1
|
Chan KKP, Lee YCG. Tuberculous pleuritis: clinical presentations and diagnostic challenges. Curr Opin Pulm Med 2024; 30:210-216. [PMID: 38323466 PMCID: PMC10990028 DOI: 10.1097/mcp.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
PURPOSE OF REVIEW Tuberculous pleuritis (TBP) is one of the most common types of extrapulmonary tuberculosis. We highlight the latest epidemiology of TBP, the heterogeneity of its presentation and the performance of different diagnostic strategies. RECENT FINDINGS There are differential trends in the incidences of TBP worldwide. Its incidence increased in China but decreased in the United States in the past decade. The presentation of TBP is heterogeneous regarding clinical symptoms, radiological findings and pleural fluid analysis results. Conventional microbiological tests have low sensitivities to diagnose TBP. Recent research focused on various diagnostic tools with better yield. The sensitivity of nucleic acid amplification tests (NAAT) in pleural fluid, including the latest generation of PCR and sequencing-based techniques for detecting tuberculosis, remains suboptimal. Various pleural fluid biomarkers have been explored, but there is a lack of consensus on their clinical utility and cutoff levels. SUMMARY The heterogeneity of clinical presentation poses obstacles to diagnosing TBP. Further development of diagnostic tools, including more robust NAAT and biomarkers with additional validation, is needed before incorporation into routine clinical practice.
Collapse
Affiliation(s)
- Ken Ka Pang Chan
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Yun Chor Gary Lee
- Institute for Respiratory Health and Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| |
Collapse
|
2
|
McNally E, Ross C, Gleeson LE. The tuberculous pleural effusion. Breathe (Sheff) 2023; 19:230143. [PMID: 38125799 PMCID: PMC10729824 DOI: 10.1183/20734735.0143-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
Pleural tuberculosis (TB) is a common entity with similar epidemiological characteristics to pulmonary TB. It represents a spectrum of disease that can variably self-resolve or progress to TB empyema with severe sequelae such as chronic fibrothorax or empyema necessitans. Coexistence of and progression to pulmonary TB is high. Diagnosis is challenging, as pleural TB is paucibacillary in most cases, but every effort should be made to obtain microbiological diagnosis, especially where drug resistance is suspected. Much attention has been focussed on adjunctive investigations to support diagnosis, but clinicians must be aware that apparent diagnostic accuracy is affected both by the underlying TB prevalence in the population, and by the diagnostic standard against which the specified investigation is being evaluated. Pharmacological treatment of pleural TB is similar to that of pulmonary TB, but penetration of the pleural space may be suboptimal in complicated effusions. Evidence for routine drainage is limited, but evacuation of the pleural space is indicated in complicated disease. Educational aims To demonstrate that pleural TB incorporates a wide spectrum of disease, ranging from self-resolving lymphocytic effusions to severe TB empyema with serious sequelae.To emphasise the high coexistence of pulmonary TB with pleural TB, and the importance of obtaining sputum for culture (induced if necessary) in all cases.To explore the significant diagnostic challenges posed by pleural TB, and consequently the frequent lack of information about drug sensitivity prior to initiating treatment.To highlight the influence of underlying TB prevalence in the population on the diagnostic accuracy of adjunctive investigations for the diagnosis of pleural TB.To discuss concerns around penetration of anti-TB medications into the pleural space and how this can influence decisions around treatment duration in practice.
Collapse
Affiliation(s)
- Emma McNally
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
| | - Clare Ross
- Department of Respiratory Medicine, Imperial NHS Healthcare Trust, London, UK
| | - Laura E. Gleeson
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
- Department of Clinical Medicine, Trinity College Dublin School of Medicine, St James's Hospital, Dublin, Ireland
| |
Collapse
|
3
|
Zhou Y, Luo D, Liu K, Chen B, Chen S, Pan J, Liu Z, Jiang J. Trend of the Tuberculous Pleurisy Notification Rate in Eastern China During 2017-2021: Spatiotemporal Analysis. JMIR Public Health Surveill 2023; 9:e49859. [PMID: 37902822 PMCID: PMC10644181 DOI: 10.2196/49859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/31/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Tuberculous pleurisy (TP) presents a serious allergic reaction in the pleura caused by Mycobacterium tuberculosis; however, few studies have described its spatial epidemiological characteristics in eastern China. OBJECTIVE This study aimed to determine the epidemiological distribution of TP and predict its further development in Zhejiang Province. METHODS Data on all notified cases of TP in Zhejiang Province, China, from 2017 to 2021 were collected from the existing tuberculosis information management system. Analyses, including spatial autocorrelation and spatial-temporal scan analysis, were performed to identify hot spots and clusters, respectively. The prediction of TP prevalence was performed using the seasonal autoregressive integrated moving average (SARIMA), Holt-Winters exponential smoothing, and Prophet models using R (The R Foundation) and Python (Python Software Foundation). RESULTS The average notification rate of TP in Zhejiang Province was 7.06 cases per 100,000 population, peaking in the summer. The male-to-female ratio was 2.18:1. In terms of geographical distribution, clusters of cases were observed in the western part of Zhejiang Province, including parts of Hangzhou, Quzhou, Jinhua, Lishui, Wenzhou, and Taizhou city. Spatial-temporal analysis identified 1 most likely cluster and 4 secondary clusters. The Holt-Winters model outperformed the SARIMA and Prophet models in predicting the trend in TP prevalence. CONCLUSIONS The western region of Zhejiang Province had the highest risk of TP. Comprehensive interventions, such as chest x-ray screening and symptom screening, should be reinforced to improve early identification. Additionally, a more systematic assessment of the prevalence trend of TP should include more predictors.
Collapse
Affiliation(s)
- Ying Zhou
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Dan Luo
- School of Public Health, Hangzhou Medical College, Hangzhou, China
| | - Kui Liu
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
- National Centre for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Bin Chen
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Songhua Chen
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Junhang Pan
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Zhengwei Liu
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Jianmin Jiang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
- Key Laboratory of Vaccine, Prevention and Control of Infectious Disease of Zhejiang Province, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| |
Collapse
|
4
|
Zheng SC, Huang ZY, Zhai K, Shi HZ, Shao MM. Hepatocyte growth factor combined with adenosine deaminase as biomarker for diagnosis of tuberculous pleural effusion. Front Microbiol 2023; 14:1181912. [PMID: 37485530 PMCID: PMC10359098 DOI: 10.3389/fmicb.2023.1181912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
Background The simple, rapid, and accurate diagnosis of tuberculous pleural effusion (TPE) remains difficult. This study aimed to determine the accuracy of hepatocyte growth factor (HGF) in the diagnosis of TPE. Methods We quantified the expression of HGF, adenosine deaminase (ADA), and interferon gamma (IFN-γ) in pleural effusion (PE) in 97 TPE subjects and 116 non-TPE subjects using an enzyme-linked immunosorbent assay (ELISA) or a fully automatic biochemical analyzer. The diagnostic performance of these three biomarkers was evaluated using a receiver operating characteristic (ROC) curve of subjects by age and gender. Results We discovered that the TPE group had much higher levels of HGF than the non-TPE group, regardless of age or gender, and that there was no statistically significant difference between the two groups' levels of HGF expression in peripheral plasma. In female TPE patients aged ≤65 years, the AUCs of TPE and non-TPE diagnosed by HGF, ADA or IFN-γ were 0.988, 0.964, and 0.827, respectively. HGF plus ADA had the highest diagnostic efficacy in female TPE patients aged ≤65 years. With HGF plus ADA having a cut-off value of 0.219 for distinguishing TPE from non-TPE, the area under the curve (AUC), sensitivity (SEN), specificity (SPE), positive predictive value (PPV), and negative predictive value (NPV) were, respectively, 0.998 (95% confidence interval [CI], 0.993-1.000), 100 (95% CI, 89.997-100.000), 96.667 (95% CI, 82.783-99.916), 97.222 (95% CI, 83.594-99.586), and 100. Conclusion This study confirmed that HGF plus ADA has high diagnostic efficacy in younger female TPE patients and has the potential to be an excellent biomarker.
Collapse
Affiliation(s)
- Sheng-Cai Zheng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| | - Zhong-Yin Huang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| | - Kan Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| | - Ming-Ming Shao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| |
Collapse
|
5
|
Lei X, Wang J, Yang Z. Development and validation of a prediction model to assess the probability of tuberculous pleural effusion in patients with unexplained pleural effusion. Sci Rep 2023; 13:10904. [PMID: 37407665 DOI: 10.1038/s41598-023-38048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 07/01/2023] [Indexed: 07/07/2023] Open
Abstract
Differentiating tuberculous pleural effusion (TPE) from non-tuberculosis pleural effusion remains a challenge in clinical practice. This study aimed to develop and externally validate a novel prediction model using the peripheral blood tuberculous infection of T cells spot test (T-SPOT.TB) to assess the probability of TPE in patients with unexplained pleural effusion. Patients with pleural effusion and confirmed etiology were included in this study. A retrospective derivation population was used to develop and internally validate the predictive model. Clinical, radiological, and laboratory features were collected, and important predictors were selected using the least absolute shrinkage and selection operator. The prediction model, presented as a web calculator, was developed using multivariable logistic regression. The predictive performance of the model was evaluated for discrimination and calibration and verified in an independent validation population. The developed prediction model included age, positive T-SPOT.TB result, logarithm of the ratio of mononuclear cells to multiple nuclear cells in pleural effusion (lnRMMPE), and adenosine deaminase in pleural effusion ≥ 40 U/L. The model demonstrated good discrimination [with area under the curve of 0.837 and 0.903, respectively] and calibration (with a Brier score of 0.159 and 0.119, respectively) in both the derivation population and the validation population. Using a cutoff value of 60%, the sensitivity and specificity for identifying TPE were 70% and 88%, respectively, in the derivation population, and 77% and 92%, respectively, in the validation population. A novel predictive model based on T-SPOT.TB was developed and externally validated, demonstrating good diagnostic performance in identifying TPE.
