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Pleural Pleural TBTB

Case Case 22

33y

33y Male

Male Smoker

Smoker (10

(10 pack)

pack) Aboriginal

Aboriginal

11 Month

Month Cough,

Cough, SOBE

SOBE ,Fever

,Fever

Cough

Cough non

non productive

productive

No

No orthopnea

orthopnea ,, PND

PND ,, LLLL swelling

swelling

Fever

Fever intermittent

intermittent ,night

,night sweating

sweating

Wt

Wt loss

loss 1212 lbs

lbs ,, decrease

decrease appetite

appetite

History

History

Lives

Lives inin reserve

reserve

No

No Contact

Contact with

with TBTB

No

No travel

travel ,pets

,pets

PMH

PMH –ve

–ve

PSH

PSH :: MVA

MVA Rt

Rt armarm atrophy

atrophy 1991

1991

Blood

Blood TxTx after

after MVA

MVA

No

No IVIV drugs

drugs

Examination

Examination

Temp Temp 39.8 39.8 BPBP 120/65 120/65 HRHR 8080

RRRR 1616

Sat 93%93% RARA

Sat

No

No enlarged

enlarged LNLN

Chest

Chest :: decreased

decreased BSBS Lt

Lt lower

lower 2/3

2/3 Post

Post

Dull percussion

Dull

percussion note

note

CNS

CNS :: Rt

Rt Arm

Arm weakness

weakness 3/5

3/5 distal

distal >> proximal

proximal

Abd Abd && LLLL Unremarkable Unremarkable

CBC CBC NN

Investigation

Investigation

Creat Creat ,, BUN BUN ,, Lytes Lytes NN

LFT LFT && Liver Liver enzymes enzymes NN

CXR CXR

Investigation

Investigation

Sputum

Sputum GSGS && C/S

C/S

-ve

-ve

Sputum

Sputum AFB

AFB –ve

ve 33 times

times

PPD

PPD +ve

+ve

1818 mmmm

VATS

VATS  Pleura

Pleura Thickened

Thickened with

with adhesions

adhesions

  • 1500 1500 Pleural

Pleural fluid

fluid drained

drained

Pleural lysis

Pleural

lysis

Pleural BxBx  Granuloma

Pleural

Granuloma

with

with +ve

+ve DNA

DNA For

For Mycobacterium

Mycobacterium

Management

Management

44 Anti

Anti TBTB RxRx ++ Pyridoxine

Pyridoxine

Improved

Improved afebrile

afebrile ,no

,no SOB

SOB

Chest

Chest tube

tube was

was removed

removed

Discharged

Discharged Home

Home

TBTB Pleural

Pleural Effusion

Effusion

5%5% of

of all

all diseases

diseases attributed

attributed toto TBTB

Results

Results from

from delayed

delayed hypersensitivity

hypersensitivity reaction

reaction

toto TBTB antigen

antigen

Different

Different from

from tuberculous

tuberculous empyema

empyema which

which isis

purulent fluid

purulent

fluid abundant

abundant inin TBTB organism

organism with

with

thickened calcified

thickened

calcified pleura

pleura

Different

Different presentation

presentation inin Non

Non HIV

HIV Vs

Vs HIV

HIV

Presentation

Presentation

6060 Pt

Pt study

study

*In

*In Non

Non HIV

HIV

Non productive

Non

productive Cough

Cough ,Pleuritic

,Pleuritic CPCP ,, SOB

SOB

Fever ,Night

Fever

,Night sweating

sweating && Wt

Wt Loss

Loss

** InIn HIV

HIV

Younger

Younger Patient

Patient ,, more

more Wt

Wt Loss

Loss &&

extrapulmonary involvement

extrapulmonary

involvement

Frye

Frye et

et al

al

Chest

Chest Aug

Aug 1997

1997

Imaging

Imaging

**InIn Non

Non HIV

HIV

7070 Pleural

Pleural TB/1700

TB/1700 Dx

Dx TBTB patient

patient

Unilateral

Unilateral effusion

effusion

Associated

Associated Lung

Lung infiltrates

infiltrates 50%50%

Upper Lobes

Upper

Lobes 75%75%  Reactivation

Reactivation

Lower lobes

Lower

lobes 25%25%  Primary

Primary Disease

Disease

Seibert

Seibert et

et al

al

Chest April

Chest

April 1991

1991

