkin et al

  • Chest may 1994

13
Microbiology
  • Sputum culture ve 20-50
  • ? involvement of lung parenchyma
  • Pleural Fluid culture ve 40-50
  • Pleural Bx culture ve 60-80
  • Higher yield in HIV patients in all specimens

14
ADA
  • 216 Patients 100 TB , 86 Malignancy
  • 19 empyema , 6
    transudate
  • 15 miscellaneous , 8
    unknown
  • High ADA in TB 110 in Empyema 191
  • No difference Between HIV ve -ve TB Pt
  • Cut off 60 u/l ? PPV NPV 95

  • Riantawan P et al

  • Chest 1999 Jul

15
ADA
  • 106 lymphocytic effusion Non TB
  • ADA measured once in all
  • second time 6weeks later in 26 cases
  • 45 Post CABG , 27 Malignant
  • 10 Miscellaneous , 24 Transudative
  • With cut off 40 u/l only 3 patients ve
  • 2 Lymphoma 1 complicated parapneumonic
  • High NPV reproducible

  • Gary Lee et al

  • Chest Aug 2001

16
ADA ,PCR Interferon Gamma
  • 140 Patient
  • ?had ADA , PCR INF pleural fluid levels
  • 42 Confirmed TB
  • (ve fluid smear or culture or ve
    histology)
  • 19 Probable TB
  • Symptoms or signs , Bx chronic
    inflammation
  • ve sputum or Response to Anti TB
  • 70 Non TB etiology , 9 Unknown

  • Villegas Chest, Nov 2000

17
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20
Treatment
  • Similar to Pulmonary TB
  • Steroid ? Effect small study 40 pt
  • faster resolution of Fever SOB effusion
  • But no effect on pleural thickening
  • Drainage Small study 60 pt
  • Initial improvement in SOB in first week
  • No effect later on symptoms
  • or pleural thickening
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