Collapse
Affiliation(s)
- Xiaoli Lei
- Department of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - Junli Wang
- Department of Cardiopulmonary Function, Fuwai Central China Cardiovascular Hospital, Zhengzhou, 451464, Henan, China
| | - Zhigang Yang
- Department of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China.
| |
Collapse
|
6
|
Wang H, Liu Y, Wang J, Ren T, Luo G, You H, Wang X, Li D, Wang L, Wang M. Rapid on-site evaluation of touch imprints of medical thoracoscopy biopsy tissue for the management of pleural disease. Front Med (Lausanne) 2023; 10:1196000. [PMID: 37359022 PMCID: PMC10288871 DOI: 10.3389/fmed.2023.1196000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Abstract
Background and objective Medical thoracoscopy (MT) plays an important role in the diagnosis and treatment of pleural diseases, and rapid on-site evaluation (ROSE) has long been used for transbronchial needle aspiration or fine-needle aspiration to evaluate the adequacy of biopsy materials for the diagnosis of peripheral lung lesions. However, research on ROSE combined with MT for the management of pleural disease has been rarely reported. We aimed to evaluate the diagnostic performance of ROSE for pleura biopsies and visual diagnosis by thoracoscopists for gross thoracoscopic appearance. The secondary objective was to assess the intermodality agreement between ROSE and the final histopathologic diagnosis. Methods A total of 579 patients with exudative pleural effusion (EPE) who underwent MT combined with ROSE from February 2017 to December 2020 at Taihe Hospital were included in the study. Thoracoscopists' visual diagnosis of gross thoracoscopic appearance, ROSE results, histopathologic findings, and the final diagnosis was recorded. Results Thoracoscopic pleural biopsies were performed in 565 patients (97.6%); 183 patients were confirmed to have malignant pleural effusion (MPE), and 382 patients were confirmed to have benign pleural effusion (BPE). The area under the curve of ROSE for the diagnosis of MPE was 0.96 (95% CI: 0.94-0.98, p < 0.001), with a sensitivity of 98.7%, a specificity of 97.2%, a diagnostic accuracy of 97.1%, a positive predictive value of 97.2%, and a negative predictive value of 97.2%. Diagnostic consistency between ROSE and histopathology was good (κ ± SE = 0.93 ± 0.02, p < 0.001). The area under the curve of the thoracoscopists' visual diagnosis of gross thoracoscopic appearance was 0.79 (95% CI: 0.75-0.83, p < 0.01), with a sensitivity of 76.7%, a specificity of 80.9%, a positive predictive value of 62.4%, and a negative predictive value of 89.3%. Conclusion ROSE of touch imprints of MT biopsy tissue during MT showed high accuracy for distinguishing between benign and malignant lesions. In addition, ROSE was in good agreement with the histopathological diagnosis, which may help thoracoscopists perform pleurodesis (talc poudrage) directly during the procedure, especially in patients with malignant results.
Collapse
Affiliation(s)
- Hansheng Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yan Liu
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Jiankun Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Tao Ren
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Guoshi Luo
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Hui You
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xiao Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Dan Li
- Department of Pathology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Lei Wang
- Department of Laboratory, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Meifang Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| |
Collapse
|
7
|
Ebrahimzadeh A, Pagheh AS, Mousavi T, Fathi M, Moghaddam SGM. Serosal membrane tuberculosis in Iran: A comprehensive review of evidences. J Clin Tuberc Other Mycobact Dis 2023; 31:100354. [PMID: 36874623 PMCID: PMC9982686 DOI: 10.1016/j.jctube.2023.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Tuberculosis (TB) is among the most common cause of serositis. There are many uncertainties in diagnostic and therapeutic approach to serous membranes tuberculosis. Our aim in the present review is to discuss the regional facilities for timely diagnosis, rapid decision-making and appropriate treatment regarding to serous membranes tuberculosis; with emphasis on situation in Iran. A comprehensive literature searches about the status of serous membranes tuberculosis in Iran were performed in English databases including Google Scholar, Science Direct, Scopus, Pub Med, and Web of Sciences, Persian SID databases, between 2000 and 2021. The main findings of the present review are as follow: a) pleural tuberculosis is more common than pericardial or peritoneal tuberculosis. b) Clinical manifestations are non-specific and so non-diagnostic. c) Smear and culture, PCR and characteristic granulomatous reaction have been used for definitive TB diagnosis by physicians. d) With Adenosine Deaminase Assays and Interferon-Gamma Release Assays in mononuclear dominant fluid, a possible diagnosis of TB is proposed by experienced physicians in Iran. e) In area of endemic for tuberculosis including Iran, a possible diagnosis of TB is enough to begin empirical treatment. f) In patients with uncomplicated tuberculosis serositis, treatment is similar to pulmonary tuberculosis. First line drugs are prescribed unless evidence of MDR-TB is detected. g) The prevalence of drug resistant tuberculosis (MDR-TB) in Iran is between 1% and 6%, and are treated by empirical standardized treatment. h) It is not known whether adjuvant corticosteroids are effective in preventing long term complication. i) Surgery may be recommended for MDR-TB. Tamponade or constrictive pericarditis and intestinal obstruction. In conclusion, it is recommended to consider serosal tuberculosis in patients who have unknown mononuclear dominant effusion and prolonged constitutional symptoms. Experimental treatment with first line anti-TB drugs can be started based on possible diagnostic findings.
Collapse
Affiliation(s)
- Azadeh Ebrahimzadeh
- Infectious Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Abdol Sattar Pagheh
- Infectious Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Tahoora Mousavi
- Molecular and Cell Biology Research Center (MCBRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Fathi
- Parasitology Department of Medical School, Tarbiat Modares University, Tehran, Iran
| | | |
Collapse
|
8
|
Li C, Hou L, Pan J, Chen H, Cai X, Liang G. Tuberculous pleural effusion prediction using ant colony optimizer with grade-based search assisted support vector machine. Front Neuroinform 2022; 16:1078685. [PMID: 36601381 PMCID: PMC9806141 DOI: 10.3389/fninf.2022.1078685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Although tuberculous pleural effusion (TBPE) is simply an inflammatory response of the pleura caused by tuberculosis infection, it can lead to pleural adhesions and cause sequelae of pleural thickening, which may severely affect the mobility of the chest cavity. Methods In this study, we propose bGACO-SVM, a model with good diagnostic power, for the adjunctive diagnosis of TBPE. The model is based on an enhanced continuous ant colony optimization (ACOR) with grade-based search technique (GACO) and support vector machine (SVM) for wrapped feature selection. In GACO, grade-based search greatly improves the convergence performance of the algorithm and the ability to avoid getting trapped in local optimization, which improves the classification capability of bGACO-SVM. Results To test the performance of GACO, this work conducts comparative experiments between GACO and nine basic algorithms and nine state-of-the-art variants as well. Although the proposed GACO does not offer much advantage in terms of time complexity, the experimental results strongly demonstrate the core advantages of GACO. The accuracy of bGACO-predictive SVM was evaluated using existing datasets from the UCI and TBPE datasets. Discussion In the TBPE dataset trial, 147 TBPE patients were evaluated using the created bGACO-SVM model, showing that the bGACO-SVM method is an effective technique for accurately predicting TBPE.
Collapse
Affiliation(s)
- Chengye Li
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lingxian Hou
- Department of Rehabilitation, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Jingye Pan
- Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, Zhejiang, China,Collaborative Innovation Center for Intelligence Medical Education, Wenzhou, Zhejiang, China,Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou, Zhejiang, China,Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Huiling Chen
- College of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, Zhejiang, China,*Correspondence: Huiling Chen,
| | - Xueding Cai
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China,Xueding Cai,
| | - Guoxi Liang
- Department of Information Technology, Wenzhou Polytechnic, Wenzhou, China
| |
Collapse
|
9
|
Yan Z, Wen JX, Wang H, Jiang TW, Huang JH, Chen H, Yan L, Hu ZD, Zheng WQ. Diagnostic accuracy of pleural fluid lactate dehydrogenase to adenosine deaminase ratio for tuberculous pleural effusion: an analysis of two cohorts. BMC Pulm Med 2022; 22:428. [PMCID: PMC9675061 DOI: 10.1186/s12890-022-02247-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to evaluate the diagnostic accuracy of pleural fluid (PF) lactate dehydrogenase (LDH) to adenosine deaminase (ADA) (LDH/ADA) ratio for tuberculous pleural effusion (TPE). Especially to explore whether the LDH/ADA ratio provides added diagnostic value to ADA. Methods The diagnostic accuracy of PF LDH/ADA ratio and ADA for TPE was evaluated in two cohorts, named the BUFF (Biomarkers for patients with Undiagnosed pleural eFFusion) cohort (62 with TPE and 194 with non-TPE) and the SIMPLE (a Study Investigating Markers in PLeural Effusion) cohort (33 with TPE and 177 with non-TPE). Receiver operating characteristic (ROC) curve and decision curve were used to measure the diagnostic accuracy of the PF LDH/ADA ratio. The added diagnostic value of the LDH/ADA ratio to ADA was evaluated with net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results The area under the ROC curves (AUCs) of PF ADA and LDH/ADA ratio in the BUFF cohort were 0.76 and 0.74, respectively. In the SIMPLE cohort, the AUCs of PF ADA and LDH/ADA ratio were 0.80 and 0.85, respectively. The decision curves of PF LDH/ADA and ADA were close in both the BUFF and SIMPLE cohorts. The NRI and IDI analyses did not reveal any added diagnostic value of LDH/ADA to ADA. Conclusions PF LDH/ADA ratio has moderate diagnostic accuracy for TPE. It does not provide added diagnostic value beyond ADA. The current evidence does not support LDH/ADA ratio for diagnosing TPE.
Collapse
Affiliation(s)
- Zhi Yan
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China ,grid.410612.00000 0004 0604 6392Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Jian-Xun Wen
- grid.410612.00000 0004 0604 6392Department of Medical Experiment Center, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Hua Wang
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China ,grid.410612.00000 0004 0604 6392Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Ting-Wang Jiang
- grid.417303.20000 0000 9927 0537Department of Key Laboratory, The Affiliated Changshu Hospital of Xuzhou Medical University, Suzhou, 215500 China
| | - Jin-Hong Huang
- grid.417303.20000 0000 9927 0537Department of Pulmonary and Critical Care Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Suzhou, 215500 China
| | - Hong Chen
- grid.417303.20000 0000 9927 0537Department of Pulmonary and Critical Care Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Suzhou, 215500 China
| | - Li Yan
- grid.413375.70000 0004 1757 7666Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Zhi-De Hu
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China
| | - Wen-Qi Zheng
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China ,grid.410612.00000 0004 0604 6392Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| |
Collapse
|
10
|
Tao T, Bao X, Wang Y, Tang N. The Diagnostic Value of Medical Thoracoscopy Pleural Biopsy, Ultrasound-guided Pleural Biopsy, and Closed Pleural Biopsy in Tuberculous Pleurisy: A propensity score matching analysis.. [DOI: 10.21203/rs.3.rs-2099835/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Abstract
Background and objective
For diagnosis of exudative pleural effusion in tuberculous pleurisy, medical thoracoscopic pleural biopsy (MTPB) enables direct vision and is most widely applied, although ultrasound-guided pleural biopsy (USPB) and closed pleural biopsy (CPB) are also viable. This retrospective study compared the diagnostic efficiencies and safety of USPB, CPB, and MTPB.
Methods
Patients enrolled from 2014 through 2020 underwent USPB, CPB, or MTPB (n = 69, 69, and 110, respectively). Propensity score matching (PSM) analysis was used to compare the diagnostic sensitivities of CPB, MTPB, and USPB. The secondary outcomes were postoperative complications and hospitalization stay.
Results
PSM analysis resulted in 40 (USPB vs. CPB), 47 (USPB vs. MTPB), and 52 (CPB vs. MTPB) matched pairs. The diagnostic sensitivities of the USPB and CPB groups were 72.5% and 55.0% (P = 0.162); that of USPB and MTPB were 70.2% and 80.9% (P = 0.337); the CPB and MTPB groups were comparable(P = 0.152). The rates of associated pain and subcutaneous emphysema of the MTPB group were higher than that of the USPB or CPB (P = 0.000, both).Hospitalization time of the MTPB group was longest, and significantly longer than that of the USPB (P = 0.029).