Imaging

Imaging

InIn HIV HIV

  • 963 963 HIV

HIV Vs

Vs 1000

1000 Non

Non HIV

HIV

Unilateral

Unilateral effusion

effusion

Lung

Lung infiltrate

infiltrate Lower

Lower Lobes

Lobes

Adenopathy

Adenopathy 5-18%

5-18%

Miliary

Miliary Pattern

Pattern 7-10%

7-10%

Less

Less cavitations

cavitations 33%33%

Tshibwabwa-Tumba

Tshibwabwa-Tumba et

et al

al

Clin Radiol

Clin

Radiol 1997

1997 Nov

Nov

PPD Skin

PPD

Skin Test

Test

7070 Patients

Patients 4343 HIV

HIV && 2727 Non

Non HIV

HIV

HIV mainly

HIV

mainly IVDU

IVDU

Non Non HIV HIV 73%73% +ve +ve Vs Vs 41%41% HIV HIV

Age Age Non Non HIV HIV 5252 Vs Vs 3737 HIV HIV

Relkin

Relkin et

et al

al

Chest

Chest may

may 1994

1994

Microbiology

Microbiology

Sputum

Sputum culture

culture +ve

+ve 20-50%

20-50%

 involvement

involvement of

of lung

lung parenchyma

parenchyma

Pleural

Pleural Fluid

Fluid culture

culture +ve

+ve 40-50

40-50 %%

Pleural

Pleural BxBx culture

culture +ve

+ve 60-80

60-80 %%

Higher

Higher yield

yield inin HIV

HIV patients

patients inin all

all specimens

specimens

ADA

ADA

216 216 Patients Patients 100 100 TBTB ,, 8686 Malignancy Malignancy

  • 1919 empyema

empyema ,, 66 transudate

transudate

  • 1515 miscellaneous

miscellaneous ,, 88 unknown

unknown

High High ADA ADA inin TBTB 110 110 && inin Empyema Empyema 191 191

No difference

No

difference Between

Between HIV

HIV +ve

+ve && -ve

-ve TBTB Pt

Pt

Cut

Cut off

off 6060 u/l

u/l  PPV

PPV && NPV

NPV 95%95%

Riantawan PP et

Riantawan

et al

al

Chest

Chest 1999

1999 Jul

Jul

ADA

ADA

106

106 lymphocytic

lymphocytic effusion

effusion {Non

{Non TB}

TB}

ADA

ADA measured

measured once

once inin all

all

&& second

second time

time 6weeks

6weeks later

later inin 2626 cases

cases

4545 Post

Post CABG

CABG ,, 2727 Malignant

Malignant

1010 Miscellaneous

Miscellaneous ,, 2424 Transudative

Transudative

With

With cut

cut off

off 4040 u/l

u/l only

only 33 patients

patients +ve

+ve

22 Lymphoma

Lymphoma && 11 complicated

complicated parapneumonic

parapneumonic

High

High NPV

NPV && reproducible

reproducible

Gary

Gary Lee

Lee et

et

al

al

Chest Aug

Chest

Aug 2001

2001

ADA ,PCR

ADA

,PCR && Interferon

Interferon Gamma

Gamma

140 Patient

140

Patient

had

had ADA

ADA ,, PCR

PCR && INF

INF pleural

pleural fluid

fluid levels

levels

4242 Confirmed

Confirmed TBTB

(+ve fluid

(+ve

fluid smear

smear oror culture

culture oror +ve

+ve histology)

histology)

1919 Probable

Probable TBTB

Symptoms oror signs

Symptoms

signs ,, BxBx chronic

chronic inflammation

inflammation

+ve

+ve sputum

sputum oror Response

Response toto Anti

Anti TBTB

7070 Non

Non TBTB etiology

etiology ,, 99 Unknown

Unknown

Villegas Chest,

Villegas

Chest, Nov

Nov 2000

2000

Treatment

Treatment

Similar

Similar toto Pulmonary

Pulmonary TBTB

Steroid

Steroid ?? Effect

Effect small

small study

study 4040 pt

pt

faster resolution

faster

resolution of

of Fever

Fever && SOB

SOB && effusion

effusion

But nono effect

But

effect onon pleural

pleural thickening

thickening

Drainage

Drainage Small

Small study

study 6060 pt

pt

Initial improvement

Initial

improvement inin SOB

SOB inin first

first week

week

No effect

No

effect later

later onon symptoms

symptoms

or pleural

or

pleural thickening

thickening