Conclusions
While the three techniques were similarly effective in diagnosing tuberculous pleurisy, USPB and CPB showed fewer associated complications and shorter hospital stays compared with MTPB. The image guidance offered by USPB benefited reduction in postoperative complications.
Collapse
Affiliation(s)
- Tao Tao
- Chongqing University Fuling Hospital
| | | | | | - Nan Tang
- Chongqing University Fuling Hospital
| |
Collapse
|
11
|
Bian Y, Deng M, Zhang Q, Hou G. Global trends of research on tuberculous pleurisy over the past 15 years: A bibliometric analysis. Front Cell Infect Microbiol 2022; 12:937811. [PMID: 36111237 PMCID: PMC9468418 DOI: 10.3389/fcimb.2022.937811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculous pleurisy (TP) is a common type of extrapulmonary tuberculosis (EPTB). With the development of research and changes in TP patient characteristics, an increasing number of studies have revealed the prevalence, risk factors, and novel diagnosis techniques. Thus, this bibliometric analysis was performed to identify global scientific output characteristics and research hotspots and frontiers for TP over the past 15 years. We searched the Web of Science Core Collection (WoSCC) Science Citation Index Expanded (SCI-expanded) for literature published between 2007 and 2021 and recorded their information. The Bibliometrix software package was used for bibliometric indicator analysis, and VOSviewer was used to visualize the trends of and hotspots in TP research. A total of 1,464 original articles were reviewed, and the results indicated that the annual number of publications (Np) focusing on TP has increased over the past 15 years. China had the largest number of papers and the highest H-index, and the United States ranked first for number of citations (Nc). EGYPTIAN KNOWLEDGE BANK and PLOS ONE were the most prolific unit and journal, respectively. The use of the Xpert assay and immune-related biomarker detection to diagnose TP appears to be a recent research hotspot. This bibliometric study demonstrated that the number of publications related to TP have tended to increase. China is a major producer, and the United States is an influential country in this field. Research in the past 15 years has been predominantly clinical research. The diagnosis of TP was the focus of research, and the exploration of novel diagnostic techniques, verification of diagnostic markers, and combination of diagnostic methods have been recent research hotspots. Immune-related biomarkers should be given more attention in the field of TP diagnosis.
Collapse
Affiliation(s)
- Yiding Bian
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Mingming Deng
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Qin Zhang
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- *Correspondence: Gang Hou,
| |
Collapse
|
12
|
The Value of 18F-FDG PET/CT in the Diagnosis of Tuberculous Pleurisy and in the Differential Diagnosis between Tuberculous Pleurisy and Pleural Metastasis from Lung Adenocarcinoma. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4082291. [PMID: 35965614 PMCID: PMC9357728 DOI: 10.1155/2022/4082291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022]
Abstract
Objectives This study aims to investigate the diagnostic value of 18F-FDG PET/CT in tuberculous pleurisy (TBP) and the differential diagnostic value of 18F-FDG PET/CT between TBP and pleural metastasis from lung adenocarcinoma (PMLAC). Materials and Methods The features of pleura on PET and hybrid CT were retrospectively studied in 20 patients with TBP and 32 patients with PMLAC. The ROC curve was used to evaluate the diagnostic effectiveness of these indices for TBP and PMLAC, and binary logistic regression analysis was conducted to identify independent predictors of TBP and PMLAC. Results There were significant differences in pleural 18F-FDG uptake pattern on PET (P=0.001), pleural morphology pattern on CT (P=0.002), the maximum diameter of the pleural nodule (P=0.001), and interlobular fissure nodule (P=0.001) between TBP and PMLAC groups. The diffused pleural FDG uptake type on PET (odds ratio (OR) = 6.0, 95% CI 2.216–16.248, P=0.001) and the lamellar pleural thickening type on CT (OR = 4.4, 95% CI 2.536–7.635, P=0.001) were independent predictors of TBP, with 60% and 55% sensitivity, 96.6% and 90.6% specificity, and 82.7% and 77.0% accuracy. The combined diagnostic sensitivity, specificity, and accuracy for TBP were 70%, 87.5%, and 80.8%. The mixed pleural FDG uptake type on PET (OR = 5.106, 95% CI 2.024–12.879, P=0.001), the mixed pleural thickening type on CT (OR = 2.289, 95% CI 1.442–3.634, P=0.001), and the maximum diameter of the pleural nodule (OR = 1.027, 95% CI 1.012–1.042, P=0.001) were independent predictors of PMLAC, with 78.1%, 71.9%, and 87.5% sensitivity, 85%, 80%, and 85% specificity, and 80.8%, 75%, and 86.5% accuracy. The combined diagnostic sensitivity, specificity, and accuracy for PMLAC were 96.9%, 85%, and 90.4%. Conclusions 18F-FDG PET/CT is of great clinical value in the diagnosis of TBP and in the differential diagnosis between TBP and PMLAC.
Collapse
|
13
|
Qiao X, Shao MM, Yi FS, Shi HZ. Complement Component C1q as an Emerging Biomarker for the Diagnosis of Tuberculous Pleural Effusion. Front Microbiol 2021; 12:765471. [PMID: 34790186 PMCID: PMC8591783 DOI: 10.3389/fmicb.2021.765471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: The accurate differential diagnosis of tuberculous pleural effusion (TPE) from other exudative pleural effusions is often challenging. We aimed to validate the accuracy of complement component C1q in pleural fluid (PF) in diagnosing TPE. Methods: The level of C1q protein in the PF from 49 patients with TPE and 61 patients with non-tuberculous pleural effusion (non-TPE) was quantified by enzyme-linked immunosorbent assay, and the diagnostic performance was assessed by receiver operating characteristic (ROC) curves based on the age and gender of the patients. Results: The statistics showed that C1q could accurately diagnose TPE. Regardless of age and gender, with a cutoff of 6,883.9 ng/mL, the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of C1q for discriminating TPE were 0.898 (95% confidence interval: 0.825-0.947), 91.8 (80.4-97.7), 80.3 (68.2-89.4), 78.9 (69.2-86.2), and 92.5 (82.6-96.9), respectively. In subgroup analysis, the greatest diagnostic accuracy was achieved in the younger group (≤ 50 years of age) with an AUC of 0.981 (95% confidence interval: 0.899-0.999) at the cutoff of 6,098.0 ng/mL. The sensitivity, specificity, PLR, NLR, PPV, and NPV of C1q were 95.0 (83.1-99.4), 92.3 (64.0-99.8), 97.4 (85.2-99.6), and 85.7 (60.6-95.9), respectively. Conclusion: Complement component C1q protein was validated by this study to be a promising biomarker for diagnosing TPE with high diagnostic accuracy, especially among younger patients.
Collapse
Affiliation(s)
- Xin Qiao
- Department of Respiratory and Critical Care Medicine, Clinical Center for Pleural Diseases, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ming-Ming Shao
- Department of Respiratory and Critical Care Medicine, Clinical Center for Pleural Diseases, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Feng-Shuang Yi
- Department of Respiratory and Critical Care Medicine, Clinical Center for Pleural Diseases, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Clinical Center for Pleural Diseases, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
14
|
Abstract
Pleural tuberculosis (TB) is common and often follows a benign course but may result in serious long-term morbidity. Diagnosis is challenging because of the paucibacillary nature of the condition. Advances in Mycobacterium culture media and PCR-based techniques have increased the yield from mycobacteriologic tests. Surrogate biomarkers perform well in diagnostic accuracy studies but must be interpreted in the context of the pretest probability in the individual patient. Confirming the diagnosis often requires biopsy, which may be acquired through thoracoscopy or image-guided closed pleural biopsy. Treatment is standard anti-TB therapy, with optional drainage and intrapleural fibrinolytics or surgery in complicated cases.
Collapse
Affiliation(s)
- Jane A Shaw
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa.
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, PO Box 241, Cape Town 8000, South Africa
| |
Collapse
|
15
|
Clinical and Epidemiological Features of Tuberculous Pleural Effusion in Alicante, Spain. J Clin Med 2021; 10:jcm10194392. [PMID: 34640410 PMCID: PMC8509524 DOI: 10.3390/jcm10194392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to (1) evaluate the incidence of tuberculous pleural effusion (TPE) over 25 years in our centre; (2) measure the yield of different diagnostic techniques; (3) compare TPE features between immigrant and native patients. Retrospective study of patients who underwent diagnostic thoracentesis and pleural biopsy in our hospital between 1995 and 2020. TPE was diagnosed in 71 patients (65% natives, 35% immigrants). Onset was acute in 35%, subacute in 26% and prolonged in 39%. Radiological features were atypical in 42%. Thoracentesis specimens were lymphocyte-predominant in 84.5% of patients, with elevated adenosine deaminase in 75% of patients. Diagnostic yield of pleural biopsy was 78%. Compared with native patients, more immigrants had previous contact with TB (54% vs. 17%, p = 0.001), prior TB (21% vs. 4%, p < 0.02) and atypical radiological features (58% vs. 34%, p < 0.03). TPE incidence was six times higher in the immigrant population (6.7 vs. 1.1 per 100,000 person-years, p < 0.001). TPE has an acute onset and sometimes atypical radiological features. Pleural biopsy has the highest diagnostic yield. Reactivation, prior contact with TB, atypical radiological features, complications, and positive microbiology results are more common in immigrant patients.
Collapse
|
16
|
Diagnosis of tuberculous pleural effusions: A review. Respir Med 2021; 188:106607. [PMID: 34536698 DOI: 10.1016/j.rmed.2021.106607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/19/2021] [Accepted: 09/03/2021] [Indexed: 01/24/2023]
Abstract
Tuberculous pleural effusion (TPE) is the second most common presentation of extrapulmonary tuberculosis. The paucibacillary nature of the effusion poses diagnostic challenges. Biomarkers like adenosine deaminase and interferon-γ have some utility for diagnosing TPEs, as do cartridge-based polymerase chain reaction (PCR) methods. When these fluid studies remain indeterminate, pleural biopsies must be performed to confirm the diagnosis. This review article elaborates on the scientific evidence available for various diagnostic tests and presents a practical approach to the diagnosis of TPEs.
Collapse
|
17
|
Zahid M, Naushad VA, Purayil NK, Jamshaid MB, Parambil J, Rashid F, Ismail S, Saddique M, Chalihadan S. Profile of Patients With Tuberculous Pleural Effusion in Qatar: A Retrospective Study. Cureus 2020; 12:e12391. [PMID: 33532154 PMCID: PMC7845742 DOI: 10.7759/cureus.12391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Tuberculosis (TB) remains one of the top 10 causes of death globally. Around 1.7 billion people are infected with mycobacterium TB worldwide, and almost 90% of cases each year are found in 30 high TB burden countries. Due to the influx of a large expatriate population mainly from the high TB burden countries, there is an increased number of pulmonary TB as well as tuberculous pleural effusion cases reported in Qatar. Objectives The demographic, clinical, laboratory, and histopathological parameters of patients with tuberculous pleural effusion were assessed. Methods A single-center study was conducted at Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar. Adults diagnosed to have tuberculous pleural effusion were included, and those with clinical suspicion of tuberculous pleural effusion with positive sputum acid-fast bacillus (AFB) but negative AFB in pleural samples were excluded. Results A total of 106 patients were reviewed, of whom 100 were included for the final analysis, with 86% being men. Majority were from the Asian subcontinent, and the mean age was 33.8 years (SD ± 10.3). Main symptoms in decreasing order were cough (77%), fever (56%), and chest pain (54%). Of the patients, 72% had normal BMI, and rest were above the normal range. Anemia and hypoalbuminemia were found in 36.7% and 89.8% of the patients, respectively. Positive AFB culture was observed in pleural biopsy (79%), pleural fluid (13%), and sputum (16%). Positive AFB by polymerase chain reaction (PCR) was observed in pleural biopsy (57%), pleural fluid (3%), and sputum (2.2%), whereas AFB smear was positive in 2% of pleural biopsy samples. Caseating granuloma was seen in 80% of patients. All the three Light's criteria were met by 30% of the patients whereas 52% had two criteria fulfilled. No association between the number of Light's criteria and AFB yield was observed. Conclusions TPE was more common in healthy young adults. The AFB yield on pleural biopsy, PCR, and culture was significantly higher than that on all other samples. The number of positive Light's criteria did not have any association with positive AFB yield.
Collapse
Affiliation(s)
| | - Vamanjore A Naushad
- Internal Medicine, Hamad General Hospital/Hamad Medical Corporation, Doha, QAT.,Internal Medicine, Weill Cornell Medical College, Doha, QAT.,Internal Medicine, College of Medicine, Qatar University, Doha, QAT
| | - Nishan K Purayil
- Internal Medicine, Hamad Medical Corporation, Doha, QAT.,Internal Medicine, Weill Cornell Medical College, Doha, QAT.,Internal Medicine, College of Medicine, Qatar University, Doha, QAT
| | | | | | - Farah Rashid
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | | | | | | |
Collapse
|
18
|
Park M, Kon OM. Use of Xpert MTB/RIF and Xpert Ultra in extrapulmonary tuberculosis. Expert Rev Anti Infect Ther 2020; 19:65-77. [PMID: 32806986 DOI: 10.1080/14787210.2020.1810565] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Tuberculosis (TB) remains a major global health burden. There still remains a large gap between the notified and estimated incident cases. Extrapulmonary (EP) TB represents 15% of all TB cases and the diagnosis is more challenging due to the paucity of the organism. Smear microscopy is often insensitive and culture methods are prolonged. With the introduction of Xpert MTB/RIF and more recently Xpert Ultra, this has changed TB diagnostics by providing a rapid accessible platform to diagnose TB and identify rifampicin resistance within 2 h. AREAS COVERED The diagnostic accuracy and the clinical role of Xpert MTB/RIF and Xpert Ultra in the different forms of EPTB. EXPERT OPINION Whilst significant advances have been made in TB diagnostics, there is still a need to optimize the diagnostic yield of Xpert MTB/RIF and Xpert Ultra in EPTB samples. Research is needed to facilitate standardization and optimal preparation of samples as well as understanding the role of Xpert MTB/RIF and Xpert Ultra in different burden settings. Alongside the current GeneXpert platform, the launch of rapid second-line drug resistance polymerase chain reactions and whole genome sequencing may help tackle the global health burden with a more comprehensive diagnostic approach and appropriate treatment.
Collapse
Affiliation(s)
- Mirae Park
- Imperial College Healthcare NHS Trust, St Mary's Hospital , London, UK.,National Heart and Lung Institute, Imperial College London , London, UK
| | - Onn Min Kon
- Imperial College Healthcare NHS Trust, St Mary's Hospital , London, UK.,National Heart and Lung Institute, Imperial College London , London, UK
| |
Collapse
|
19
|
Shaikh F, Lentz RJ, Feller-Kopman D, Maldonado F. Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician. Expert Rev Respir Med 2020; 14:987-1000. [PMID: 32588676 DOI: 10.1080/17476348.2020.1788940] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics. AREAS COVERED Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years. EXPERT OPINION As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.
Collapse
Affiliation(s)
- Faisal Shaikh
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of Los Angeles , Los Angeles, CA, USA
| | - Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Interventional Pulmonology , Nashville, TN, USA
| | - David Feller-Kopman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins Hospital , Baltimore, MD, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Interventional Pulmonology , Nashville, TN, USA
| |
Collapse
|
20
|
Zhao T, Chen B, Xu Y, Qu Y. Clinical and pathological differences between polymorphonuclear-rich and lymphocyte-rich tuberculous pleural effusion. Ann Thorac Med 2020; 15:76-83. [PMID: 32489442 PMCID: PMC7259391 DOI: 10.4103/atm.atm_15_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/31/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Analysis of the occurrence factors and disease characteristics of tuberculous (TB) pleural effusion (TPE) dominated by neutrophils. METHODS We retrospectively analyzed the clinical data of 304 patients with two types of TB pleurisy. The clinical, laboratory, and pathological features of TB pleurisy separately dominated by lymphocytes and neutrophils were analyzed. RESULTS Neutrophil-predominant effusion was observed in 33 (10.9%) patients. The patients with TPE with polymorphonuclear leukocytes (PMNLs) had higher fever rates and higher decortication rates than those with lymphocyte-predominant TPE. Otherwise, they had lower chest distress rates and lower positive rates of pulmonary TB and lower biopsy tissue culture-positive rates than patients with lymphocyte-predominant TPE. PMNL TPE patients had higher lactic acid dehydrogenase (LDH) (1297 vs. 410 U/l, P < 0.001) and adenosine deaminase (ADA) levels (54.1 vs. 42.9 U/l, P = 0.043) and lower pleural fluid glucose (1.92 vs. 4.70 mmol/L, P < 0.001) and protein (47.4 vs. 48.4 g/L, P = 0.024) levels than that of lymphocyte-predominant TPE. Otherwise, they had lower blood ALB levels and higher C-reactive protein levels than lymphocyte-predominant TPE. Finally, PMNL TPE patients had lower rates of granuloma formation (27.2% vs. 75.2%, P < 0.001) and pleural nodules than patients with lymphocyte-predominant TPE and more frequent findings of pus, caseous exudate, and necrosis. CONCLUSION The TB pleurisy patients dominated by neutrophils show strong inflammatory reactions and higher ADA levels in pleural effusion. These findings can significantly improve the positive rate of Mycobacterium tuberculosis in neutrophil-predominant TPE under thoracoscopy.
Collapse
Affiliation(s)
- Tingting Zhao
- Department of Respiratory and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China.,Department of Respiratory and Critical Care Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Bing Chen
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Yurong Xu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Yiqing Qu
- Department of Respiratory and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
| |
Collapse
|
21
|
Predictive Model for Discrimination of Tuberculous Pleural Effusion From Severe Mycoplasma pneumoniae Pneumonic Effusion in Children. Pediatr Infect Dis J 2019; 38:1100-1103. [PMID: 31626044 DOI: 10.1097/inf.0000000000002438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Tuberculous pleural effusion (TPE) is often misdiagnosed as severe Mycoplasma pneumoniae pneumonic effusion (SMPPE) in children at early stage. The aim of this study was to develop a predictive model based on clinical and laboratory indices to make accurate differential diagnosis. METHODS Patients included in this study were 167 children (83 patients with TPE and 84 with SMPPE), containing 117 patients for predictive model development and 50 patients for external validation. Multivariate logistic regression analysis was conducted to select potentially useful characteristics for discrimination of TPEs. External validation was performed for model evaluation. RESULTS Multivariate analysis revealed that blood neutrophils and serum lactate dehydrogenase were significant independent factors to discriminate between TPEs and SMPPEs. The results indicated that blood neutrophils ≤69.6% and concentration of serum lactate dehydrogenase ≤297 U/L were the extremely important discrimination factors of TPEs. The area under the receiver operating characteristic curve of the model was 0.9839. The accuracy rate, sensitivity and specificity of the model were 94.02%, 98.28% and 89.83%, respectively. Meanwhile, the accuracy rate of the external validation from the 50 patients was 94.0%. CONCLUSIONS Applying a predictive model with clinical and laboratory indices can facilitate the differential diagnosis of TPE from SMPPE in children, which seems helpful when a microbiologic or histologic diagnosis of pleural tuberculosis could not be established.
Collapse
|
22
|
Liou A, Rodriguez-Castro CE, Rodriguez-Reyes A, Zreik R, Jones S, Prince W. Pleural tuberculosis. Proc (Bayl Univ Med Cent) 2019; 32:622-623. [PMID: 31656443 DOI: 10.1080/08998280.2019.1646599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/08/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022] Open
Abstract
A 35-year-old woman with previously untreated latent tuberculosis was admitted to the hospital for management of a right-sided empyema. After a prolonged hospitalization and several interventions, including chest tubes, bronchoscopy with bronchoalveolar lavage, and a video-assisted thoracoscopic surgery, positive acid-fast bacilli cultures on the initial thoracentesis ultimately led to the diagnosis of pleural tuberculosis. This case highlights the importance of utilizing a combination of diagnostic tests to diagnose pleural tuberculosis, especially in the setting of a negative pleural adenosine deaminase level.
Collapse
Affiliation(s)
- Ashley Liou
- Department of Pulmonary and Critical Care, Baylor Scott & White Medical Center-Temple and Texas A&M College of MedicineTempleTexas
| | - Carlos E Rodriguez-Castro
- Department of Pulmonary and Critical Care, Baylor Scott & White Medical Center-Temple and Texas A&M College of MedicineTempleTexas
| | - Abel Rodriguez-Reyes
- Department of Medicine, Hospital Juan Maria De Salvatierra, Universidad Autonoma de MexicoLa PazBaja California SurMexico
| | - Riyam Zreik
- Department of Pathology, Baylor Scott & White Medical Center-Temple and Texas A&M College of MedicineTempleTexas
| | - Shirley Jones
- Department of Pulmonary and Critical Care, Baylor Scott & White Medical Center-Temple and Texas A&M College of MedicineTempleTexas
| | - Whitney Prince
- Department of Pulmonary and Critical Care, Baylor Scott & White Medical Center-Temple and Texas A&M College of MedicineTempleTexas
| |
Collapse
|
23
|
Shaw JA, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusion. Respirology 2019; 24:962-971. [PMID: 31418985 DOI: 10.1111/resp.13673] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/05/2019] [Accepted: 07/23/2019] [Indexed: 12/19/2022]
Abstract
Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti-tuberculous therapy or a guideline-based individualized regimen in the case of drug resistance. There is low-quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short- and long-term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.
Collapse
Affiliation(s)
- Jane A Shaw
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW To summarize data regarding categories, detection methods, prevalence and patterns of drug resistance among patients with tuberculous pleural effusion (TPE) and to comment on the management of suspected drug-resistant TPE. RECENT FINDINGS Pleural and pulmonary tuberculosis (TB) present similar patterns of drug resistance. Approximately 10% and 6-10% of pleural Mycobacterium tuberculosis isolates are resistant to at least one first-line anti-TB drug or at least isoniazid, respectively. The prevalence of multidrug-resistant-pleural and extensively drug-resistant-pleural TB is 1-3% and 0-1%, respectively. SUMMARY Although guidelines suggest the empirical standard anti-TB regimen (i.e. 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol followed by 4 months of isoniazid and rifampicin) for TPE treatment, the data regarding drug resistance among TPE patients are limited. The few studies examining the issue report a notable drug resistance. In suspected drug-resistant TPE, every effort is warranted to isolate M. tuberculosis to perform drug susceptibility testing and provide guided therapy. For this purpose, the use of cultures or molecular methods with pleural biopsies is superior to their use in pleural fluid. If still M. tuberculosis cannot be detected, prolonged administration of ethambutol with isoniazid and rifampicin during the continuation phase of treatment might be considered.
Collapse
Affiliation(s)
- Vasileios S Skouras
- Department of Pulmonary Medicine, 401 General Army Hospital.,1st Department of Pulmonary Medicine, Hygeia Hospital
| | - Ioannis Kalomenidis
- 1st Department of Critical Care & Pulmonary Medicine, Medical School of Athens University, 'Evangelismos' General Hospital, Athens, Greece
| |
Collapse
|
25
|
Zhao T, Xu Y, Song Q, Wang X, Jin M, Lin D. Medical thoracoscopy for tuberculous pleurisy: A retrospective analysis of 575 cases. Ann Thorac Med 2019; 14:134-140. [PMID: 31007765 PMCID: PMC6467019 DOI: 10.4103/atm.atm_359_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 12/30/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The objective of this retrospective study was to assess the efficacy of medical thoracoscopy in diagnosing of tuberculous pleurisy and characterize tuberculous pleurisy with medical thoracoscopy. METHODS A total of 575 patients with tuberculous pleurisy who underwent medical thoracoscopy were included in the study. Demographic data, clinical manifestations, and routine and biochemical tests on pleural fluid, cultures of pleural fluid, sputum, and pleural biopsy for the detection of Mycobacterium tuberculosis and pathological findings were evaluated. RESULTS Sputum, pleural fluid, and pleural biopsy cultures were positive for M. tuberculosis in 12.5%, 19.2%, and 41.9% of patients, respectively. Furthermore, there were significant differences in total positive tuberculosis (TB) tests in the pleural cavity according to patient's age (<18 years old, 50.0%; 18-34 years old, 50.2%; 35-59 years old, 34.8%; >60 years old, 18.6%; and all groups vs. >60 years old, P < 0.001). Patients with 18-34 years old were more likely to have granuloma in pleural biopsy specimens when compared to patients >60 years old (77.0% vs. 37.9%). The percentage of patients with high adenosine deaminase (ADA) levels in pleural fluid (>40 U/L), who were <18, 18-34, 35-59, and > 60 years old, was 83.3% (15/18), 72.8% (193/265), 51.2% (88/172), and 34.7% (17/49), respectively (all groups vs. >60 years old, P < 0.001). CONCLUSION Medical thoracoscopy is effective for diagnosing tuberculous pleurisy. Younger patients with tuberculous pleurisy have a higher number of positive TB tests in the pleural cavity, are more likely to have granuloma in pleural biopsy specimens, and have higher ADA levels in the pleural fluid.
Collapse
Affiliation(s)
- Tingting Zhao
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Shandong, China
| | - Yurong Xu
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Shandong, China
| | - Qian Song
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Shandong, China
| | - Xinjie Wang
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Shandong, China
| | - Minghua Jin
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Shandong, China
| | - Dianjie Lin
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| |
Collapse
|
26
|
Lazović B, Blažić I, Detanac D, Milić R, Šarac S, Detanac D, Žugić V. Tuberculous pleural effusion in the previously healthy man-case report and review of the literature. SANAMED 2019. [DOI: 10.24125/sanamed.v14i2.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Although pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of the pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. Case report: We present a previously healthy man who had no contagious or TB contact but developed massive tuberculous pleural effusion which eventually was unexpected tuberculous. He started with therapy per protocol and feeling well. The purpose of this case and review of literature was to remind the physicians that tuberculosis is not a sickening illness, but on the contrary, it is in the expansion. Discussion: When a patient presents with new pleural effusion, the diagnosis of tuberculous pleuritis should be considered. The patient is at great risk for developing pulmonary or extra pulmonary TB if the diagnosis is not made properly. Between 3% and 25% of patients with TB will have TB pleuritic or more in immunocompromised patients. The treatment for TB pleuritis is the same as that for pulmonary TB. Conclusion: The gold standard for the diagnosis of tuberculous pleural effusion remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli.
Collapse
|
27
|
Shaw JA, Irusen EM, Diacon AH, Koegelenberg CF. Pleural tuberculosis: A concise clinical review. CLINICAL RESPIRATORY JOURNAL 2018; 12:1779-1786. [PMID: 29660258 DOI: 10.1111/crj.12900] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/23/2018] [Accepted: 04/04/2018] [Indexed: 12/18/2022]
Abstract
Tuberculosis (TB) is the leading infectious cause of death worldwide, and the commonest cause of death in people living with HIV. Globally, pleural TB remains one of the most frequent causes of pleural exudates, particularly in TB-endemic areas and in the HIV positive population. Most TB pleural effusions are exudates with high adenosine deaminase (ADA), lymphocyte-rich, straw-coloured and free flowing, with a low yield on mycobacterial culture. TB pleurisy can also present as loculated neutrophil-predominant effusions which mimic parapneumonic effusions. Rarely, they can present as frank TB empyema, containing an abundance of mycobacteria. Up to 80% of patients have parenchymal involvement on chest imaging. The diagnosis is simple if M. tuberculosis is detected in sputum, pleural fluid or biopsy specimens, and the recent advent of liquid medium culture techniques has increased the microbiological yield dramatically. Where the prevalence of TB is high the presence of a lymphocyte-predominant exudate with a high ADA has a positive predictive value of 98%. In low prevalence areas, the absence of an elevated ADA and lymphocyte predominance makes TB very unlikely, and pleural biopsy should be performed to confirm the diagnosis. Pleural biopsy for liquid culture and susceptibility testing must also be considered where the prevalence of drug resistant TB is high. Treatment regimens are identical to those administered for pulmonary TB. Initial pleural drainage may have a role in symptom relief and in hastening the resolution of the effusion. Surgical intervention may be required in loculated effusions and empyemas.
Collapse
Affiliation(s)
- Jane A Shaw
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Elvis M Irusen
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Coenraad F Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| |
Collapse
|
28
|
Korczyński P, Górska K, Konopka D, Al-Haj D, Filipiak KJ, Krenke R. Significance of congestive heart failure as a cause of pleural effusion: Pilot data from a large multidisciplinary teaching hospital. Cardiol J 2018; 27:254-261. [PMID: 30406935 DOI: 10.5603/cj.a2018.0137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/06/2018] [Accepted: 10/28/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Epidemiological data on the causes of pleural effusion (PE) are scarce. Data on the local prevalence of various causes of PE may play a crucial role in the management strategy of patients with PE. The aim of the study was to investigate the causes of PE and to assess 30-day mortality rate in unselected adult patients treated in a large, multidisciplinary hospital. METHODS Retrospective analysis of medical records, including chest radiographs, of 2835 consecutive patients admitted to the hospital was performed. Radiograhic signs of PE were found in 195 of 1936 patients in whom chest radigraphs were available. These patients formed the study group. RESULTS The leading causes of PE were as follows: congestive heart failure (CHF; 37.4%), pneumonia (19.5%), malignancy (15.4%), liver cirrhosis (4.2%) and pulmonary embolism. The cause of PE in 6.7% patients was not established. There was a significant predominance of small volume PE as compared to a moderate or large volume PEs (153, 28 and 14 patients, respectively). Almost 80% of patients with CHF presented with small volume PE, while almost 50% of patients with malignant PE demonstrated moderate or large volume PE. Thirty-day mortality rate ranged from 0% for tuberculous pleurisy to 40% for malignant PE (MPE). CONCLUSIONS Pleural effusion was found in 10.1% of patients treated in a large multidisciplinary hospital. CHF was the leading cause of PE. Although 30-day mortality in patients with CHF was rela-tively high, it was lower than that in parapneumonic PE and MPE.
Collapse
Affiliation(s)
- Piotr Korczyński
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland
| | - Katarzyna Górska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland.
| | - Damian Konopka
- Students' Research Group "Alveolus", Medical University of Warsaw, Poland
| | - Dżamila Al-Haj
- Students' Research Group "Alveolus", Medical University of Warsaw, Poland
| | | | - Rafał Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland
| |
Collapse
|
29
|
Philip KEJ, Kon OM, Roddie M, Ross C. Pleural tuberculosis: a key differential diagnosis for pleural thickening, even without obvious risk factors for tuberculosis in a low incidence setting. BMJ Case Rep 2018; 2018:bcr-2018-224992. [PMID: 30368474 DOI: 10.1136/bcr-2018-224992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We report the case of a 64-year-old woman, presenting with pleuritic chest pain and weight loss. She had a previous history of breast malignancy and no clear risk factors for tuberculosis (TB). Initial investigations showed a right-sided pleural effusion and pleural thickening suggestive of malignancy, which would have been in keeping with the clinical presentation. Initial pleural biopsy showed features suggestive of possible TB infection, though no growth on cultures. A repeat biopsy was negative on initial microscopy, but was culture positive for Mycobacterium tuberculosis, also identifying isoniazid resistance. This case highlights that TB remains an important differential even in the absence of classical risk factors, and illustrates the diagnostic challenges it poses. It also highlights the value of culture positivity in identification of drug resistance and facilitation of appropriate treatment.
Collapse
Affiliation(s)
| | - Onn Min Kon
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Mary Roddie
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Clare Ross
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
30
|
Chen RL, Zhang YQ, Wang J, Wu H, Yang SM. Diagnostic value of medical thoracoscopy for undiagnosed pleural effusions. Exp Ther Med 2018; 16:4590-4594. [PMID: 30542409 PMCID: PMC6257817 DOI: 10.3892/etm.2018.6742] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/20/2017] [Indexed: 12/17/2022] Open
Abstract
To investigate the diagnostic value of medical thoracoscopy for the diagnosis of undiagnosed pleural effusions, a retrospective study was performed on the clinical data of 86 patients with undiagnosed pleural effusions who had medical thoracoscopy at Shaanxi Provincial People's Hospital (Xi'an, China) between May 2012 and November 2013. Of the 86 patients, 79 cases of pleural effusions were confirmed by medical thoracoscopic biopsy with a diagnosis rate of 91.9%. In these 79 confirmed patients, 37 had pleura cancer metastasis (43.0%) and 20 had tuberculous pleuritis (23.3%). The most common type of malignant tumor was lung cancer, accounting for 86.5% of the patients with pleural metastasis. Tuberculosis was often observed in the 16–35 years of age patient group, while malignant tumors were typically detected in the 36–65 year and 65 years and above patient groups. Notably, the overall diagnosis distribution had little connection with sex or smoking-history. Neither mortality nor major complications were observed in patients who received medical thoracoscopy examination. In conclusion, medical thoracoscopy is a safe and effective examination method and has an important diagnostic value for unidentified pleural effusion in patients.
Collapse
Affiliation(s)
- Rui-Lin Chen
- Department of Respiratory Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, P.R. China
| | - Yong-Qing Zhang
- Department of Respiratory Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, P.R. China
| | - Jun Wang
- Department of Respiratory Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, P.R. China
| | - Hua Wu
- Department of Respiratory Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, P.R. China
| | - Shu-Mei Yang
- Department of Respiratory Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, P.R. China
| |
Collapse
|
31
|
Boonsarngsuk V, Mangkang K, Santanirand P. Prevalence and risk factors of drug-resistant extrapulmonary tuberculosis. CLINICAL RESPIRATORY JOURNAL 2018; 12:2101-2109. [PMID: 29424965 DOI: 10.1111/crj.12779] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/04/2017] [Accepted: 02/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Physicians are usually aware of the occurrence of drug-resistant (DR) pulmonary tuberculosis (PTB), but lack concern about DR-extrapulmonary TB (EPTB). Data regarding the prevalence and risk factors of DR-EPTB remain limited. OBJECTIVES To determine the prevalence and risk factors of DR-EPTB. METHODS A retrospective study was performed in patients who had culture-proven Mycobacterium tuberculosis (MTB) from various specimens between January 2013 and December 2015. Patients were classified into three groups: PTB, EPTB and concomitant PTB and EPTB (PTB + EPTB). Clinical data, chest radiographic extent of disease and patterns of DR were collected. RESULTS There were 1014 culture-proven MTB specimens (716 pulmonary specimens and 298 extrapulmonary specimens) from 986 patients (648 PTB, 218 EPTB and 120 PTB + EPTB). The prevalences of isoniazid-, rifampicin- and multidrug-resistant EPTB were 7.8%, .5% and .5%, respectively, which were lower than those of PTB. When PTB and EPTB coexisted, a higher rate of DR-TB was observed than for PTB alone. Of 338 EPTB patients, the extent of radiographic disease was associated with isoniazid-, rifampicin- and multidrug-resistant TB. Previous history of TB and use of steroids/immunosuppressive drugs were also associated with rifampicin- and multidrug-resistant TB in multivariate analysis. CONCLUSIONS The prevalence of DR-EPTB was high in patients who had concomitant PTB. Although the prevalences of rifampicin- and multidrug-resistant TB were low in isolated EPTB, the prevalence of isoniazid-resistant TB remained high. Therefore, drug susceptibility testing should be performed in EPTB patients, especially those who carry the aforementioned risk factors.
Collapse
Affiliation(s)
- Viboon Boonsarngsuk
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Khattiya Mangkang
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pitak Santanirand
- Microbiology Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| |
Collapse
|
32
|
Li C, Hou L, Sharma BY, Li H, Chen C, Li Y, Zhao X, Huang H, Cai Z, Chen H. Developing a new intelligent system for the diagnosis of tuberculous pleural effusion. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 153:211-225. [PMID: 29157454 DOI: 10.1016/j.cmpb.2017.10.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVE In countries with high prevalence of tuberculosis (TB), clinicians often diagnose tuberculous pleural effusion (TPE) by using diagnostic tests, which have not only poor sensitivity, but poor availability as well. The aim of our study is to develop a new artificial intelligence based diagnostic model that is accurate, fast, non-invasive and cost effective to diagnose TPE. It is expected that a tool derived based on the model be installed on simple computer devices (such as smart phones and tablets) and be used by clinicians widely. METHODS For this study, data of 140 patients whose clinical signs, routine blood test results, blood biochemistry markers, pleural fluid cell type and count, and pleural fluid biochemical tests' results were prospectively collected into a database. An Artificial intelligence based diagnostic model, which employs moth flame optimization based support vector machine with feature selection (FS-MFO-SVM), is constructed to predict the diagnosis of TPE. RESULTS The optimal model results in an average of 95% accuracy (ACC), 0.9564 the area under the receiver operating characteristic curve (AUC), 93.35% sensitivity, and 97.57% specificity for FS-MFO-SVM. CONCLUSIONS The proposed artificial intelligence based diagnostic model is found to be highly reliable for diagnosing TPE based on simple clinical signs, blood samples and pleural effusion samples. Therefore, the proposed model can be widely used in clinical practice and further evaluated for use as a substitute of invasive pleural biopsies.
Collapse
Affiliation(s)
- Chengye Li
- Department of Pulmonary and Critical Care Medicine,The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, China
| | - Lingxian Hou
- Department of Neurology, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou 325027, China
| | - Bishundat Yanesh Sharma
- Department of Pulmonary and Critical Care Medicine,The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, China; Jawaharlal Nehru Hospital, Rose Belle, Grand-Port District 00230, Mauritius
| | - Huaizhong Li
- Department of Computing, Lishui University, Lishui 323000, Zhejiang, China
| | - ChengShui Chen
- Department of Pulmonary and Critical Care Medicine,The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, China
| | - Yuping Li
- Department of Pulmonary and Critical Care Medicine,The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, China
| | - Xuehua Zhao
- School of Digital Media, Shenzhen Institute of Information Technology, Shenzhen 518172, China
| | - Hui Huang
- College of Physics and Electronic Information Engineering, Wenzhou University, Wenzhou 325035, China
| | - Zhennao Cai
- College of Physics and Electronic Information Engineering, Wenzhou University, Wenzhou 325035, China
| | - Huiling Chen
- College of Physics and Electronic Information Engineering, Wenzhou University, Wenzhou 325035, China.
| |
Collapse
|
33
|
|
34
|
Triple Cultures Increase the Diagnostic Sensitivity of Mycobacterial Tuberculosis Empyema. Tuberc Res Treat 2017; 2017:4362804. [PMID: 29057121 PMCID: PMC5605862 DOI: 10.1155/2017/4362804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/12/2017] [Accepted: 07/26/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is a continuous debate on the appropriate diagnostic approach and surgical management of mycobacterial empyema, with widely varied diagnostic practices and surgical outcomes. The aim of this study is to highlight the diagnostic approach and clinical features of patients who required surgical intervention for mycobacterial empyema. METHODS We performed a 5-year retrospective cohort study of all patients with mycobacterial empyema requiring surgery in a single institution from November 2009 to November 2014. RESULTS Eighteen patients (15 males and 3 females, median age 48.5 years) required surgery. Seventeen patients required decortication via posterolateral thoracotomy and one patient underwent video-assisted thoracic surgery drainage and pleural debridement. Prolonged air leak was the commonest surgical complication (50%, n = 9). 94.4% (n = 17) had necrotizing granulomatous inflammation on histological examination. The sensitivity of mycobacterium smear and culture ranged between 12.5% and 75% for pleural tissue, sputum, and pleural fluid individually. The combination of all 3 samples increased the diagnostic yield to 100%. CONCLUSION With the implementation of pleural tissue culture at surgery, the novel combination of sputum, pleural fluid, and pleural tissue culture provides excellent diagnostic yield.
Collapse
|
35
|
Makdisi G, Hooker R, Caldeira C. Pulmonary tuberculous and tuberculous pericardial tamponade post lung transplant. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:308. [PMID: 28856148 DOI: 10.21037/atm.2017.04.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary tuberculosis (TB) associated with tuberculous pericarditis after lung transplantation is a very rare entity. Here we report a unique case of cardiac tamponade due to tuberculous pericarditis, in a patient 4 months after single right lung transplantation, the patient underwent a subxyphoid pericardial window. The pericardial effusion analysis showed exudate effusion with high level of lymphocyte concentration. Both patient and donor didn't have history of TB or TB Exposure.
Collapse
Affiliation(s)
- George Makdisi
- Division of Cardiothoracic Surgery, University of South Florida, Tampa General Hospital, Tampa, FL, USA
| | - Robert Hooker
- Division of Cardiothoracic Surgery, University of South Florida, Tampa General Hospital, Tampa, FL, USA
| | - Christiano Caldeira
- Division of Cardiothoracic Surgery, University of South Florida, Tampa General Hospital, Tampa, FL, USA
| |
Collapse
|
36
|
Tong X, Lu H, Yu M, Wang G, Han C, Cao Y. Diagnostic value of interferon-γ-induced protein of 10kDa for tuberculous pleurisy: A meta-analysis. Clin Chim Acta 2017; 471:143-149. [PMID: 28577960 DOI: 10.1016/j.cca.2017.05.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/30/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND The accurate diagnosis of tuberculous pleurisy is still a clinical challenge. Many studies reported that interferon-γ-induced protein of 10kDa (IP-10) plays a role in diagnosing tuberculous pleurisy, but with considerable variance of results. This meta-analysis aimed to evaluate the overall diagnostic accuracy of IP-10 for tuberculous pleurisy. METHODS PubMed, EMBASE, and other databases were searched for studies examining accuracy of pleural IP-10 for diagnosing tuberculous pleurisy. Related data were extracted and sensitivity/specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR) were pooled. Summary receiver operating characteristic curve and area under the curve (AUC) were performed and calculated to summarize the overall test performance. RESULTS Fourteen studies involving 1382 subjects met inclusion criteria, including 715 cases of tuberculous pleurisy and 667 controls. Summary estimates of the diagnostic performance of the IP-10 for tuberculous pleurisy were listed as follows: sensitivity, 0.84 (95%CI 0.81 to 0.87); specificity, 0.90 (95% CI 0.88 to 0.92); PLR, 7.96 (95% CI 5.59 to 11.32); NLR, 0.19 (95% CI 0.15 to 0.24); DOR, 49.82 (95% CI 28.08 to 88.38); and AUC 0.94. No publication bias was detected. CONCLUSION Pleural IP-10 is a useful diagnostic marker for tuberculous pleurisy. Nevertheless, its result should be interpreted together with the results of conventional test and clinical information of patients.
Collapse
Affiliation(s)
- Xiaomeng Tong
- Department of Laboratory Medicine and Department of Blood transfusion, China-Japan Friendship Hospital, Beijing 100029, China
| | - Hongkai Lu
- Department of Laboratory Medicine and Department of Blood transfusion, China-Japan Friendship Hospital, Beijing 100029, China
| | - Min Yu
- Department of Laboratory Medicine and Department of Blood transfusion, China-Japan Friendship Hospital, Beijing 100029, China
| | - Guozhen Wang
- Department of Laboratory Medicine and Department of Blood transfusion, China-Japan Friendship Hospital, Beijing 100029, China
| | - Chengwu Han
- Department of Laboratory Medicine and Department of Blood transfusion, China-Japan Friendship Hospital, Beijing 100029, China.
| | - Yongtong Cao
- Department of Laboratory Medicine and Department of Blood transfusion, China-Japan Friendship Hospital, Beijing 100029, China.
| |
Collapse
|
37
|
Xie S, Lu L, Li M, Xiong M, Zhou S, Zhang G, Peng A, Wang C. The efficacy and safety of adjunctive corticosteroids in the treatment of tuberculous pleurisy: a systematic review and meta-analysis. Oncotarget 2017; 8:83315-83322. [PMID: 29137345 PMCID: PMC5669971 DOI: 10.18632/oncotarget.18160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 03/09/2017] [Indexed: 01/11/2023] Open
Abstract
Purpose To evaluate the efficacy and safety of adjunctive corticosteroids in the treatment of patients with tuberculous pleurisy. Methods The PubMed, Cochrane, Medline, Embase, Web of Science and Chinese National Knowledge Infrastructure were searched. Clinical trials of corticosteroids compared with control were eligible for inclusion. Results Ten studies (6 randomized controlled trials [RCTs] and 4 non-RCTs) with 957 participants met the inclusion criteria. Compared to the controls (placebos or non-steroids), adjunctive corticosteroid use reduced the risk of residual pleural fluid after 4 weeks and the number of days to symptom improvement; however, there was no convincing evidence to support the positive effects of corticosteroids over the long term (8 weeks) on residual pleural fluid, pleural thickening, or pleural adhesions, and there was no statistical difference between the corticosteroid group and control group with respect to 7-days relief of the clinical symptoms or death from any cause. In addition, more adverse events were observed in patients who received corticosteroids than in those in the control group. Conclusions Our results suggest that adjunctive corticosteroid use did not improve long-term efficacy and might induce more adverse events, although the risk of residual pleural fluid at 4 weeks and the number of days to symptom improvement were reduced.
Collapse
Affiliation(s)
- Shuanshuan Xie
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Lin Lu
- Department of Nephrology, North Huashan Hospital, Fudan University, Shanghai, China
| | - Ming Li
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Mengting Xiong
- Department of Cardiology Medicine, Pudong Hospital, Fudan University, Shanghai, China
| | - Shunping Zhou
- Department of Cardiology Medicine, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoliang Zhang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Aimei Peng
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Changhui Wang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| |
Collapse
|
38
|
Zantah M, Datta D. Tuberculous pleural effusion occurring concurrently with asbestos-related pleural disease. Respir Med Case Rep 2017; 21:135-137. [PMID: 28491491 PMCID: PMC5413209 DOI: 10.1016/j.rmcr.2017.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/11/2017] [Accepted: 04/22/2017] [Indexed: 11/17/2022] Open
Abstract
An eighty-four-year-old man presented with progressive exertional dyspnea, productive cough and weight loss for two months. His physical exam was notable for diminished breath sounds at the right base, with dullness to percussion. Chest-x-ray showed moderate right-sided pleural effusion and bilateral calcified pleural plaques as well as diaphragmatic plaques consistent with asbestos-related pleural disease (ARPD). Pleural fluid was exudative with predominantly mononuclear cells, negative acid fast bacilli stain, negative cultures, and negative cytology for malignant cells. Due to recurrence of the effusion, 4 weeks after drainage, thoracoscopic pleural biopsy was planned but pleural fluid cultures came back positive for mycobacteria tuberculosis. Patient was started on anti-tubercular therapy but treatment had to be stopped due to liver toxicity. Patient subsequently developed pneumonia and deteriorated despite antibiotic therapy and expired.
Collapse
Affiliation(s)
- Massa Zantah
- Division of Internal Medicine, University of CT Health Center, Farmington, CT, 06030, United States
| | - Debapriya Datta
- Division of Pulmonary & Critical Care Medicine, University of CT Health Center, Farmington, CT, 06030, United States
- Corresponding author.
| |
Collapse
|
39
|
Makdisi G, Haddad TJ, Makdisi PB, Bittner HB. Tuberculous Empyema Post Bilateral Lung Transplant. Ann Thorac Surg 2017; 103:e419-e421. [PMID: 28431715 DOI: 10.1016/j.athoracsur.2016.10.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 10/23/2016] [Accepted: 10/29/2016] [Indexed: 11/24/2022]
Abstract
Tuberculous empyema in lung transplantation recipients is a rare entity, with only a handful of cases reported in the English-language literature. We are reporting a case of tuberculous empyema 3 months after uncomplicated bilateral lung transplantation. The recipient underwent video-assisted thoracic surgery for diagnosis and decortication. Both the recipient and donor lacked a history of tuberculosis or tuberculosis exposure.
Collapse
Affiliation(s)
- George Makdisi
- Division of Cardiothoracic Surgery, Tampa General Hospital, Tampa, Florida.
| | | | | | | |
Collapse
|
40
|
Ko Y, Kim C, Chang B, Lee SY, Park SY, Mo EK, Hong SJ, Lee MG, Hyun IG, Park YB. Loculated Tuberculous Pleural Effusion: Easily Identifiable and Clinically Useful Predictor of Positive Mycobacterial Culture from Pleural Fluid. Tuberc Respir Dis (Seoul) 2016; 80:35-44. [PMID: 28119745 PMCID: PMC5256342 DOI: 10.4046/trd.2017.80.1.35] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 08/30/2016] [Accepted: 09/01/2016] [Indexed: 12/15/2022] Open
Abstract
Background Isolation of M. tuberculosis (MTB) is required in cases of Tuberculous pleural effusion (TBPE) for confirming diagnosis and successful therapy based on drug sensitivity test. Several studies have focused on predictors of MTB culture positivity in TBPE. However, the clinical role of loculated TBPE as a predictor of MTB cultivation from TBPE remains unclear. The aim of this study was to examine possible predictors including loculation of TBPE of MTB culture positivity in TBPE. Methods We retrospectively examined associations between clinical, radiological, microbiological, and laboratory characteristics and positive MTB culture from TBPE to determine a potent predictor of culture positivity. Results From January 2011 to August 2015, 232 patients with TBPE were identified. Of these, 219 were finally analyzed. Among them, 69 (31.5%) were culture positive for MTB in TBPE and 86 (39.3%) had loculated TBPE. In multivariate logistic regression analysis, the loculation of TBPE was independently associated with culture positivity for MTB in TBPE (adjusted odds ratio [OR], 40.062; 95% confidence interval [CI], 9.355–171.556; p<0.001). In contrast, the lymphocyte percentage of TBPE (adjusted OR, 0.934; 95% CI, 0.899–0.971; p=0.001) was inversely associated with culture positivity for MTB in TBPE. Conclusion In clinical practice, identification of loculation in TBPE is easy, reliable to measure, not uncommon and may be helpful to predict the possibility of positive mycobacterial culture.
Collapse
Affiliation(s)
- Yousang Ko
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Changhwan Kim
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Boksoon Chang
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Suh-Young Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - So Young Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Eun-Kyung Mo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Su Jin Hong
- Department of Radiology, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Myung Goo Lee
- Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea.; Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - In Gyu Hyun
- Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea.; Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Yong Bum Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| |
Collapse
|
41
|
Porcel JM. Advances in the diagnosis of tuberculous pleuritis. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:282. [PMID: 27570776 DOI: 10.21037/atm.2016.07.23] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pleural tuberculosis (TB) remains difficult to diagnose. In about two-thirds of the cases the diagnosis is reliant upon clinical suspicion along with consistent fluid biochemistries (i.e., lymphocytic predominant exudates) and exclusion of other potential causes for the effusion. Microbiological methods for a confirmatory diagnosis of pleural TB, which include acid-fast smears (Ziehl-Nelseen), cultures on solid media (Lowenstein-Jensen) and polymerase chain reaction tests from either pleural fluid or sputum samples, remain suboptimal since they are positive in only a minority of patients. Liquid media, however, significantly increase sensitivity while shortening culture positivity as compared with solid cultures. A number of pleural fluid biomarkers such as adenosine deaminase (ADA), interferon-Ƴ, interferon-Ƴ-induced protein of 10 KDa (IP-10) and interleukin-27 (IL-27), have shown promise for the rapid diagnosis of TB, but only ADA combines the accuracy and simplicity required to be considered a mainstay investigative tool for clinical decisions, particularly in areas with medium to high TB prevalence. In countries where ADA is not available, pleural biopsies to evaluate for caseating granulomas are a standard diagnostic approach. They are now frequently performed under ultrasound guidance to optimize yield and patient safety.
Collapse
Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Institut for Biomedical Research Dr Pifarre Foundation, Lleida, Spain
| |
Collapse
|
42
|
Abstract
Although it is curable, tuberculosis remains one of the most frequent causes of pleural effusions on a global scale, especially in developing countries. Tuberculous pleural effusion (TPE) is one of the most common forms of extrapulmonary tuberculosis. TPE usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. The gold standard for the diagnosis of TPE remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli, Although adenosine deaminase and interferon-γ in pleural fluid have been documented to be useful tests for the diagnosis of TPE. It can be accepted that in areas with high tuberculosis prevalence, the easiest way to establish the diagnosis of TPE in a patient with a lymphocytic pleural effusion is to generally demonstrate a adenosine deaminase level above 40 U/L. The recommended treatment for TPE is a regimen with isoniazid, rifampin, and pyrazinamide for two months followed by four months of two drugs, isoniazid and rifampin.
Collapse
Affiliation(s)
- Kan Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yong Lu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| |
Collapse
|
43
|
Mortazavi-Moghaddam SGR, Sharifzadeh GR, Rezvani MR. Status of Exudative Pleural Effusion in Adults of South Khorasan Province, Northeast Iran: Pleural Tuberculosis Tending toward Elderly. IRANIAN JOURNAL OF MEDICAL SCIENCES 2016; 41:322-7. [PMID: 27365554 PMCID: PMC4912651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The causes and situation of exudative pleural effusion vary from one area to another. A cross-sectional study was conducted on 327 patients with exudative pleural effusion in South Khorasan province (Iran). The patients were older than 12 years and comprised 172 (52.6%) males and 155 (47.4%) females. The study commenced in 2007 with seven years duration. The Light's criteria were used to define exudative effusion. Procedures including pleural fluid analysis, microbiological study, pleural biopsy, and systemic investigations were conducted to determine the special cause of pleural effusion. The mean age of the patients was 63.4±18.4 years. Malignancies, tuberculosis, and parapneumonia pleural exudation were diagnosed in 125 (38.2%), 48 (14.7%), and 45 (13.8%) cases, respectively. Among malignant effusions, metastasis from lung cancer made 48 (38.4%) of the cases. The origin of metastasis was not determined in 44 (35.2%) patients. The mean age of patients was not significantly different between malignant (66.9±14.3 years) and tuberculosis (63.9±19.7 years) cases (P=0.16). The older age of tuberculosis patients could be a new discussion point on the overall impression created on the subject of tuberculosis pleural exudation (TB-PLE) occurring in young people.
Collapse
Affiliation(s)
- Sayyed Gholam Reza Mortazavi-Moghaddam
- Department of Internal Medicine, Pulmonary Division, Vali-e-Asre Hospital, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran,Correspondence: Sayyed Gholam Reza Mortazavi-Moghaddam, MD; Department of Internal Medicine, Vali-e-Asre Hospital, Ghaffari street, Birjand, Iran Tel: +98 561 4435633 Fax: +98 561 444 5402
| | - Gholam Reza Sharifzadeh
- Department of Epidemiology, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Mohammad Reza Rezvani
- Department of Internal Medicine, Pulmonary Division, Vali-e-Asre Hospital, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| |
Collapse
|
44
|
Can pleural adenosine deaminase (ADA) levels in pleural tuberculosis predict the presence of pulmonary tuberculosis? A CT analysis. Clin Radiol 2016; 71:617.e9-617.e14. [DOI: 10.1016/j.crad.2016.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/23/2016] [Accepted: 02/11/2016] [Indexed: 11/15/2022]
|
45
|
Machado T, Fonseca AJD, Buenafuente SMF. Pleural tuberculosis in the state of Roraima, Brazil, between 2005 and 2013: quality of diagnosis. J Bras Pneumol 2016; 42:106-13. [PMID: 27167431 PMCID: PMC4853063 DOI: 10.1590/s1806-37562015000000082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/25/2015] [Indexed: 11/21/2022] Open
Abstract
Objective: To evaluate the quality of diagnosis and the epidemiological profile of patients with pleural tuberculosis in the state of Roraima, Brazil, in order to provide technical support for the development and implementation of public policies to combat the disease. Methods: This was a cross-sectional study designed to determine the prevalence of pleural forms of tuberculosis in Roraima between 2005 and 2013 and to evaluate the diagnostic criteria used, as well as their determinants. This study was based on secondary data from the Brazilian Case Registry Database, including all reported cases of pleural tuberculosis in the state during the study period. Diagnoses based on bacteriological or histopathological confirmation were defined as high-quality diagnoses. Results: Among the 1,395 cases of tuberculosis reported during the study period, 116 (8.3%) were cases of pleural tuberculosis, accounting for 38.9% of all cases of extrapulmonary tuberculosis in the sample. The incidence rate of pleural tuberculosis did not follow the downward trend observed for the pulmonary form of the disease during the same period. The prevalence of cases with a high-quality diagnosis was 28.5% (95% CI: 20.4-37.6%). In a univariate analysis, none of the demographic or clinical characteristics collected from the database were found to have a significant impact on the outcome (as explanatory variables). Conclusions: The quality of the diagnoses in our study sample was considered unsatisfactory. Limited access to specific diagnostic methods might have contributed to these results.
Collapse
|
46
|
Sharan LA, Price TP, Hehn B, Manoff D, Cowan SW. A 22-year-old man with pleural tuberculosis associated hydropneumothorax: Case report and literature review. Respir Med Case Rep 2016; 18:27-30. [PMID: 27144114 PMCID: PMC4840424 DOI: 10.1016/j.rmcr.2016.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 11/25/2022] Open
Abstract
A 22-year-old Asian male presented with fever, non-productive cough, right-sided pleuritic chest pain and was found to have a large right hydropneumothorax. A chest tube was placed. Pleural fluid analysis revealed a lymphocytic predominant exudate and he was subsequently started on four-drug daily anti-tuberculosis therapy (isoniazid, ethambutol, rifampin, pyrazinamide). Pleural biopsy revealed acid-fast bacilli. Given his persistent pleural effusion, he was given four doses of intrapleural tissue plasminogen activator (tPA) and dornase alpha (DNase) via his chest tube over a period of 6 days resulting in clinical and radiologic improvement. Pleural biopsy and pleural fluid culture specimens later revealed Mycobacterium tuberculosis. Intrapleural tPA-DNase therapy has demonstrated improved resolution of infections and shortened hospitalizations for parapneumonic infectious effusions. However, there is little literature on the use of intrapleural fibrinolytics specifically for pleural tuberculosis associated effusions. Furthermore, the American Thoracic Society does not comment on therapeutic thoracentesis or intrapleural fibrinolytic therapy in their recommendations for treatment of pleural tuberculosis. In our case of pleural TB-associated hydropneumothorax, the use of intrapleural tPA-DNase therapy facilitated pleural fluid drainage and resulted in near-complete resolution of the effusion.
Collapse
Key Words
- ADA, adenosine deaminase
- AFB, acid fast bacilli
- CT, chest tube
- CXR, chest radiograph
- EMB, ethambutol
- Fibrinolytic therapy
- HD, hospital day
- INH, isoniazid
- PZA, pyrazinamide
- Pleural effusion
- Pleural tuberculosis
- RIF, rifampin
- TB, tuberculosis
- Tuberculosis
Collapse
Affiliation(s)
- Lauren A. Sharan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thea P. Price
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Boyd Hehn
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - David Manoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Cowan
- Department of Surgery, Division of Thoracic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
- Corresponding author. Thoracic Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 607, Philadelphia, PA 19107, USA.Thoracic SurgeryThomas Jefferson University Hospital1025 Walnut StreetSuite 607PhiladelphiaPA19107USA
| |
Collapse
|
47
|
Analysis of Cytokine Levers in Pleural Effusions of Tuberculous Pleurisy and Tuberculous Empyema. Mediators Inflamm 2016; 2016:3068103. [PMID: 27034588 PMCID: PMC4789481 DOI: 10.1155/2016/3068103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 02/01/2016] [Indexed: 11/17/2022] Open
Abstract
The aim is to examine whether the interleukin-1β (IL-1β), IL-2, IL-6, tumor necrosis factor-α (TNF-α), plasminogen activator inhibitor type-1 (PAI-1), and tissue plasminogen activator (t-PA) levels were different in pleural effusions of tuberculous pleurisy and tuberculous empyema. IL-1β, IL-2, IL-6, TNF-α, PAI-1, and t-PA levels in pleural fluids of 40 patients with tuberculous pleurisy and 38 patients with tuberculous empyema were measured. The levels of IL-1β, PAI-1, and t-PA in the pleural effusions were different between tuberculous pleurisy and tuberculous empyema; it could be helpful to differentiate the two diseases. The levels of PAI-1, IL-1β were higher and t-PA, IL-6 were lower in pleural effusions of the patients with tuberculous empyema and who must undergo operation than the patients who could be treated with closed drainage and anti-TB chemotheraphy. These indications may be helpful to evaluate whether the patient needs the operation.
Collapse
|
48
|
Maduskar P, Philipsen RHMM, Melendez J, Scholten E, Chanda D, Ayles H, Sánchez CI, van Ginneken B. Automatic detection of pleural effusion in chest radiographs. Med Image Anal 2015; 28:22-32. [PMID: 26688067 DOI: 10.1016/j.media.2015.09.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 09/10/2015] [Accepted: 09/16/2015] [Indexed: 11/29/2022]
Abstract
Automated detection of Tuberculosis (TB) using chest radiographs (CXRs) is gaining popularity due to the lack of trained human readers in resource limited countries with a high TB burden. The majority of the computer-aided detection (CAD) systems for TB focus on detection of parenchymal abnormalities and ignore other important manifestations such as pleural effusion (PE). The costophrenic angle is a commonly used measure for detecting PE, but has limitations. In this work, an automatic method to detect PE in the left and right hemithoraces is proposed and evaluated on a database of 638 CXRs. We introduce a robust way to localize the costophrenic region using the chest wall contour as a landmark structure, in addition to the lung segmentation. Region descriptors are proposed based on intensity and morphology information in the region around the costophrenic recess. Random forest classifiers are trained to classify left and right hemithoraces. Performance of the PE detection system is evaluated in terms of recess localization accuracy and area under the receiver operating characteristic curve (AUC). The proposed method shows significant improvement in the AUC values as compared to systems which use lung segmentation and the costophrenic angle measurement alone.
Collapse
Affiliation(s)
- Pragnya Maduskar
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Rick H M M Philipsen
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Jaime Melendez
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Ernst Scholten
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Duncan Chanda
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Helen Ayles
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Clara I Sánchez
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Bram van Ginneken
- Radboud University Medical Center, Post 767, Radiology Department, PO box 9101, 6500 HB Nijmegen, The Netherlands.
| |
Collapse
|
49
|
Singh PK, Jain A. Epidemiological perspective of drug resistant extrapulmonary tuberculosis. World J Clin Infect Dis 2015; 5:77-85. [DOI: 10.5495/wjcid.v5.i4.77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/20/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Tuberculosis (TB) remains one of the leading infectious diseases causing significant morbidity and mortality worldwide. Although, pulmonary TB is the most common presentation and is the main transmissible form of the disease, extrapulmonary TB also significantly contributes to the burden of disease and can cause severe complications and disabilities. At present, the most serious issue with TB control programme is emergence of multi and extensively drug resistant Mycobacterium tuberculosis strain world-wide. As the number of drug resistant pulmonary TB is increasing around the world, the number of drug resistant TB with extrapulmonary manifestations are also on rise. However, there is surprisingly scant information in medical literatures on prevalence and impact of extrapulmonary drug-resistant TB. Here, we appraise the recent epidemiological studies that underpin the status and impact of drug resistance in TB cases with extrapulmonary manifestations.
Collapse
|
50
|
Chuchottaworn C, Thanachartwet V, Sangsayunh P, Than TZM, Sahassananda D, Surabotsophon M, Desakorn V. Risk Factors for Multidrug-Resistant Tuberculosis among Patients with Pulmonary Tuberculosis at the Central Chest Institute of Thailand. PLoS One 2015; 10:e0139986. [PMID: 26444421 PMCID: PMC4596622 DOI: 10.1371/journal.pone.0139986] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/21/2015] [Indexed: 01/22/2023] Open
Abstract
There are limited data available on the risk factors for multidrug-resistant tuberculosis (MDR-TB). Therefore, we here conducted a retrospective matched case-control study among adults with pulmonary TB who received treatment at the Central Chest Institute of Thailand (CCIT) between January 2007 and December 2013, in order to determine the risk factors associated with MDR-TB among patients with pulmonary TB. We identified 145 patients with pulmonary MDR-TB (cases) and 145 patients with drug-sensitive pulmonary TB (controls). Multivariate analysis identified the independent risk factors for MDR-TB as follows: (1) ≥ 2 episodes of prior pulmonary TB (odds ratio [OR] 39.72, 95% confidence interval (95% CI) 7.86-200.66), (2) duration of illness > 60 days (OR 3.08, 95% CI 1.52-6.22), (3) sputum acid fast bacilli smear 3+ (OR 13.09, 95% CI 4.64-36.91), (4) presence of lung cavities (OR 3.82, 95% CI 1.89-7.73), and (5) presence of pleural effusion (OR 2.75, 95% CI 1.06-7.16). Prior pulmonary TB management with a non-category I regimen (P = 0.012) and having treatment failure or default as treatment outcomes (P = 0.036) were observed in a higher proportion among patients with MDR-TB. Particular characteristics of lung cavities, including the maximum diameter ≥ 30 mm (P < 0.001), the number of cavities ≥ 3 (P = 0.001), bilateral involvement (P < 0.001), and ≥ 2 lung zones involved (P = 0.001) were more commonly observed in patients with MDR-TB. In conclusion, these clinical factors and chest radiographic findings associated with MDR-TB among patients with pulmonary TB may help physicians to provide proper management of cases for prevention of the development and spread of MDR-TB in future.
Collapse
Affiliation(s)
- Charoen Chuchottaworn
- Division of Respiratory Medicine, Central Chest Institute of Thailand (CCIT), Nonthaburi, Thailand
| | - Vipa Thanachartwet
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Piamlarp Sangsayunh
- Division of Respiratory Medicine, Central Chest Institute of Thailand (CCIT), Nonthaburi, Thailand
| | - Thu Zar Myint Than
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Duangjai Sahassananda
- Information Technology Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Manoon Surabotsophon
- Division of Pulmonary and Critical Care Medicine, Ramkhamhaeng Hospital, Bangkok, Thailand
| | - Varunee Desakorn
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|